Post Course Research Articles

CLOT OR NOT? AN UNUSUAL CTEPH MIMIC

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of severe pulmonary hypertension (PH) resulting from pulmonary thromboembolic events with subsequent remodeling of pulmonary vasculature. As one of the few forms of PH with potentially definitive management via pulmonary thromboendarterectomy (PTE), it is imperative that the diagnosis of CTEPH involves careful assessment of the patient's history and available studies, including echocardiograms, ventilation-perfusion (V/Q) scans, computed tomography (CT) scans, right heart catheterizations, and pulmonary angiography. This is especially true when considering other conditions that may mimic the presentation of CTEPH. Herein, we discuss a rare instance of pulmonary artery sarcoma (PAS) mimicking CTEPH in a patient with progressive shortness of breath. CASE PRESENTATION: A 53-year-old female with past medical history remarkable for breast cancer status-post lumpectomy and radiation on adjuvant anastrazole monotherapy presented to an outside hospital for progressive shortness of breath and weight loss. CT chest angiography suggested large pulmonary embolism clot burden, and the patient subsequently underwent catheter-directed thrombolysis with tissue plasminogen activator in bilateral pulmonary artery catheters for 24 hours, with minimal change in mean pulmonary artery pressures between times of insertion and removal. The patient subsequently transferred institutions for consideration of PTE.Review of her CT scans and a new V/Q scan suggested a more lobulated, large volume appearance of the obstructing material in her pulmonary vasculature, raising concern for malignant obstruction as opposed to CTEPH. Subsequent positron emission tomography (PET) CT scan showed equivocal fluorodeoxyglucose (FDG) uptake. The patient was brought to surgery, wherein bilateral intravascular tumor involving the main pulmonary artery extending into both branches was discovered consistent with PAS. The mass was extracted, and the patient was eventually discharged with oncologic follow-up, with post discharge course complicated by metastatic disease currently undergoing her third line of therapy. DISCUSSION: This case demonstrates the complexity diagnosing CTEPH. Important mimics of CTEPH outside of PAS include fibrosing mediastinitis, sarcoidosis, large vessel vasculitis, amongst others. Early clinical clues suggesting against the patient's initial diagnosis include recent weight loss and the lobulated appearance of the pulmonary arterial mass. The prognosis of PAS is extremely poor, due to diagnostic and management delays given the stark similarity to CTEPH, with mean survival rates between 12 and 18 months. (1,2) CONCLUSIONS: Diagnosis and management of CTEPH requires expert, multidisciplinary care, especially with the complexity of properly diagnosing the condition amidst other possible mimicking conditions. REFERENCE #1: Bandyopadhyay D, et al. Primary pulmonary artery sarcoma: a close associate of pulmonary embolism-20-year observational analysis. J Thorac Dis 2016; 8: 2592–2601. REFERENCE #2: Wong HH, et al. Presentation and management of pulmonary artery sarcoma. Clin Sarcoma Res 2015; 5: 3. DISCLOSURES: No relevant relationships by Adam Custer, source=Web Response No relevant relationships by NEVEEN El-Farra, source=Web Response No relevant relationships by Jane Wang, source=Web Response No relevant relationships by Alexander Yuen, source=Web Response

Acute Lymphoblastic Leukemia

Acute Lymphoblastic Leukemia

On New Generalized Fuzzy Directed Divergence Measure and Its Application in Decision Making Problem

The concept of fuzzy sets presented by Zadeh has conquered an enormous achievement in numerous fields. Uncertainty in real world is ubiquitous. Entropy is an important tool with uncertainty and fuzziness. In this article, we propose new measure of directed divergence on fuzzy set. The extension of the fuzzy sets and one that integrated with other theories have been applied by some researchers. To prove the validity of measure, some axioms are proved. Using the proposed measure, we generate a method about decision making criteria and give a suitable method. In this article, we describe directed divergence measure for fuzzy set. Properties of proposed measure are discussed. In the real world, the multicriteria decision making is a very practical method and has a wide range of uses. By using multicriteria decision making, we can find best choice among the given criteria. In recent years, many researchers extensively apply fuzzy directed divergence for multicriteria decision making. Also some researchers defined the application of parameterized Hesitant Fuzzy Soft Set theory in decision making. In this article, we shall investigate the multiple criteria decision making problem under fuzzy environment. Application of introduced measure is given for decision making problem. A numerical example is given for decision making problem. In a fuzzy multicriteria problem, the analysis is given by an illustration example of the new define approach regarding admission preference of a student for post graduate course of science stream.

