Debt Inequity Among Clients of a Community Mental Health Center

Debt is an overlooked social determinant of health that reinforces systems of discrimination. This study examined the impact of debt among individuals with serious mental illness. Individuals with serious mental illness who identified as Black, Indigenous, or other people of color carried a disproportionate amount of debt, often from attempting to meet basic needs. Increased levels of debt were associated with symptoms of depression. Addressing debt inequity is essential to both financial justice and mental health recovery.

Derivation and validation of a novel preoperative risk prediction model for surgical site infection in pancreaticoduodenectomy and comparison of preoperative antibiotics with different risk stratifications in retrospective cohort

BACKGROUND

Surgical site infections (SSIs) are common postoperative complications of pancreaticoduodenectomy.

AIM

To develop a model for preoperative identification of the risk of SSI that may improve outcomes and guide preoperative antibiotics.

METHODS

The prediction model was built by meta-analysis. After literature search and inclusion, data extraction, and quantitative synthesis, the prediction model was established based on the pooled odds ratio of predictors. A single-centre retrospective cohort was the validation cohort. Receiver operating characteristic curves and area under the curve were used to assess the model's ability. We also created a decision curve and a calibration plot to assess the nomogram. The effects of prophylactic antibiotics on SSI were compared between groups by multivariable logistic regression with different risk stratifications.

FINDINGS

Twenty-eight studies were included in the meta-analysis, 17 studies in the derivation cohort. Age, male gender, body mass index, pancreatic duct diameter, high-risk diagnosis, and preoperative biliary drainage were selected to build the prediction model. The model was validated in an external cohort. The cut-off value was 3.5 and area under the curve (AUC) was 0.76 in open pancreaticoduodenectomy (OPD). In laparoscopic pancreaticoduodenectomy, the cut-off value was 4.5 and AUC was 0.69. Decision curve and calibration plot showed good usability of the model, especially in OPD. Multivariable logistic regression did not indicate differences between broad- and narrow-spectrum antibiotics for SSI in different risk stratifications.

CONCLUSION

The model can identify patients with a high risk of SSI preoperatively. The choice of prophylactic antibiotics under different risk stratifications should be investigated further.

Clinical standards for drug-susceptible TB in children and adolescents

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Anterior segment biometric measurements explain misclassifications by a deep learning classifier for detecting gonioscopic angle closure

BACKGROUND/AIMS

To identify biometric parameters that explain misclassifications by a deep learning classifier for detecting gonioscopic angle closure in anterior segment optical coherence tomography (AS-OCT) images.

METHODS

Chinese American Eye Study (CHES) participants underwent gonioscopy and AS-OCT of each angle quadrant. A subset of CHES AS-OCT images were analysed using a deep learning classifier to detect positive angle closure based on manual gonioscopy by a reference human examiner. Parameter measurements were compared between four prediction classes: true positives (TPs), true negatives (TNs), false positives (FPs) and false negatives (FN). Logistic regression models were developed to differentiate between true and false predictions. Performance was assessed using area under the receiver operating curve (AUC) and classifier accuracy metrics.

RESULTS

584 images from 127 participants were analysed, yielding 271 TPs, 224 TNs, 77 FPs and 12 FNs. Parameter measurements differed (p<0.001) between prediction classes among anterior segment parameters, including iris curvature (IC) and lens vault (LV), and angle parameters, including angle opening distance (AOD). FP resembled TP more than FN and TN in terms of anterior segment parameters (steeper IC and higher LV), but resembled TN more than TP and FN in terms of angle parameters (wider AOD). Models for detecting FP (AUC=0.752) and FN (AUC=0.838) improved classifier accuracy from 84.8% to 89.0%.

CONCLUSIONS

Misclassifications by an OCT-based deep learning classifier for detecting gonioscopic angle closure are explained by disagreement between anterior segment and angle parameters. This finding could be used to improve classifier performance and highlights differences between gonioscopic and AS-OCT definitions of angle closure.

Demographic and physiological factors associated with clinically significant eyelid edema in patients following upper eyelid surgery

PURPOSE

To investigate demographic and physiological variables associated with clinically significant edema after upper eyelid surgery.

