Low-latency gravitational wave alert products and their performance at the time of the fourth LIGO-Virgo-KAGRA observing run.

Multimessenger searches for binary neutron star (BNS) and neutron star-black hole (NSBH) mergers are currently one of the most exciting areas of astronomy. The search for joint electromagnetic and neutrino counterparts to gravitational wave (GW)s has resumed with ALIGO's, AdVirgo's and KAGRA's fourth observing run (O4). To support this effort, public semiautomated data products are sent in near real-time and include localization and source properties to guide complementary observations. In preparation for O4, we have conducted a study using a simulated population of compact binaries and a mock data challenge (MDC) in the form of a real-time replay to optimize and profile the software infrastructure and scientific deliverables. End-toend performance was tested, including data ingestion, running online search pipelines, performing annotations, and issuing alerts to the astrophysics community. We present an overview of the low-latency infrastructure and the performance of the data products that are now being released during O4 based on the MDC. We report the expected median latency for the preliminary alert of full bandwidth searches (29.5 s) and show consistency and accuracy of released data products using the MDC. We report the expected median latency for triggers from early warning searches (-3.1 s), which are new in O4 and target neutron star mergers during inspiral phase. This paper provides a performance overview for LIGO-Virgo-KAGRA (LVK) low-latency alert infrastructure and data products using theMDCand serves as a useful reference for the interpretation of O4 detections.

CS-iCCA, A New Clinically Based Staging System for Intrahepatic Cholangiocarcinoma: Establishment and External Validation.

INTRODUCTION: Intrahepatic cholangiocarcinoma (iCCA) is a primary liver malignancy with poor prognosis. Current prognostic methods are most accurate for patients with surgically resectable disease. However, a significant proportion of patients with iCCA are not surgical candidates. We aimed to develop a generalizable staging system based on clinical variables to determine prognosis of all patients with iCCA. METHODS: The derivation cohort included 436 patients with iCCA seen between 2000 and 2011. For external validation, 249 patients with iCCA seen from 2000 to 2014 were enrolled. Survival analysis was performed to identify prognostic predictors. All-cause mortality was the primary end point. RESULTS: Eastern Cooperative Oncology Group status, tumor number, tumor size, metastasis, albumin, and carbohydrate antigen 19-9 were incorporated into a 4-stage algorithm. Kaplan-Meier estimates for 1-year survival were 87.1% (95% confidence interval [CI] 76.1-99.7), 72.7% (95% CI 63.4-83.4), 48.0% (95% CI 41.2-56.0), and 16% (95% CI 11-23.5), respectively, for stages I, II, III, and IV. Univariate analysis yielded significant differences in risk of death for stages II (hazard ratio [HR] 1.71; 95% CI 1.0-2.8), III (HR 3.32; 95% CI 2.07-5.31), and IV (HR 7.44; 95% CI 4.61-12.01) compared with stage I (reference). Concordance indices showed the new staging system was superior to the TNM staging for predicting mortality in the derivation cohort, P < 0.0001. In the validation cohort, however, the difference between the 2 staging systems was not significant. DISCUSSION: The proposed independently validated staging system uses nonhistopathologic data to successfully stratify patients into 4 stages. This staging system has better prognostic accuracy compared with the TNM staging and can assist physicians and patients in treatment of iCCA.

Evaluation of Computer-Aided Detection During Colonoscopy in the Community (AI-SEE): A Multicenter Randomized Clinical Trial.

INTRODUCTION: There has been increasing interest in artificial intelligence in gastroenterology. To reduce miss rates during colonoscopy, there has been significant exploration in computer-aided detection (CADe) devices. In this study, we evaluate the use of CADe in colonoscopy in community-based, nonacademic practices. METHODS: Between September 28, 2020, and September 24, 2021, a randomized controlled trial (AI-SEE) was performed evaluating the impact of CADe on polyp detection in 4 community-based endoscopy centers in the United States Patients were block-randomized to undergoing colonoscopy with or without CADe (EndoVigilant). Primary outcomes measured were adenomas per colonoscopy and adenomas per extraction (the percentage of polyps removed that are adenomas). Secondary end points included serrated polyps per colonoscopy; nonadenomatous, nonserrated polyps per colonoscopy; adenoma and serrated polyp detection rates; and procedural time. RESULTS: A total of 769 patients were enrolled (387 with CADe), with similar patient demographics between the 2 groups. There was no significant difference in adenomas per colonoscopy in the CADe and non-CADe groups (0.73 vs 0.67, P = 0.496). Although the use of CADe did not improve identification of serrated polyps per colonoscopy (0.08 vs 0.08, P = 0.965), the use of CADe increased identification of nonadenomatous, nonserrated polyps per colonoscopy (0.90 vs 0.51, P < 0.0001), resulting in detection of fewer adenomas per extraction in the CADe group. The adenoma detection rate (35.9 vs 37.2%, P = 0.774) and serrated polyp detection rate (6.5 vs 6.3%, P = 1.000) were similar in the CADe and non-CADe groups. Mean withdrawal time was longer in the CADe group compared with the non-CADe group (11.7 vs 10.7 minutes, P = 0.003). However, when no polyps were identified, there was similar mean withdrawal time (9.1 vs 8.8 minutes, P = 0.288). There were no adverse events. DISCUSSION: The use of CADe did not result in a statistically significant difference in the number of adenomas detected. Additional studies are needed to better understand why some endoscopists derive substantial benefits from CADe and others do not. ClinicalTrials.gov number: NCT04555135.

