Unexpected Case Research Articles

An unanticipated case of B‐cell lymphoma, presenting as skin bruises, detected incidentally during initial sonography

AbstractIntroductionLymphomas are cancers of lymphatic origins, commonly presenting as a painless swelling of the lymph gland (adenopathy). Lymphomas are broadly categorised into Hodgkin and Non‐Hodgkin lymphoma. This report aims to present an unexpected case of B‐cell lymphoma that presented as skin bruises, incidentally detected on ultrasound as a nonspecific retroperitoneal mass.Case PresentationA 75‐year‐old female presented with a vaccine‐induced flare of her known Immune Thrombocytopenic Purpura (ITP). An initial ultrasound scan requested to examine her spleen revealed a right retroperitoneal abnormality affecting the adjacent right kidney and IVC. A subsequent triple‐phase contrast‐enhanced computed tomography (CT) scan revealed a large infiltrative mass involving the right kidney extending across the midline to the right of the patient's abdominal aorta. Lymphoma was suspected. Immunohistochemistry analysis of the CT‐guided biopsy samples revealed the presence of CD5‐negative low‐grade B‐cell lymphoma.DiscussionThis report presents a unique case of B‐cell lymphoma that manifested as skin bruises.Although ultrasound is not the gold standard imaging modality to test for lymphoma in the abdomen, it is imperative that ultrasound practitioners continue to complete a thorough abdominal ultrasound, even when specific organ requests are made, as in this case report. Ultrasound has a role in the detection of clinically asymptomatic incidental abdominal masses.ConclusionIt is important that a targeted ultrasound examination is avoided for patients with no recent imaging history within the department. This case highlights the importance of thorough ultrasound scanning to avoid missing incidental abnormalities as opposed to an organ‐specific targeted scanning.

An unexpected case of a dog from Poland co-infected with Dirofilaria repens and Dirofilaria Immitis.

Dirofilariasis is a vector-borne disease caused by parasitic nematodes of the genus Dirofilaria spp., considered an emerging concern in both veterinary and human medicine. Climate changes and human activities, such as pet travel, contribute to the spread of diseases to new non-endemic regions. Poland is dominated by subcutaneous dirofilariasis caused by D. repens infections. Cardiopulmonary dirofilariasis, also known as a heartworm disease is much more rare with only single autochthonous cases reported so far. Also, imported infections are observed sporadically in dogs traveling to endemic countries. In this study, we report the first case of a dog in Poland, never having traveled abroad, co-infected with Dirofilaria repens and Dirofilaria immitis. A 14-year-old mixed breed, an intact male dog with fever, lightly pale mucosal membranes, moderate abdominal pain, and a mild cough was presented in a veterinary clinic in Warsaw, Poland. The examination of the blood sample collected for complete morphology and biochemistry revealed the presence of live microfilariae. Presence of the DNA of both microfilariae species was detected using Real-Time PCR with species-specific primers. Since the remaining diagnostic methods like Knott's test, antigen test or echocardiography did not reveal the presence of D. immitis, we discussed the impact of microfilariae periodicity and low worm burden infections on the limited efficiency of these techniques. We strongly recommend using a mixed diagnostic approach for the most sensitive and specific diagnosis since the ideal diagnostic method does not exist, and several factors may contribute to misdiagnosis. Furthermore, we considered factors that contribute to the uncontrolled spread of dirofilariasis such as climate changes, introduction of new species of mosquitoes competent for the transmission of the disease, and wildlife animals as an important reservoir of this parasitosis. Given that Poland shares borders with countries classified as endemic and pre-endemic for D. immitis, such as Slovakia and Ukraine, it is reasonable to anticipate a rise in autochthonous heartworm infections and shifts in the epidemiological pattern of dirofilariasis in the coming years.

War-Torn Territories and Society: Migration Processes, Cases, Contexts of Ukraine

Large-scale population displacement is one of the key consequences of the Russian-Ukrainian war. It has been determined that Ukraine has abnormal demographic patterns at all levels. The aim of the research was to identify the general features of new patterns in the demographic space of Ukraine at different levels and to present case studies of migration processes in the de-occupied communities of Kherson region. An analysis of demographic history and the dramatic changes of the last ten years have revealed a restructuring of the demographic space that has changed the dominant trends of previous periods. The authors differentiate the regions of Ukraine by population concentration, which demonstrates a catastrophic drop in the demographic weight of the regions that became the battlefield. At a national level, there have been catastrophic demographic losses due to refugees, deaths, and natural decline. At a regional level, there has been a significant shift in population distribution, resulting in the rapid growth of the relative demographic importance of Ukraine's western and central regions. There have been predictable and unexpected migration cases at the local level, where emotional and psychological factors such as strengthening identity and regional belonging have become more essential alongside rational choices and decisions.