METHODS

A retrospective chart review was performed on patients who underwent blepharoplasty or external levator advancement with or without lid crease formation between January 2018 and January 2021 at the University of Southern California. Age, sex, pertinent medical history (medications causing edema and comorbidities), and pertinent surgical procedures were all collected. Postoperative photos were graded by two independent physician graders on a newly developed photographic scale ranging from 0 (no edema) to 3 (severe edema). Clinically significant edema of the eyelids was defined as Grade 3 edema at any postoperative point or ≥ Grade 1 edema after 90 days post operation. Patients without postoperative photos were excluded. Mann-Whitney U test, Fisher's exact test, and χ2 test were used to compare groups with and without significant edema. All analyses were conducted using SAS version 9.4 (SAS Institute Inc.) with α=0.05.

RESULTS

Out of 217 patients, East Asian participants had higher odds of developing edema than White participants (odds ratio, 7.92; CI, 3.15-19.93, p < 0.0001) and Hispanic participants (odds ratio, 3.47; CI, 1.51-7.97, p = 0.003). Southeast Asian participants also had higher odds of developing CSEE than White participants (odds ratio, 6.19; CI, 1.71-22.43, p = 0.006). Fifty-four (24.9%) patients had clinically significant edema. Although BMI, medical comorbidities, medication use, and age did not affect edema, there was a statistically significant relationship between race and incidence of edema (p = 0.0001). Those in the CSEE group were also more likely to require reoperation (p = 0.0143).

CONCLUSIONS

There is a statistically significant relationship between Asian race and the incidence of clinically significant eyelid edema. CSEE is associated with a higher incidence of reoperation.

An integrative web-based software tool for multi-dimensional pathology whole-slide image analytics

Objective.In the era of precision medicine, human tumor atlas-oriented studies have been significantly facilitated by high-resolution, multi-modal tissue based microscopic pathology image analytics. To better support such tissue-based investigations, we have developed Digital Pathology Laboratory (DPLab), a publicly available web-based platform, to assist biomedical research groups, non-technical end users, and clinicians for pathology whole-slide image visualization, annotation, analysis, and sharing via web browsers.Approach.A major advancement of this work is the easy-to-follow methods to reconstruct three-dimension (3D) tissue image volumes by registering two-dimension (2D) whole-slide pathology images of serial tissue sections stained by hematoxylin and eosin (H&E), and immunohistochemistry (IHC). The integration of these serial slides stained by different methods provides cellular phenotype and pathophysiologic states in the context of a 3D tissue micro-environment. DPLab is hosted on a publicly accessible server and connected to a backend computational cluster for intensive image analysis computations, with results visualized, downloaded, and shared via a web interface.Main results.Equipped with an analysis toolbox of numerous image processing algorithms, DPLab supports continued integration of community-contributed algorithms and presents an effective solution to improve the accessibility and dissemination of image analysis algorithms by research communities.Significance.DPLab represents the first step in making next generation tissue investigation tools widely available to the research community, enabling and facilitating discovery of clinically relevant disease mechanisms in a digital 3D tissue space.

The feasibility of amide proton transfer imaging at 3 T for bladder cancer: a preliminary study

AIM

To investigate the optimal amide proton transfer (APT) imaging parameters for bladder cancer (BCa), the influence of different protein concentrations and pH values on APT imaging, and to establish the reliability of APT imaging in healthy volunteers and patients with BCa.

MATERIALS AND METHODS

The optimal APT imaging parameters for BCa were experimentally optimised using cross-linked bovine serum albumin (BSA) phantoms. BSA phantoms were scanned with different values for the saturation power, saturation duration and number of excitations. Meanwhile, BSA phantoms containing different protein concentrations and solutions of different pH levels were scanned. The interobserver agreement of the asymmetric magnetisation transfer ratio (MTR_asym) was assessed in 11 healthy volunteers and 18 patients with BCa.

RESULTS

The optimal scanning scheme consisted of 1 excitation, a saturation power of 2 μT, and a saturation time of 2 s. The APT signal intensity increased as the protein concentration increased and as the pH decreased. The MTR_asym showed good concordance for all subjects. The MTR_asym of BCa tissue was significantly higher (1.81 ± 0.71) than that of bladder wall in healthy volunteers (0.34 ± 0.12) and normal bladder wall in patients with BCa (0.31 ± 0.11; p<0.001). There was no significant difference between the bladder wall of healthy volunteers and the normal bladder wall of patients with BCa.