A Rare Case of Pseudotumoral Ureteric Tuberculosis Causing Forniceal Rupture

A 55-year-old woman, with no medical history, presented with acute right flank pain. She had no history of other urinary complaints. On physical examination, the patient was tachycardic (pulse rate: 100bpm) and tachypneic (respiratory rate: 24 breaths/min), blood pressure was11/6 and temperature was 37.4°. The abdominal examination showed severe tenderness in the right flank and the right iliac fossa. All blood reports were normal, including C-reactive protein, cell blood count and serum creatinine. Computed Tomography of the abdomen revealed a right hydronephrosis with delayed phase contrast leak and a retroperitoneal mass of 48x36mm of unknown nature, enhanced after contrast injection, which seemed to compress the right ureter causing the forniceal rupture. A double J ureteral stent was insterted into the right renal cavities with favorable evolution and immediate resolution of pain. Surgical management of the mass was scheduled one month later after the inflammatory phase and resorption of the urinoma. The patient underwent an exploratory laparotomy. Intraoperatively, a tissular retroperitoneal mass of 4 cm was discovered which invadedthe right proximal ureter as well asthe duodenum and the ileocecal pedicle (Figure 1). Resection of the tumor was performed as well as a segmental ureterectomy, right colectomy, and resection of a small portion of the duodenum. Both ureteric and colic anastomosis were then performed along with duodenal suture. The post operative course was uneventful.

BEST of Surgical Training: the pan-London Core Surgical Training induction programme: “There’s no I in team, but there is a me.”

BackgroundIn the UK, Core Surgical Training (CST) marks the start of a surgical career, but previous experience and skills vary widely. Whilst Individual hospital Trusts offer local inductions, these are generally of a generic, administrative nature rather than advising trainees on how best to harness training opportunities. We designed a regional induction programme, ‘Building Excellence in Surgical Training’ (BEST) to address this, develop essential technical and non-technical skills, and engender support networks. MethodsAll incoming London Core Surgical Trainees (annual cohort size 90) were invited to participate, during the week prior to commencement of training. Trainees undertook 3 modules (portfolio, surgical skills and human factors-based simulation) and a research paper presentation day. We collected qualitative and quantitative data through a structured evaluation form, pre and post course Likert-scale scores and self-assessment utilising the non-technical skills for surgeons (NOTSS) framework. Results972 CSTs have completed BEST over the past 12 years. In 2019, significant improvements were seen in: confidence for starting CST, 45% (n = 22/49)-83% (n = 33/40,p = 0.00045); feeling the core programme cared about them, 55% (n = 27/49)-98% (n = 41/42, p =< 0.00001); getting to know peers 16% (n = 8/49)-88% (n = 35/40, p =< 0.00001); understanding human factors 82% (n = 40/49)-95% (n = 36/38, p = 0.00427); gaining confidence of trainers, 49% (n = 23/47)-86% (n = 31/36, p = 0.00114), and ability to speak out over patient safety concerns, 78% (n = 38/49)-97% (n = 37/38,p = 0.00019). NOTSS assessments showed significant improvement across all 4 criteria (n = 142, p =< 0.00001). ConclusionBEST equips trainees with the fundamental skills and confidence to safely embark on surgical training and provides tools to navigate the challenges training presents. The ethos of collaboration and support will aid the development of more resilient and empowered surgeons, vital in this era.

A longitudinal course pilot to improve surgical resident acquisition of quality improvement skills.