Case of Malignant Proliferating Trichilemmal Tumour in Gluteal Region

Malignant Proliferating Trichilemmal Tumour (MPTT) is a rare, malignant cutaneous adnexal tumour that originates from the outer root sheath cells of the isthmus of hair follicles. This article aims to report a rare case of a high-grade malignant trichilemmal tumour arising in the context of a proliferating Trichilemmal Cyst (TC) in a 65-year-old female who presented with a painless swelling in the left gluteal region that had been present for two months. There have been only about 100 cases reported so far. Both the clinical features and the imaging findings were suggestive of an ostensibly benign lesion. As a result, the cyst was excised; however, further histopathological evaluation revealed an unexpected case of rare MPTT. Consequently, a timely second revision surgery was performed to ensure tumour-free margins. This case illustrates that the diagnosis of MPTT is highly challenging. Without prior knowledge and a high index of suspicion, the diagnosis of MPTT could easily be missed. MPTT is often misdiagnosed as a variant of Squamous Cell Carcinoma (SCC). The subtle nuances of the unique histopathological pattern of MPTT can help differentiate it from SCC.

Can cannabinoids contribute to complicated cholecystitis - an unexpected case of gangrenous cholecystitis

Can cannabinoids contribute to complicated cholecystitis - an unexpected case of gangrenous cholecystitis

Donor blood cultures and outcomes after lung transplantation: a single-center report.

Transplanting lungs from donors with positive blood cultures has not been shown to adversely affect survival. There is limited evidence for potential effects on other outcomes, such as hospital course, graft function, and transmission of infection. This retrospective cohort study included adult patients who underwent lung-only transplantation for the first time between March 2010 and December 2022. Outcomes of patients whose donors had positive blood cultures within 72h of transplant were compared to patients whose donors had negative blood cultures. Twenty-five (10.8%) of 232 donors had positive blood cultures, including a single, unexpected case with candidemia. The most commonly isolated bacteria were Enterobacter cloacae (n=5), Klebsiella pneumoniae (n=5), Acinetobacter baumannii (n=3), Pseudomonas aeruginosa (n=3), and Staphylococcus aureus (n=3). Eleven donors had identical bacteria in their respiratory cultures. All patients who were transplanted from donors with positive blood cultures survived beyond 90 days. Positive donor blood cultures were not associated with longer hospital stay, in-hospital complications, acute cellular rejection, or the achievement of 80% predicted forced expiratory volume in the first second. Probable transmission of donor bacteremia occurred in only two cases (both with S. aureus). These two donors had positive respiratory cultures with the same organism. The study did not find an increased risk of adverse events when transplanting lungs from donors with positive blood cultures. Allograft cultures may be more predictive of the risk of transmitting infections.

A Study on Patient Safety Incidents and the Second Victim Phenomenon Among Healthcare Providers in Al-Ahsa, Saudi Arabia.

A second victim (SV) is a healthcare worker who is traumatized by an unexpected adverse patient case, therapeutic mistake, or patient-associated injury that has not been anticipated. Often, the second victim experiences direct guilt for the harm caused to the patients. Healthcare organizations are often unaware of the emotional toll that adverse events can have on healthcare providers (HCPs) who can be harmed by the same incidents that harm their patients. Second victims (SVs) were present in 10.4% up to 43.3% of cases following an adverse event. This study aims to examine the second victimphenomenon among healthcare providers at Al-Ahsa hospitals, its prevalence, symptoms, associated factors, and support strategies. Four major public hospitals participated in this cross-sectional study. The study used the German standardized questionnaire "SeViD-I survey." The directors of the four hospitals sent invitations with links to participate to healthcare providers who had worked in their hospitals for over six months after completing their internship program. More than one-quarter of the respondents (90 (28%)) have been victims of a second victim incident before; of those, 63 (70%) have had it once, 12 (13.3%) twice, and 15(16.7) repeatedly. In our study, the risk factors for a second victim only appeared in the male gender and were statistically significant. Strong reactivation of situations outside of the workplace was reported in 36 (40%) participants. Thirty-five (38.9%) participants reported reactivating the situation on the job site. Twenty-eight (31%) participants reported aggressive psychosomatic reactions (headaches and back pain). In 28 (31.1%) participants, sleep problems or excessive sleep needs were pronounced. The median of feeling symptoms was 7.2. As for supporting strategies, 64 (71.1%) respondents considered emotional support and crisis management to be very helpful. Sixty-six (73.3%) respondents found a safe chance to be very helpful. The findings of this study indicate that healthcare providers in Al-Ahsa, Saudi Arabia, suffer from second victim traumatization at high rates. Several symptoms appear in the second victim, and most do not receive enough support.