CONCLUSION

APT imaging showed potential value for application in BCa.

[Predictive value of prognostic inflammatory and tumor score in intrahepatic cholangiocarcinoma]

Objective: To compare and analyze the predictive value of different inflammatory factors and tumor markers in intrahepatic cholangiocarcinoma and to develop a new and effective preoperative prognostic scoring system. Methods: 102 and 72 cases with intrahepatic cholangiocarcinoma who underwent radical surgery in Tianjin Medical University Cancer Institute and Hospital and the Affiliated Hospital of Weifang Medical University were selected as the experimental group and the validation group, respectively. Clinicopathological and follow-up data were collected. Cox proportional-hazards model was used to analyze the predictive value of different prognostic markers. The relationship between prognostic markers and clinicopathological data was analyzed by rank sum test, χ² or Fisher's exact test. Results: Among the direct inflammatory factors, tumor markers and combined inflammatory factors, prognostic inflammatory index (PII), carbohydrate antigen (CA) 19-9 and systemic inflammation score (SIS) were the most significant predictive factors for postoperative survival outcomes in patients with intrahepatic cholangiocarcinoma. The prognostic inflammatory and tumor score (PITS) was proposed as a new prognostic scoring system for intrahepatic cholangiocarcinoma. PII and CA19-9 were included into the scoring criteria for prognostic stratification of patients. PITS was an independent predictor of tumor-free survival and overall survival in patients with intrahepatic cholangiocarcinoma. Patients with high-grade PITS had later tumor grade and higher frequency of vascular invasion. Conclusion: PITS is highly effective prognostic scoring system for patients with intrahepatic cholangiocarcinoma. In addition, PITS is recommended for preoperative prognostic stratification in patients with intrahepatic cholangiocarcinoma.

Metastatic neuroendocrine tumors mimicking as primary ocular disease

Purpose

To report two cases of metastatic neuroendocrine tumors masquerading as primary ocular disease.

Observations

Case 1 is a 38-year-old man who was referred with subacute onset diplopia and fluctuating ptosis suggestive of myasthenia gravis. Case 2 is a 21-year-old man who presented with blurry vision and was found to have a pigmented ciliary body mass and retinal detachment suggestive of uveal melanoma. Both patients were ultimately diagnosed with metastatic neuroendocrine tumors.

Conclusions and Importance

Neuroendocrine tumors, though rare and infrequently metastatic to the eye and orbit, can initially present with ocular signs. A broad differential and careful consideration of ocular and systemic symptoms are critical in such challenging cases.

MiR-21-5p in macrophage-derived extracellular vesicles affects podocyte pyroptosis in diabetic nephropathy by regulating A20

OBJECTIVES

Podocyte pyroptosis, characterized by inflammasome activation, plays an important role in inflammation-mediated diabetic nephropathy (DN). Our study aimed to investigate whether miR-21-5p in macrophage-derived extracellular vesicles (EVs) could affect podocyte injury in DN.

METHODS

EVs were extracted after the treatment of RAW 264.7 (mouse macrophage line) with high glucose (HG). The podocyte pyroptosis was determined using the flow cytometry and the western blot. After the knockdown of miR-21-5p in HG-induced RAW264.7 cells, we injected the extracted EVs into DN model mice.

RESULTS

The level of miR-21-5p was higher in HG-stimulated macrophage-derived EVs than in normal glucose-cultured macrophage-derived EVs. The co-culture of EVs and podocytes promoted reactive oxygen species (ROS) production and activation of inflammatory in MPC5 cells (mouse podocyte line). However, restraint of miR-21-5p in EVs reduced ROS production and inhibit inflammasome activation in MPC5 cells, thereby reducing podocytes injury. Meanwhile, we found that miR-21-5p inhibited the A20 expression through binding with its 3'-untranslated regions in MPC5 cells. Further studies showed that A20 was also involved in the regulation of miR-21-5p of RAW 264.7-derived EVs on MPC5 injury. At the same time, it was also proved in the DN model mice that miR-21-5p in macrophage-derived EVs could regulate podocyte injury.

CONCLUSION

MiR-21-5p in macrophage-derived EVs can regulate pyroptosis-mediated podocyte injury by A20 in DN.