ProblemDespite mounting evidence that incorporation of QI curricula into surgical trainee education improves morbidity and outcomes, surgery training programs lack standardized QI curricula and tools to measure QI knowledge. In the current study, we developed, implemented, and evaluated a quality improvement curriculum for surgical residents.InterventionSurgical trainees participated in a longitudinal, year-long (2019–2020) curriculum based on the Institute for Healthcare Improvement’s online program. Online curriculum was supplemented with in person didactics and small group projects. Acquisition of skills was assessed pre- and post- course via self-report on a Likert scale as well as the Quality Improvement Knowledge Application Tool (QIKAT). Self-efficacy scores were assessed using the General Self-Efficacy Scale. 9 out of 18 total course participants completed the post course survey. This first course cohort was analyzed as a pilot for future work.ContextThe project was developed and deployed among surgical residents during their research/lab year. Teams of surgical residents were partnered with a faculty project mentor, as well as non-physician teammates for project work.ImpactParticipation in the QI course significantly increased skills related to studying the process (p = 0.0463), making changes in a system (p = 0.0167), identifying whether a change leads to an improvement (p = 0.0039), using small cycles of change (p = 0.0000), identifying best practices and comparing them to local practices (p = 0.0020), using PDSA model as a systematic framework for trial and learning (p = 0.0004), identifying how data is linked to specific processes (p = 0.0488), and building the next improvement cycle upon success or failure (p = 0.0316). There was also a significant improvement in aim (p = 0.037) and change (p = 0.029) responses to one QIKAT vignette.Lessons learnedWe describe the effectiveness of a pilot longitudinal, multi component QI course based on the IHI online curriculum in improving surgical trainee knowledge and use of key QI skills.

O11 Association Between Food Security and Food Skills Education Among Cooking Matters Participants

ObjectiveTest the association between food security and food skills education among Cooking Matters participants.Use of Theory or ResearchCooking Matters uses evidence-based curricula built upon the Social Cognitive Theory, with a focus on increasing self-efficacy through participatory food skills education to enable positive behavior change.Target AudienceLow-income adults, parents and caregivers, and families during 2017 and 2019.Program DescriptionCooking Matters for Adults, Cooking Matters for Parents, and Cooking Matters for Families curricula were applied to teach participants how to shop for and prepare healthy meals on a limited budget.Evaluation MethodsCooking Matters participants completed pre and post course surveys. Food security was assessed with 1 item to capture “How often do you worry your food might run out before you get money to buy more?” Never or rarely (food secure) versus sometimes, often, or always (food insecure) responses were collapsed. Chi-square tests were applied to test the relationship between food security or food insecurity and demographics, dietary choices, cooking behaviors, and food resource management from pre to post (P < 0.05).ResultsIn total, 20,018 Cooking Matters participants responded to the food security question during 2017 (n = 9,893) and 2019 (n = 10,125). Worry about running out of food significantly decreased from 56.5% to 53.5% (P < 0.001), with 2,622 (13.1%) of all participants decreasing worry. Participants who identified as male, Hispanic or Latino, non-Caucasian, aged 18-39, those with lower education levels, and larger household sizes were significantly more likely to decrease worry about running out of food than other demographic groups (P < 0.01). Participants that decreased worry were significantly more likely to increase healthy dietary choices, positive cooking behaviors, and practice food resource management skills than decrease these variables (P < 0.01).ConclusionMore research is needed to understand the relationship between changes in food security and food skills education. Test the association between food security and food skills education among Cooking Matters participants. Cooking Matters uses evidence-based curricula built upon the Social Cognitive Theory, with a focus on increasing self-efficacy through participatory food skills education to enable positive behavior change. Low-income adults, parents and caregivers, and families during 2017 and 2019. Cooking Matters for Adults, Cooking Matters for Parents, and Cooking Matters for Families curricula were applied to teach participants how to shop for and prepare healthy meals on a limited budget. Cooking Matters participants completed pre and post course surveys. Food security was assessed with 1 item to capture “How often do you worry your food might run out before you get money to buy more?” Never or rarely (food secure) versus sometimes, often, or always (food insecure) responses were collapsed. Chi-square tests were applied to test the relationship between food security or food insecurity and demographics, dietary choices, cooking behaviors, and food resource management from pre to post (P < 0.05). In total, 20,018 Cooking Matters participants responded to the food security question during 2017 (n = 9,893) and 2019 (n = 10,125). Worry about running out of food significantly decreased from 56.5% to 53.5% (P < 0.001), with 2,622 (13.1%) of all participants decreasing worry. Participants who identified as male, Hispanic or Latino, non-Caucasian, aged 18-39, those with lower education levels, and larger household sizes were significantly more likely to decrease worry about running out of food than other demographic groups (P < 0.01). Participants that decreased worry were significantly more likely to increase healthy dietary choices, positive cooking behaviors, and practice food resource management skills than decrease these variables (P < 0.01). More research is needed to understand the relationship between changes in food security and food skills education.