Combined renal small cell carcinoma: an extremely rare and unexpected case.

Combined renal small cell carcinoma: an extremely rare and unexpected case.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution.

Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution. Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details. There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging. Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

THU449 An Unexpected Case Of Cutaneous Leukocytoclastic Vasculitis Following Zoledronic Acid Infusion

Abstract Disclosure: B. Zahedi: None. Z.S. Wallace: None. M.M. Cote: None. E.W. Yu: Grant Recipient; Self; Amgen Inc. Background: Zoledronic acid is a potent amino-bisphosphonate frequently used in the treatment of osteoporosis. We report a case of small-vessel vasculitis with cutaneous manifestations occurring after zoledronic acid infusion, previously not reported in the literature. Clinical case: A 58-year old woman with a history of sleeve gastrectomy 1.5 years prior was treated for bone protection with an intravenous infusion of zoledronic acid (Zol) 5mg. This was the patient’s first exposure to a bisphosphonate medication. Within minutes of the infusion, she developed a single episode of diffuse watery diarrhea. Although GI symptoms resolved quickly, within a few hours she experienced generalized myalgias and skin tenderness in her abdomen and extremities, for which she took NSAIDs. These symptoms progressed in severity over the next 3-5 days, manifesting as bilateral hand and lower extremity edema and erythema; no fever/chills/sweats, mucocutaneous ulcers, or urinary symptoms were present. By Day 5, she developed palpable purpura without blanching above the ankles and extending to the knees. By Day 7, prednisone 60mg was started. Prior to Zol, labs showed sufficient 25-hydroxyvitamin D, normal calcium, renal and liver function. On Days 10 and 14, labs revealed AST and ALT, twice and thrice the upper limit of normal respectively. Other notable labs included normal UA, Ca, WBC, eGFR, nonelevated ESR/CRP, and a negative work up for an underlying infectious, inflammatory, ANCA-associated, hypocomplementemic or autoimmune process. Cutaneous findings resolved within 3 weeks of Zol, and transaminitis and edema resolved by week 4. In the setting of a negative lab workup and typical palpable purpura, the patient was diagnosed with leukocytoclastic cutaneous vasculitis (LCV), likely induced by Zol (Naranjo score of 5 consistent with probable adverse drug reaction). Although IgA-mediated Henoch-Schonlein Purpura (HSP) cannot be definitively ruled out in absence of a skin biopsy, the patient did not exhibit other clinical features of HSP, and the timeline is highly suggestive of an idiosyncratic drug reaction whereby Zol acted as a hapton to stimulate an immunologic vasculitis response. Up to 50% of patients with LCV have systemic involvement (renal, GI, pulmonary, cardiac or CNS). Cutaneous LCV usually carries a favorable prognosis after treatment with glucocorticoids. On review of the literature, no prior cases of bisphosphonate-induced LCV have been reported, although there are few cases of giant cell arteritis, uveitis and urticarial vasculitis with bisphosphonate therapy. Conclusions: This is the first case demonstrating cutaneous manifestations consistent with leukocytoclastic vasculitis due to zoledronic acid infusion, which was successfully managed with NSAIDs and glucocorticoids. Clinicians should be aware that LCV may be a rare hypersensitivity complication of Zol. Presentation: Thursday, June 15, 2023