Glaucoma Expert-Level Detection of Angle Closure in Goniophotographs With Convolutional Neural Networks: The Chinese American Eye Study

PURPOSE

To compare the performance of a novel convolutional neural network (CNN) classifier and human graders in detecting angle closure in EyeCam (Clarity Medical Systems, Pleasanton, California, USA) goniophotographs.

DESIGN

Retrospective cross-sectional study.

METHODS

Subjects from the Chinese American Eye Study underwent EyeCam goniophotography in 4 angle quadrants. A CNN classifier based on the ResNet-50 architecture was trained to detect angle closure, defined as inability to visualize the pigmented trabecular meshwork, using reference labels by a single experienced glaucoma specialist. The performance of the CNN classifier was assessed using an independent test dataset and reference labels by the single glaucoma specialist or a panel of 3 glaucoma specialists. This performance was compared to that of 9 human graders with a range of clinical experience. Outcome measures included area under the receiver operating characteristic curve (AUC) metrics and Cohen kappa coefficients in the binary classification of open or closed angle.

RESULTS

The CNN classifier was developed using 29,706 open and 2,929 closed angle images. The independent test dataset was composed of 600 open and 400 closed angle images. The CNN classifier achieved excellent performance based on single-grader (AUC = 0.969) and consensus (AUC = 0.952) labels. The agreement between the CNN classifier and consensus labels (κ = 0.746) surpassed that of all non-reference human graders (κ = 0.578-0.702). Human grader agreement with consensus labels improved with clinical experience (P = 0.03).

CONCLUSION

A CNN classifier can effectively detect angle closure in goniophotographs with performance comparable to that of an experienced glaucoma specialist. This provides an automated method to support remote detection of patients at risk for primary angle closure glaucoma.

Quality assessment of guidelines for the management of Mycobacterium tuberculosis infection in children

OBJECTIVE: The quality of paediatric clinical practice guidelines (CPGs) for the management of Mycobacterium tuberculosis infection is unclear. We aimed to comprehensively assess the quality of these CPGs and identify areas requiring improvement.DESIGN: CPGs were systematically searched and identified before being appraised by independent reviewers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) and Reporting Items for Practice Guidelines in HealThcare (RIGHT) tools. Inter-rater reliability was assessed using intra-class correlation coefficient (ICC).RESULTS: Twenty-five CPGs were evaluated. All CPG agreements among four reviewers were good (ICC 0.753-0.939). The mean CPG score was 50.5% (23.5-78.4%), and seven CPGs were recommended for use. The mean scores of three domains were low: 38% for stakeholder involvement (5.6-93.1%), 38.4% for rigour of development (1-97.4%) and 36.3% for applicability (12.5-64.6%). The mean reporting rate of Reporting Items for Practice Guidelines in HealThcare fields was 41.8%, and the evidence field had the highest reporting rate (63.1%), while the review and quality assurance field had the lowest rate (15.4%) for CPGs that include methods.CONCLUSION: The methodological and reporting quality of the CPGs was variable and poor, respectively. More effort is needed in stakeholder involvement, rigour of development, applicability domains and reporting to produce higher-quality CPGs.

A diagnostic test that uses isothermal amplification and lateral flow detection sdaA can detect tuberculosis in 60 min

AIMS

Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), is now the leading cause of death from infectious disease, thus rapid diagnostic and screening techniques for TB are urgently needed.

METHODS AND RESULTS

Here, a detection of MTB using multiple cross displacement amplification coupling with nanoparticles-based lateral flow device (MCDA-LFD) was developed and validated, targeting the specific sdaA gene. The whole detection procedure, including rapid genomic DNA extraction (15 min), amplification (30 min) and result reporting (2 min), was completed within 50 min. No cross-reaction with non-mycobacteria and non-tuberculous mycobacteria (NTM) strains was observed. The sensitivity of sdaA-MCDA-LFD, Xpert MTB/RIF assay and culture results was 81·6, 48·3 and 37·9%, respectively, in TB patients. Among positive culture samples, the sensitivity of sdaA-MCDA-LFD and Xpert MTB/RIF assay was 93·9% (31/33) and 81·8% (27/33), respectively. Among culture-negative samples, the sensitivity of sdaA-MCDA-LFD and Xpert MTB/RIF assay was 74·1% (40/54) and 27·8% (15/54), respectively. The specificity of sdaA-MCDA-LFD and Xpert MTB/RIF was 95·4% (62/65) and 100% (65/65) in clinical samples from non-TB patients.