Abstract 40: Pathology Training for Cancer Diagnosis in Africa: Perspectives from Two Virtual Courses

Abstract Purpose: The burden of cancer continues to grow in Africa, yet there are too few trained pathologists to manage the rising number of cancer cases. The shortage of resources in African countries, as well as the travel restrictions resulting from the COVID-19 pandemic, necessitate innovative means of training and supporting pathologists across the continent. In response to requests for training in cancer pathology, two virtual training courses were organized: one conducted in English for participants in Nigeria and another conducted in French for participants across several countries in Francophone Africa. Each course had weekly 90-minute sessions covering essential topics in cancer pathology led by global experts. Methods: Two research questions were investigated for both courses: 1) did the participants improve their knowledge of the topics covered during the course? and 2) did the course participants appreciate the virtual training format? Results: The Nigeria course enrolled 85 participants from 26 Nigerian states, while the Francophone Africa course enrolled 425 participants from 18 African countries. On the post course survey, 95.8% of Nigeria course respondents and 96.1% of Francophone Africa respondents reported being satisfied or very satisfied with the course's virtual format. In the pre-post technical assessment, participants increased their scores on average by 3.4% (p&amp;gt;0.05) in the Nigeria course and by 13.1% (p&amp;lt;0.001) in the Francophone Africa course. Conclusion: Virtual training is a promising tool to improve cancer diagnosis in Africa, as the experience of the two courses illustrates participants appreciate the virtual format. However, continued training and mentorship are required to reinforce new skills and enable the participants to appropriately apply their new knowledge to their daily practice. Citation Format: Daniel Seymour, MPA, Katy Graef, PhD, Yawale Iliyasu, MD, Mohenou Isidore Jean-Marie Diomande, MD, Samuel Jaquet, MD, Melissa Kelly, PhD, Ryan Soles, Dan Milner, MD, MSc, MBA. Pathology Training for Cancer Diagnosis in Africa: Perspectives from Two Virtual Courses [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 40.

467 FRAILTY IN SITU SIMULATION

Abstract Introduction The ability to recognise and manage frailty and its associated presentations is variable among acute hospital staff. Patients living with frailty who are admitted to hospital are more likely to suffer adverse effects than those without. We created an inter-professional in-situ simulation programme designed to improve recognition and management of frailty and its common adverse events. The programme objectives align with recommendations from the British Geriatric Society’s ‘Frailty Hub’ and Royal College of Physicians’ ‘Acute Care Toolkit’ for frailty. Method Over a two month period, seven sessions were completed on the Older Persons Unit (OPU) at St Thomas’ Hospital. These comprised a simulated scenario followed by facilitated debrief—including technical skills and human factors highlighted by the scenario. Quantitative data was collected through pre and post session questionnaires using the Human Factors Skills for Healthcare Instrument (HuFSHI) and frailty based questions. Post session qualitative data was also collected. Results 30 participants attended the sessions (nursing, medical and allied health professional). All participants completing the post course questionnaire found the sessions useful. When comparing pre and post session data, participant confidence in 10/12 sections of the HuFSHI and 8/9 frailty based questions demonstrated improvement. The qualitative data showed common learning themes around improved communication, teamwork and escalation. Participants found that the sessions were a valuable ‘opportunity to reflect’ and ‘debrief’, and learn together as a multidisciplinary team. Conclusion In-situ simulation is an effective tool for improving knowledge and confidence in managing frail patients. It increases awareness and understanding of human factors, which are key to the multidisciplinary approach frail patients require. The course is being expanded across the OPU and now has funding for a departmental manikin. The programme can be disseminated to other units to help improve the care and safety of those with frailty in hospital.