An Unexpected Case of Calcified Schwannoma

An Unexpected Case of Calcified Schwannoma

Diabetes, Vision & Homoeopathy

Treating the eye of a diabetic patient is a challenging task for an ophthalmologist as they deal with Diabetic Retinopathy (DR). Uncontrolled sugar levels further leads to complications making the challenge tougher for the ophthalmologist. To meet these challenges, the current article examines the role of homoeopathy on a large scale at the national level [9]. The article delves into the current status of DR at nation at global & national level. Thereafter moves to epidemiology of DR, diagnosis of DR, management of DR & the burden of DR in India. It sees what the homoeopathic system of medicine can offer to deal with DR cases & the burden of DR. On a large scale, the blindness prevention in public health centers on vitamin A prophylaxis or vitamin A prevention. All these efforts are done for the younger age group. Currently, vitamin A prophylaxis starts from the age of 9 months & goes on till the children complete 5 years of age. From the age 9 months one dose of vitamin A is given to the children every 6 months till they complete 5 years of age. So in all, 9 doses of vitamin A are given to U5 children [9, 10]. Other diseases like DR, cataract, refractive error & glaucoma also contribute to blindness, In recent times, there has been a rise of such cases of vision loss & it is essential to understand the cause. There is a clear link between uncontrolled sugar levels & retinopathy. This phenomenon leads to masking of vision related symptoms thus resulting in unexpected blindness cases. These are actually Diabetic Retinopathy cases [9, 10, 26].

Stainless steel corrosion under anoxic, highly saline and elevated temperature conditions

Abstract. Several countries consider hosting a deep geological repository for high-level nuclear waste (HLW) in salt rock. In the unexpected case of solution access to the emplacement caverns during the long-term evolution of such a repository, metallic containers will be exposed to highly saline brines. In this study, corrosion experiments under conditions expected to be representative of HLW disposal in salt rock have been performed with stainless steel, a material typically used to construct containers containing vitrified HLW. Experiments were performed in closed vessels under anoxic and highly saline conditions at 90 ∘C. Polished stainless steel coupons were suspended in 5 mol L−1 NaCl or 3.4 mol L−1 MgCl2 at their natural pH. At the end of the experiments (up to 294 d), vessels were cooled down to room temperature, pH and Eh were measured in situ, the ultra-centrifuged contacting brines were analyzed by (HR)ICP-MS (high-resolution inductively coupled plasma mass spectrometry) and the formed corrosion products were identified. In all corrosion experiments, pHm and Eh hardly changed with exposure time, and the nature of the salt had no significant effect. The overall corrosion rates were low, and the quantities of dissolved metal ions revealed the formation of only sparingly soluble corrosion products. The formation of a passivation layer mostly made of Cr(III) (hydr)oxide was evidenced, but no localized surface attack could be detected. The coupon corroded in 5 mol L−1 NaCl was embedded in resin and cross-cut for further analyses, using synchrotron-based techniques with a small beam footprint (X-Ray fluorescence (μXRF), X-Ray diffraction (μXRD), and X-ray absorption near-edge structure (μXANES)). Element distribution maps revealed the presence of a very thin (<1 µm) layer of corrosion products, with regions enriched either in Cr or in Fe and Ni. X-ray diffractograms identified the presence of spinel-type compounds (Fe3O4 and NiFe2O4) and Cr2O3, which was corroborated by recording μXANES at the Cr, Fe and Ni K-absorption edges. The additional presence of layered double hydroxides in addition to NiO and Ni(OH)2 was also evidenced. Overall, results point to a corrosion layer having a duplex structure, with an inner layer mostly of chromium (hydr)oxides and an outer layer made of Fe- and Ni-based spinel compounds admixed with nickel (hydr)oxides.

TUMME 2023: Tsinghua University Minnesota Master Equation program. New version announcement