CONCLUSION

The sdaA-MCDA-LFD assay was a rapid, simple, specific and sensitive TB diagnostic test.

SIGNIFICANCE AND IMPACT OF THE STUDY

The sdaA-MCDA-LFD assay holds promise for application as a useful point-of-care test to detect MTB, and will play an important role in controlling and preventing TB.

Triggers of stress cardiomyopathy and their association with clinical outcomes

Background

Stress cardiomyopathy can be a result of physical stress, emotional stress, or both. Whether the type of trigger affects clinical outcomes is not well studied.

Purpose

The objectives of this study were to identify the prevalence of emotional and physical stressors and to assess differences in patient characteristics and mortality based on the type of trigger.

Methods

We conducted a retrospective review of 523 consecutive patients who presented to our institution from 2006 to 2016. All patients presented with acute coronary syndrome. Triggers for stress cardiomyopathy were abstracted from reviewing patients' medical records. Patients were categorized into those with 1) physical trigger, 2) emotional trigger, 3) both physical and emotional trigger, or 4) no known trigger. Baseline characteristics and clinical outcomes were reported.

Results

Among 523 patients with stress cardiomyopathy, 151 (28.9%) had a physical trigger, 189 (36.1%) had an emotional trigger, 30 (5.7%) had both physical and emotional triggers, and 153 (29.3%) had no known triggers identified. Men comprised the higher proportion of patients with physical triggers. Comorbidities including diabetes, pulmonary disease, chronic kidney disease and hypothyroidism were more prevalent among patients with physical triggers. Compared to patients with no obvious triggers, patients with a physical trigger had a much higher mortality rate (hazard ratio 2.0, 95% CI 1.2–3.3, p=0.007), whereas patients with an emotional trigger had significantly lower mortality (hazard ratio 0.40, 95% CI 0.21–0.89, p=0.007).

Conclusion

Different triggers for stress cardiomyopathy is associated with different baseline characteristics and clinical outcomes. Overall survival is worst in the group with an identified physical trigger.

Figure 1

Funding Acknowledgement

Type of funding source: None

High coherence collapse of a hybrid III–V/Si semiconductor laser with a large quality factor

The high-speed dynamics of a hybrid distributed feedback semiconductor laser heterogeneously integrated onto silicon is experimentally investigated in the presence of external optical feedback. The laser fabrication relies on a proper modal engineering in which light is generated in the III–V material and stored in the low-loss silicon region in order to substantially enhance the quality factor of the cavity resonator. In this work, the hybrid laser is found to be insensitive to parasitic reflections leading to a 10 Gbps floor-free transmission with a power penalty no greater than 1.5 dB at room temperature. As a conclusion, owing to the large quality factor, a high coherence collapse level is unveiled in such laser indicating its vast potential to serve as an alternative solution for the development of isolator-free applications in future photonics integrated circuits. A qualitative interpretation is also provided by linking the standard feedback equations to the quality factor of the resonator.

Ketamine alleviates LPS induced lung injury by inhibiting HMGB1-RAGE level

OBJECTIVE

Inflammatory cytokines secretion is an important reason to promote lung tissue inflammation in acute lung injury (ALI). High mobility group box 1 (HMGB-1) and its receptor for advanced glycation end products (RAGEs) play a role in ALI. Ketamine can significantly alleviate ALI, whereas its specific mechanism has not been fully elucidated.

MATERIALS AND METHODS

A total of 60 male Wistar rats were equally randomly divided into three groups, including ALI group which was established by 10 mg/kg LPS femoral vein injection, ketamine group which was constructed by 50 mg/kg ketamine femoral vein injection based on ALI model, and control group. Blood gas analysis was applied to detect arterial blood oxygen partial pressure (PaO2) and pH. Lung tissue wet/dry weight ratio (W/D), myeloperoxidase (MPO) and superoxide dismutase (SOD) activity were detected. Real-time PCR and ELISA were used to test HMGB-1 expression in lung tissue and serum. RAGE and NF-κB changes were determined by Real-time PCR and Western blot.