Innovative psychiatry medical education initiative: empowering and supervising trainees for future teaching in psychiatry training program establishment in Somaliland

AimsSomaliland is a de facto state in the horn of Africa. It unilaterally declared independence from rest of Somalia in 1991. Medical education in Somaliland started in the year 2000.Aim of the study is to explore the feasibility of teaching program for the country by its future potential psychiatry educators. The initiative started in 2019 to seek trainees with interest in academic psychiatry and support them with medical education skills. This is intended to prepare them for leading future teaching roles in both undergraduate and residency/fellowship in psychiatryAmoud University wanted to empower junior doctors at the university to have teaching skills needed to set up residency program. The Somaliland government asked Ethiopian ministry of health to offer psychiatry residency program for general practitioners in Somaliland to have future residency and fellowship in psychiatry. Several psychiatry trainees worked with the visiting professor from the United Kingdom who joined Somaliland medical school as visiting professor in psychiatryMethodThe visiting professor supported the trainee in setting up a psychiatry undergraduate training curriculum in line with Somaliland medical school curriculum. Before the teaching methods were didactic and role play based. The faculty introduced different teaching methods including flipchart, small/large group teaching which was student centered education. Students received a online survey to reflect on psychiatry teaching they received. post course survey was conducted at the end of the teaching to evaluate the teaching initiative.ResultSurvey revealed interesting pattern that students preferred class room based teaching in comparison to online teaching. 90 percent of the attendees showed interest in flipchart teaching compared to didactic model. They expressed increasing understanding of the subject matter when they read and discuss among themselves instead of lectures. 70% of students prefer more clinical teaching compared to online sessions.52% liked the new teaching module compared to the lecturing sytle.ConclusionSupervision of early career psychiatrists to undertake future academic psychiatry roles is an important step in building psychiatry faculty in medical schools. As the case of Somaliland this retains trainees in teaching roles in the future to teach undergraduates mental health courses. The other benefit is empowering them to set up psychiatry training program to close the service delivery gap with skilled psychiatrists in the future. Somaliland plans to set up its psychiatry residency/fellowship programs soon after this initiative.

EVALUATION OF BLS WORKSHOPS, AN AUDIT OF THE JOURNEY SO FAR

Objective: Professional training workshops are routinely conducted by Professional Development Center (PDC) of DUHS to provide students golden opportunities in hands on practice on simulators and also has been working as training center of AHA since 2010 for the BLS, ACLS and PALS provider and instructor courses while has been conducting BLS workshops from Nov, 2005. The objective of this study was to assess the perceptions of attending audience by post course evaluation form in BLS program.&#x0D; Methodology: This was a retrospective survey study. Data of BLS workshops from 2017 to 2018 was collected from PDC. Two thousand and fifty six healthcare students were enrolled in BLS course from Jan 2017 till Dec 2018. The calculated sample size was about 324 at 95% confidence level. Thus the final sample size was about 350. A post workshop evaluation questionnaire was used as a tool for data collection and it was analyzed on SPSS.&#x0D; Results: PDC has conducted 714 BLS provider courses since 2005 in which 8529 participants are trained till now. The results of the evaluation show that this workshop received higher score on all assessed sections i.e. more than 90% candidates marked agree &amp; strongly agree. A clear majority of participants (97.8%) agreed that, their queries and questions were satisfactorily responded The structure and content of the workshop organized intensify participants’ skills and knowledge regarding BLS.&#x0D; Conclusion: Overall, Participants characterized the workshop as very useful and were very satisfied with the workshop facilitators and the topics discussed.