This is an updated version of TUMME (Tsinghua University Minnesota Master Equation program), which is a computer program for setting up and solving master equations for chemical kinetics of unimolecular and bimolecular reactions. The master equation is discretized in terms of energy bins, and rate constants are calculated from chemically significant eigenmodes. TUMME has interfaces to Gaussian 16, Polyrate 2023, and MSTor 2023 output files that allow the master equation code to obtain the microcanonical flux coefficients needed for the kernel of the master equation as calculated by conventional transition state theory (TST), variational transition state theory (VTST) with various tunneling methods, or multi-structural or multi-path VTST (MS-VTST or MP-VTST) with various tunneling methods. The tunneling methods supported include zero-curvature tunneling (ZCT), small-curvature tunneling (SCT), large-curvature tunneling (LCT), and microcanonically optimized multidimensional tunneling (μOMT). For mechanisms involving only unimolecular isomerization (no bimolecular pairs), TUMME can set up and solve a conservative master equation for both rate constants and time-dependent energy-bin populations. For mechanisms involving bimolecular pairs, TUMME 2023 can set up and solve two kinds of master equation: (i) a nonconservative master equation for calculating rate constants of bimolecular reactions and (ii) a conservative master equation that includes bimolecular association in the transition matrix and that can be used for calculating the time evolution of the concentration of a pseudo-first-order bimolecular reactant. TUMME is written in double precision with Python 3; quadruple and octuple precision are also available for some subtasks in C++. The Python code can run in serial or parallel (MP or MPI), and C++ code can run on a single processor or on multiple processors with OpenMP. The program includes a manual and a tutorial. New version program summaryProgram Title: TUMME 2023CPC Library link to program files:https://doi.org/10.17632/whcnvm2mc9.2Developer's repository link:https://doi.org/10.5281/zenodo.7943283Licensing Provisions: Apache-2.0 for the program and CC-BY-4.0 for the manualProgramming languages: Python 3 and C++Does the new version supersede the previous version?: YesJournal reference of previous version: Comput. Phys. Commun. 270 (2022) 108140 [1]External libraries: Numpy, Scipy, Numba, mpi4py (optional), modified mpack (optional), qd (optional), omp (optional)Interfaces to other programs: Gaussian 16 [2], Polyrate 2023 [3], and/or MSTor 2023 [4]Nature of problem: Characterize and calculate rate constants for a temperature-dependent and pressure-dependent complex reaction systemSolution method: Solve the energy-grained master equation based on the chemically significant eigenmodes to get phenomenological rate constants and time evolutions of the populations [1,5–7].Reason for new version: The new version increases the functionality and accuracy, and it offers an easier way to run the program. In addition, some bugs have been corrected.Summary of revisions:1.Added an option (available in high precision) to treat pseudo-first-order bimolecular reactions to obtain the time evolution of the reactants and intermediates. [8]2.Added an inverse-Laplace-transform option in the REACTION block.3.Abandoned rounding the sizes of energy bins to an integer wavenumber (ESOT).4.Changed the way to run TUMME by providing an executable bash script.5.Slightly adjusted the strategy for eigenmode mergers to deal with some unexpected cases.6.Adjusted the output for the partition functions.7.Added options for large-curvature tunneling (LCT) and microcanonically optimized multidimensional tunneling (μOMT).8.Added the keyword pyrfile to support a Polyrate 2023 [3] file that ends with a suffix .fu100.9.Fixed some bugs.10.Updated the manual and added a tutorial to the program distribution, so the distribution now has both a manual and a tutorial.

Fluid Overload Management in HELLP Syndrome with Pulmonary Edema Underwent Caesarean Section

Introduction: HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is a multisystemic disorder. HELLP syndrome is a life-threatening condition with high maternal and infant mortality rates. This study aimed to present an unexpected case of HELLP syndrome complicated by pulmonary edema. Case presentation: A 40-year-old woman, 80 kg, who was 26-27 weeks into her pregnancy, came to the obstetric department due to fever and nausea in the past three days. She was then referred to the internal medicine department and diagnosed with dengue fever by the symptom of fever and thrombocytopenia. After two days of in-patient treatment, the obstetrician diagnosed her with HELLP syndrome, followed by elevated liver enzymes. She was then posted for an urgent caesarean section, and we managed this case under general anaesthesia. Postoperatively, we aimed for -500 to -1,000 mL cumulative fluid balance to avoid further hypovolemia. Conclusion: The patient showed improvement, as evidenced by chest X-ray and oxygen saturation. Management of fluid overload in this patient with HELLP syndrome was challenging. On the second day in ICU, the antibiotic was changed from meropenem combined with levofloxacin to meropenem combined with amikacin because the leucocyte level increased and procalcitonin level increased in 48-72 hours.

An Unexpected Case of Difficulty in Weaning from Cardiopulmonary Bypass

An Unexpected Case of Difficulty in Weaning from Cardiopulmonary Bypass

Sudden infant death syndrome

Sudden Infant Death Syndrome (SIDS) is a type of sudden and unexpected infant death, a term that encompasses both deaths from SIDS and ultimately all unexpected infant deaths with a determined cause. 1 Between %27 and % 43 of 3500 sudden unexpected infant death cases in the USA annually are due to SIDS. 2, 3 A number of other terms are used in pediatrics to describe sudden and unexpected deaths. Sudden unexpected death of an infant can be used interchangeably with sudden unexpected infant death, and sudden death in youth (VAS) refers to such death in any child 19 years of age or younger. Sudden unexplained early neonatal death is limited to infants who die within the first week of life and is usually congenital. anomaly is caused. Sudden intrauterine unexpected death syndrome refers to stillbirths for which postmortem examination cannot identify a cause, and sudden unexpected death in epilepsy is unexpected death in a person with epilepsy (excluding trauma or suffocation) for which postmortem examination does not reveal an anatomical or toxicological cause.