RESULTS

Compared with control, ALI group presented decreased PaO2 and PH, elevated W/D, enhanced MPO activity, declined SOD activity, upregulated HMGB-1 mRNA, increased HMGB-1 secretion, and increased RAGE and NF-κB mRNA and protein (p < 0.05). Ketamine treatment significantly elevated PaO2 and PH, reduced W/D, declined MPO activity, enhanced SOD activity, inhibited HMGB-1 mRNA and secretion, and downregulated RAGE and NF-κB mRNA and protein (p < 0.05).

CONCLUSIONS

Ketamine can alleviate LPS induced lung injury through inhibiting HMGB1-RAGE level. It could be treated as a new choice for ALI treatment.

Pig Brains Have Homologous Resting-State Networks with Human Brains

Many neurological and psychiatric diseases in humans are caused by disruptions to large-scale functional properties of the brain, including functional connectivity. There has been growing interest in discovering the functional organization of brain networks in larger animal models. As a result, the use of translational pig models in neuroscience has significantly increased in the past decades. The gyrencephalic pig brain resembles the human brain more in anatomy, growth, and development than the brains of commonly used small laboratory animals such as rodents. In this work, resting-state functional magnetic resonance imaging (rs-fMRI) and diffusion tensor imaging (DTI) data were acquired from a group of pigs (n = 12). rs-fMRI data were analyzed for resting-state networks (RSNs) by using independent component analysis and sparse dictionary learning. Six RSNs (executive control, cerebellar, sensorimotor, visual, auditory, and default mode) were detected that resemble their counterparts in human brains, as measured by Pearson spatial correlations and mean ratios. Supporting evidence of the validity of these RSNs was provided through the evaluation and quantification of structural connectivity measures (mean diffusivity, fractional anisotropy, fiber length, and fiber density) estimated from the DTI data. This study shows that as a translational, large animal model, pigs demonstrate great potential for mapping connectome-scale functional connectivity in experimental modeling of human brain disorders.

BET protein proteolysis targeting chimera (PROTAC) exerts potent lethal activity against mantle cell lymphoma cells

Bromodomain extraterminal protein (BETP) inhibitors transcriptionally repress oncoproteins and nuclear factor-κB (NF-κB) target genes that undermines the growth and survival of mantle cell lymphoma (MCL) cells. However, BET bromodomain inhibitor (BETi) treatment causes accumulation of BETPs, associated with reversible binding and incomplete inhibition of BRD4 that potentially compromises the activity of BETi in MCL cells. Unlike BETi, BET-PROTACs (proteolysis-targeting chimera) ARV-825 and ARV-771 (Arvinas, Inc.) recruit and utilize an E3-ubiquitin ligase to effectively degrade BETPs in MCL cells. BET-PROTACs induce more apoptosis than BETi of MCL cells, including those resistant to ibrutinib. BET-PROTAC treatment induced more perturbations in the mRNA and protein expressions than BETi, with depletion of c-Myc, CDK4, cyclin D1 and the NF-κB transcriptional targets Bcl-xL, XIAP and BTK, while inducing the levels of HEXIM1, NOXA and CDKN1A/p21. Treatment with ARV-771, which possesses superior pharmacological properties compared with ARV-825, inhibited the in vivo growth and induced greater survival improvement than the BETi OTX015 of immune-depleted mice engrafted with MCL cells. Cotreatment of ARV-771 with ibrutinib or the BCL2 antagonist venetoclax or CDK4/6 inhibitor palbociclib synergistically induced apoptosis of MCL cells. These studies highlight promising and superior preclinical activity of BET-PROTAC than BETi, requiring further in vivo evaluation of BET-PROTAC as a therapy for ibrutinib-sensitive or -resistant MCL.