EVALUATION OF BLS WORKSHOPS, AN AUDIT OF THE JOURNEY SO FAR

Objective: Professional training workshops are routinely conducted by Professional Development Center (PDC ) of DUHS to provide students golden opportunities in hands on practice on simulators and also has been working as training center of AHA since 2010 for the BLS, ACLS and PALS provider and instructor courses while has been conducting BLS workshops from Nov, 2005. The objective of this study was to assess the perceptions of attending audience by post course evaluation form in BLS program. Methodology : This was a retrospective survey study. Data of BLS workshops from 2017 to 2018 was collected from PDC. Two thousand and fifty six healthcare students were enrolled in BLS course from Jan 2017 till Dec 2018. The calculated sample size was about 324 at 95% confidence level. Thus the final sample size was about 350. A post workshop evaluation questionnaire was used as a tool for data collection and it was analyzed on SPSS. Results: PDC has conducted 714 BLS provider courses since 2005 in which 8529 participants are trained till now. The results of the evaluation show that this workshop received higher score on all assessed sections i.e. more than 90% candidates marked agree & strongly agree. A clear majority of participants (97.8%) agreed that, their queries and questions were satisfactorily responded The structure and content of the workshop organized intensify participants’ skills and knowledge regarding BLS. Conclusion: Overall, Participants characterized the workshop as very useful and were very satisfied with the workshop facilitators and the topics discussed.

Assessing and Assisting Arab Undergraduates’ Skills in Producing Research Papers in English

This paper discusses the results of a study conducted on a group of undergraduates at the Arab International University. The study has assessed the students’ research skills via a qualitative analysis of their earlier research papers submissions and a questionnaire that determined the weaknesses and difficulties they face while writing a paper. Results showed that undergraduates find it most difficult to use and understand English references, paraphrase paragraphs and use in-text citations. Based on the quantitative and qualitative analysis of the results, the researcher devised a new course that aimed to enhance students’ practice of the main research skills. This course was based on developing student’s information literacy and assigning multiple focused tasks to practice the main research skills. The post course evaluation of students’ achievement showed a notable improvement in their research practices that aided the production of above average quality English research papers.&#x0D;

Malate Dehydrogenase CUREs Community: A Model for the Development and Sustainability of a Protein Centric CURE Combining Pedagogical and Protein Science Research

The MDH CUREs Community (MCC) was launched in 2017 with the help of an NSF IUSE grant (NSF-1726932) with 15 faculty from 12 diverse institutions including Community Colleges, MSIs, PUIs, Comprehensive and Research intensive institutions. As of January 2021 the community has grown to 29 faculty from 25 institutions, with proportional increase of all types of institutions. Faculty surveys and interviews conducted by an external evaluation team attribute this growth to 1) a combination of developed and available biological resources that have broadened the range of scientific questions that can be addressed in CUREs. Clones and expression systems were created for various classes of malate dehydrogenase (human, plant, yeast, extremophile and several disease causing pathogens such as Plasmodium falciparum). In addition constructs for several “metabolon” forming enzymes were created. These constructs allow CURE classes to be organized around a diverse array of scientific questions ranging from evolution and adaptation, to classic structure function relationships, to regulation (including post translational effects) and potential drug design. In addition several of the constructs have been developed for intracellular interaction work. 2) the sense of community and collegiality in the group, 3) developed written resources including protocols and teaching aids such as syllabi, background reviews and materials focusing on the seven common elements of MCC CUREs (Relevance, Scientific Background, Hypothesis Development, Proposal, Experiments/Teamwork to test hypothesis, Data Analysis and Conclusions, and Presentation) and 4) an annual meeting (either in person or virtual) of the group to discuss teaching approaches and plan upcoming CURE courses as well as evaluate the yearly external report and suggestions. The community investigated two pedagogical questions during the three year period, assessing the impact of CURE length, and CURE Collaboration on student outcomes. CURE length compared modular CUREs (6-7 weeks) with full semester CUREs using equivalent non CURE courses as controls. A series of validated assessments were administered pre- and post course and aggregated over the three year period. While both types of CUREs showed student gains, full semester CUREs outperformed modular CUREs in many criteria. The impact of Collaboration on student outcomes was more dramatic. Collaboration was defined as either, or, or a combination of, inter-institutional collaborations involving faculty and students from different institutions or student interactions from different institutions. While collaboration resulted in favorable outcomes in all institution types the impact was particularly noticeable in Community College student outcomes. Of the seven common elements of MCC CUREs, faculty discussion identified student hypothesis development as a key player in developing both student ownership of the projects and favorable long term outcomes. Finally, MCC CURE projects have generated significant new scientific knowledge on structure function relationships in MDHs and led to numerous presentations by students and are currently the focus of three manuscripts in preparation with multiple student authors.