Cytological features of oral malignant lymphoma in scraping liquid-based cytology: Cases of plasmablastic lymphoma and anaplastic lymphoma kinase-positive anaplastic large cell lymphoma

The main purpose of cytological examination in the oral region is to screen for squamous cell carcinoma or intraepithelial neoplasms; thus, the background tends to be considered a deterrent for microscopy. From this perspective, liquid-based cytology (LBC) is favorable for preparing clear samples with few backgrounds. However, background hemocytes are sometimes of critical importance in the diagnosis. We report two cases of oral malignant lymphoma, plasmablastic lymphoma, and anaplastic large cell lymphoma in which careful observation of the background in scraping LBC sample contributed to the early diagnosis. Atypical lymphoid cells were observed only in a very small part of the LBC samples from the presented patients; however, cytological findings, such as large lymphoid cells with outstanding nucleoli, large mitotic cells, or intermediate-to-large lymphoid cells with pleomorphic nuclei were sufficient for obtaining a cytological diagnosis of malignant lymphoma. Although the number and cell size of leukocytes in LBC with Papanicolaou staining were significantly different from those in air-dried conventional smears with Romanovsky staining, which are commonly preferred for the discrimination of hemocytes, the corresponding cytological features could be observed. Therefore, attention should be paid to the background as well as squamous epithelium to prepare for such unexpected cases. The LBC examination with Papanicolaou staining alone can suggest the possibility of malignant lymphoma.

Critical value in surgical pathology: evaluating the current status in a multicenter study

BackgroundThe concept of critical value is not evident in surgical pathology, and there is no established protocol for determining, reporting, and documenting these results.Materials and methodsA questionnaire was designed regarding critical value in surgical pathology, and all pathologists and some clinicians from five laboratories were asked to participate through an invitation link. The most important items were selected, and all pathologists were instructed to follow a standard operating procedure to deal with critical results for a year.ResultsA total of 43 pathologists and 44 non-pathologists participated in the study. Some critical or unexpected items were selected. Most participants agreed that the optimal time to announce critical reports is within 24 h of establishing the final diagnosis, and a phone call was the most dependable communication option. In addition, the most qualified recipients were the attending physicians. Therefore, a written policy was implemented for a year. One hundred seventy-seven critical or unexpected cases (0.5%) were detected. Mucormycosis and cytomegalovirus (CMV) were the most frequent critical cases.ConclusionThere are no set criteria for critical items or the reporting process in surgical pathology. It is possible to establish more uniform norms for reporting these cases by boosting pertinent research efforts and recruiting more pathologists and physicians. Additionally, it is advised that each medical facility compile its own unique critical or unexpected diagnosis list.

Management of unexpected placenta accreta spectrum cases in resource-poor settings

On a global scale, cases of placenta accreta spectrum are often just identified during cesarean delivery because they are missed during antenatal care screening. Routine operating teams not trained in the management of placenta accreta spectrum are faced with difficult surgical situations and have to make decisions that may define the clinical outcomes. Although there are general recommendations for the intraoperative management of placenta accreta spectrum, no studies have described the clinical reality of unexpected placenta accreta spectrum cases in resource-poor settings. This study aimed to describe the maternal outcomes of previously undiagnosed placenta accreta spectrum managed in resource-poor settings in Colombia and Indonesia. This was a retrospective case series of women with histologically confirmed placenta accreta spectrum treated in 2 placenta accreta spectrum centers after referral from remote resource-poor hospitals. Clinical outcomes were analyzed according to the initial type of management: (1) no cesarean delivery; (2) placenta left in situ after cesarean delivery; (3) partial removal of the placenta after cesarean delivery; and (4) post-cesarean hysterectomy. In addition, we evaluated the use of telemedicine by comparing the outcomes of women in hospitals that used the support of the placenta accreta spectrum center during the initial surgery. A total of 29 women who were initially managed in Colombia (n=2) and Indonesia (n=27) were included. The lowest volume of blood loss and the lowest frequency of complications were in women who underwent deferred cesarean delivery (n=5; 17.2%) and in those who had a delayed placental delivery (n=5; 20.7%). Five maternal deaths (14%) occurred in the group that did not receive telehelp, and 4 women died of irreversible shock because of uncontrolled bleeding. Previously undiagnosed placenta accreta spectrum in resource-poor hospitals was associated with a high risk of maternal mortality. Open-close abdominal surgery or leaving the placenta in situ seem to be the best choices for unexpected placenta accreta spectrum management in resource-poor settings. Telemedicine with a placenta accreta spectrum center may improve prognosis.