Delay in pediatric epilepsy surgery: A caregiver's perspective

The timing of epilepsy surgery is complex, and there is not a structured pathway to help families decide whether to continue medical management or pursue surgical treatment. We surveyed caregivers of pediatric epilepsy surgery patients. Fifty-eight respondents answered the majority of questions. Thirty caregivers wished their child had undergone epilepsy surgery earlier compared with twenty who felt surgery was done at the appropriate time, and eight were unsure. In retrospect, caregivers who wished their child's surgery had been performed sooner had a significantly longer duration of epilepsy prior to the surgery [44.1±71.7 (months±standard deviation (SD), N=27)], compared with those who felt content with the timing of the surgery [12.8±14.1 (months±SD, N=20), p=0.0034]. Caregivers were willing to accept a lower likelihood of seizure freedom than their physician reported was likely. Most caregivers were willing to accept deficits in all domains surveyed; caregivers had high acceptance of motor deficits, cognitive deficits, behavioral change, and language loss. Future studies are needed to focus on how to improve the education of caregivers and neurologists about the benefits and risks of epilepsy surgery and accelerate the pipeline to epilepsy surgery to improve caregiver satisfaction.

Anal Melanoma in an Elderly Woman Masquerading as Hemorrhoid

Anal melanoma is a rare and aggressive neoplasm of the anal canal seen in the elderly population in the six or seventh decade of their lives. Presentation is usually nonspecific and diagnosis is often delayed or missed initially. The management is surgical and prognosis is poor. Here we present a case of anal melanoma in an elderly patient masquerading as hemorrhoid.

Fulminant Hepatic Failure and Fatal Cerebral Edema Following Clostridium perfringens Bacteremia: Case Report and Review of Literature

Clostridium perfringens (CP) bacteremia is a rare but rapidly fatal infection. Only 36 cases of CP bacteremia with gas containing liver abscesses on image studies have been reported in the literature since 1990. In this report, we describe a 65-year-old diabetic male with CP bacteremia which progressed into fulminant hepatic failure with subsequent fatal cerebral edema.

Large Unilateral Adrenal Mass with Surrounding Brown Fat: A Case Report

Pheochromocytomas are rare tumors derived from chromaffin cells located in the adrenal and extra adrenal tissues. Pheochromocytomas are diagnosed biochemically and localized using different imaging modalities. The definitive management is surgical resection. Brown adipose tissues are normally present during fetal development, with regression over time. Brown adipose tissues are thermogenic and usually located in the neck, mediastinum, and retroperitoneum. Here, we report a case of a unilateral pheochromocytoma surrounded by brown fat. The abnormal stimulation of brown fat noted on positive emission tomography scan (PET) resolved after the pheochromocytoma was resected.

Natural History Of an Untreated Type 1 Endoleak: A Case Report

We present a case of giant abdominal aortic aneurysm greater than 17 cm complicated by an endoleak, demonstrating the natural history of an untreated Type 1 endoleak.

Female patients display poorer burn-specific quality of life 12 months after a burn injury

INTRODUCTION

Although gender differences in morbidity and mortality have been measured in patients with moderate to severe burn injury, little attention has been directed at gender effects on health-related quality of life (HRQoL) following burn injury. The current study was therefore conducted to prospectively measure changes in HRQoL for males and females in a sample of burn patients.

METHODS

A total of 114 adults who received treatment at a statewide burns service for a sustained burns injury participated in this study. Instruments measuring generic health status (Short Form 36 Medical Outcomes Survey version 2), burn-specific HRQoL (Burns Specific Health Scale-Brief), psychological distress (Kessler Psychological Distress Scale) and alcohol use (Alcohol Use Disorders Identification Tool) were prospectively measured at 3, 6 and 12 months post-burn.

RESULTS

In the 12 months post-injury, female patients showed overall poorer physical (p=0.01) and mental health status (p<0.001), greater psychological distress (p<0.001), and greater difficulty with aspects of burn-specific HRQoL: body image (p<0.001), affect (p<0.001), interpersonal functioning (p=0.005), heat sensitivity (p=0.01) and treatment regime (p=0.01). While significant interaction effects suggested that female patients had more improvement in difficulties with treatment regime (p=0.007), female patients continued to report greater difficulty with multiple aspects of physical and psychosocial health status 12 months post-injury.

CONCLUSION

Even though demographic variables, injury characteristics and burn care interventions were similar across genders, following burn injury female patients reported greater impairments in generic and burn-specific HRQoL along with psychological morbidity, when compared to male patients. Urgent clinical and research attention utilising an evidence-based research framework, which incorporates the use of larger sample sizes, the use of validated instruments to measure appropriate outcomes, and a commitment to monitoring long-term care, can only improve burn-care.