Atypical Neurologic Complications Post Autologous Stem Cell Transplantation

We describe the case of a patient with high grade, triple hit, Non-Hodgkin’s Lymphoma (NHL) who underwent high-dose chemotherapy and Autologous Stem Cell Transplantation (ASCT) as a consolidation. Patient received BEAM conditioning regimen. She engrafted after usual post ASCT course. However, 2 months post ASCT she developed atypical neurologic symptoms and findings leading to general weakness mainly in the lower extremities with multiple falls, mental status changes and high CSF protein with severe sensorimotor neuropathy. She initially failed treatment with IVIg but responded to high dose steroids. More than one year after transplant, she has maintained her neurological improvement, but unable to walk, while her NHL continues to be in remission.

Enhancing E-Learning Through Integration of Online Formative Assessment and Teaching Presence

The proliferation of information communication technologies (ICT) continues to increase opportunities for effective pedagogical approaches and online learning. This paper reports a study on integration of online formative assessment from a teaching presence perspective of the community of inquiry (CoI) framework. The effects of this integrative pedagogical approach on students' learning experiences are explored. The study was conducted in a post graduate online course. Case study research design was utilized. The study exemplified the core elements of formative assessment including integration of authentic assessment activities within teaching and learning processes, explicit learning goals, formative feedback, and documentation of evidence of learning. These elements were aligned to the functions of teaching presence, namely design, facilitation, and direct instruction. This approach enhanced meaningful engagement with critical learning experiences including interactive collaboration, critical thinking, reflective thinking, multi-dimensional perspectives, and self-regulation.

90. Serous borderline paraovarian tumor: a rare presentation in an adolescent girl

<h3>Background</h3> Borderline serous ovarian tumors represent less than 1% of all ovarian tumors in children and adolescents. Even more rare are serous borderline paratubal tumors. There are a few case reports of this rare tumor in the adult literature, but to our knowledge we report the youngest patient with a serous borderline paratubal tumor. <h3>Case</h3> A 17 year-old girl presented with progressive weight gain and lower abdominal distension over a three month period. She also reported intermittent crampy suprapubic abdominal pain as well as irregular menses and increasing fatigue. Workup revealed a 19 × 15 × 10 cm mass adjacent to the left ovary. Laboratory evaluation was remarkable only for a mild elevation in LDH (641). She underwent laparoscopic, ovarian sparing resection of a paratubal cyst. Final pathology was consisted with a serous borderline tumor without invasion or microinvasion. Cytology from the cyst fluid also showed "atypical cells with serous morphology." She had an uneventful post operative course, her LDH levels normalized, and she is currently being followed with serial ultrasounds and LDH levels. <h3>Comments</h3> Serous borderline paratubal tumors are extremely rare tumors, usually occurring in young women. There are only scant case reports in the adult literature and this is the first reported case in an adolescent to our knowledge. These tumors generally present as early stage and have good clinical outcomes. Continued reporting is essential to ensure a better understanding of these tumors.

Post liver transplant complications of Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is a rare, life-threatening disease characterized by hepatic venous outflow obstruction. Liver transplantation (LT) is widely accepted as an effective therapeutic measure for irreversible liver failure due toBCS. There is debate on differences in the post LT course and complications in patients withBCS as compared to non-Budd-Chiari (NBC) patients. In this retrospective study, data on all patients who received a liver transplant for BCS at the Shiraz Organ Transplantation Center between January 1996 and September 2017 were reviewed and compared to data ofa control group who had received liver transplants over the same period but due to other causes (NBC). Out of 4225 patients who received liver transplants in the study period, 108 hadBCS and an age- and gender-matched control group consisted of 108NBCcases. The mean ± standard deviation (SD) of model for end-stage liver disease (MELD) scores were 19.1 ± 3 and 20 ± 3 for BCS and NBC groups, respectively (p = 0.33). One-, 3-, 5-, and 10-year survival rates in the BCS group were as follows: 82%, 78%, 76%, and 76% compared with the NBC rates of 83%, 83%, 83%, and 76%, respectively (p = 0.556). There was no difference between the two groups in complication ratesafter 6months. In the later period, vascular thrombosis was more common in BCS. Whole-organ LT from deceased donors in patients with BCS had comparable outcomes with LT due to other causes of end-stage liver disease. In most instances, these patients should receive lifelong anticoagulation.

Surgical treatment of stent migration to pancreatic duct: case report

Endoprotheses are common in the treatment of biliary system disorders. Long term biliary plastic stenosis placement is known to cause several complications, 1.7-6 % of stents migrate. Treatment is mostly done by conventional endoscopic procedures, however 10 % will require surgical intervention. One reason for the failure of the endoscopic treatment is the de novo stent stone complex formation. In this case we are reporting a stent migration to the pancreatic duct and the de novo stent stone complex formation caused failure of the endoscopic treatment. We report the case of a 48-year-old Hispanic female who presents to the emergency department with abdominal pain for the last 72 hours. In her past medical history she reported recurrent abdominal pain similar to the actual episode. She also reported choledocholithiasis treated with ERCP and stent two years ago with no follow up. Pancreatitis was documented, diagnostic studies show a dilated Wirsung duct with three images that correspond to stones and a migrated stent in the lumen of the pancreatic duct. She was diagnosed with chronic pancreatitis. ERCP was unable to remove the stent. A pancreaticojejunostomy (Puestow procedure) and a stent removal was performed. The patient had an uncomplicated post operative course with complete resolution of abdominal pain. She remains asymptomatic tree months after surgery. Follow up after stent placement is important to avoid unintentional retention. In the case this occurs, first line treatment is the endoscopic approach, occasionally surgery is needed for resolution.Stent removal from pancreatic ductView Large Image Figure ViewerDownload Hi-res image Download (PPT)

LAPROSCOPIC ASSISTED SWENSON PULL-THROUGH FOR CLASSIC HIRSCHSPRUNG’S DISEASE WITH SIGMOID COLOSTOMY: A SINGLE CENTER EXPERIENCE

OBJECTIVE: To share our experience of laparoscopic assisted Swenson pull-through for classic Hirschsprung’s disease (HD) with sigmoid colostomy. METHODS: Thirty-one patients with HD and sigmoid colostomy operated in Pediatric Surgery department, Khyber Teaching Hospital, Peshawar, Pakistan, between June 2014 and June 2018 were included. Patients with long segment HD, and those operated elsewhere were excluded from the study. Demographic characteristics, intraoperative findings and post operative course were retrieved from files. Post-operative outcome at 3rd, 6th and 12th month follow ups were taken from follow up charts. RESULTS: Mean age and weight of patients were 13.23±1.76 months and 7.89±1.42 kg, respectively. Male to female ratio was 6.75:1. Mean operative time, duration of urinary catheterization and hospital stay were 171.87±15.76 min, 0.79±1.02 days and 5.91±1.01 days, respectively. After surgery, stool consistency was liquid in 12 (61.29% ) and loose in 12 (38.7 %) patients. However, stool frequency was >3 times/day in 10 (32.25%) cases, 2-3 times/day in 18 (58.06%) patients and 0-1 time/day in 3 (9.67% ) patients. Surgical site infection and perianal excoriation were seen in 2 (6.45%) and 11 (35.48%) patients, respectively. Progressive improvement in stool consistency and frequency was noticed at 12th month follow up. Perianal excoriation was seen 11 (35.48%) patients at 3rd month, 6 (19.35% ) patients at 6th and 1 (3.22%) patient at 12th month follow up. CONCLUSION: Laparoscopic assisted Swenson pull-through is a good treatment option for patient with recto-sigmoid HD and bears a predictable and acceptable stooling pattern, optimum hospital stay and minimal complications.