Large posterior mediastinal ganglioneuroma with intradural cervical spine extension: A rare case report and review of literature.

Introduction: Ganglioneuroma (GN) is a rare benign tumor of ganglion cell origin and can occur anywhere along the sympathetic chain. These tumors can grow to a significant size without any symptoms unless they exert a mass effect on the region they grow and start showing symptoms. Spinal extensions are rare and they may produce neurological symptoms warranting further investigation. Case presentation: We described a case of posterior mediastinal ganglioneuroma in a 4-year-old boy with cervical extension who presented with quadriparesis. The radiological scan revealed large ganglioneuroma having an intradural extramedullary extension with a large posterior mediastinal component compressing and displacing the surrounding structures. He underwent consecutive surgeries for complete excision of the tumor following which he regained his power in his upper and lower limbs over the period of 2 months. Conclusion: Para spinal mass with consistent radiological features suggests ganglioneuroma but confirmation should be done with biopsy. Complete excision of the tumor is the treatment of choice with close follow-up for clinical improvement and recurrence.

Invasive cutaneous squamous cell carcinoma of scalp: A case report.

Introduction and importance: Cutaneous Squamous cell carcinoma(cSCC) represents approximately 16% of scalp tumors. Overall, cSCC is significantly more common in the oropharyngeal mucosa than the skin. Smoking is a risk factor for mucosal lesions, risk factors for developing cutaneous SCC include age, ultraviolet light exposure, chronic scarring, history of ionizing radiation, androgenetic alopecia (in men), and immunosuppression. The rates of bone invasion in cutaneous SCC have not been well noted in the literature. Case report: We report a case of 57-year-old man with invasive squamous cell carcinoma of scalp with extension into bone, cortex and dura mater. Gross total removal of the tumor with extension of bony defect followed by repair of dura and repair of skin defect by VY advancement flap was done under general anaesthesia. At a 3-month follow-up, his wound is well healed. No evidence of metastasis is noted. Discussion: Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer, and its incidence is steadily increasing. Although the majority of cSCCs are successfully eradicated by surgical excision, advanced cSCC poses a significant risk in terms of morbidity, impact on quality of life, and risk of death. Conclusions: Invasive cutaneous squamous cell carcinoma of scalp is a rare entity. Invasion to bone, cortex, and dura mater is furthermore rare. Therefore, proper management of advanced cSCC is of the utmost importance since local invasion, delayed diagnosis, and metastasis contribute to increased costs and morbidity. A multi-disciplinary team approach is recommended.

A rare case of Erdheim-chester disease reported from Nepal.

Introduction: Erdheim-Chester Disease (ECD) is a rare non-Langerhans cell histiocytosis with a propensity to involve multiple organs. Case presentation: We report a case of a patient in mid-60s with occipital headache and ataxia. Following the radiological and immunohistochemical investigations and genomic studies, a diagnosis of ECD was made with two intracerebral lesions. Brain lesions were resected and the patient was discharged with the medication Vemurafenib. After 3 years of diagnosis and 13 years of initial presentation, patient passed away. Discussion: ECD frequently presents with Diabetes Insipidus as initial presentation, long bone osteosclerosis as the most common presentation, and has multi-system predisposition. ECD can be differentiated from Langerhans Cell Histiocytosis (LCH) with immunohistochemistry images of the biopsy specimens. Further, with genomic analysis of ECD, the neoplastic nature has been highlighted and targeted therapies like Vemurafenib and Cobimetinib are shown to be effective. Conclusion: Good clinical judgement and supporting investigations can aid in diagnosing rare entities like ECD even in resource-limited settings.

Metastatic Renal Cell Cancer With Pancreatic Mass.

A pancreatic mass is mostly discovered late in the course of the disease and is usually asymptomatic in the early stages. In rare cases, a pancreatic mass may be metastatic, and presentation may depend on the presence and locations of other metastasis or to the primary lesion. Renal cell cancer is the most common tumor presenting as metastatic pancreatic mass. Most metastases occur within the first ten years after diagnosis. We present a case of metastatic renal cell cancer to the contralateral adrenal and pancreas causing pancreatic duct dilation, 15 years after radical nephrectomy.

Metastases after mastectomy for ductal carcinoma in situ of the male breast; A case report.

Introduction: and importance: Male breast cancer is a rare entity. Ductal carcinoma in situ (DCIS), constituting 10% of all male breast cancer, is confined within the breast ducts and lobules, rarely metastasizing and even less so after mastectomy. Case presentation: A 71 years old male with no history of trauma presented with pain, swelling, and deformity of the left arm. He had continuous back pain for 6 months and a history of mastectomy of the right breast. Fracture of shaft of the left humerus was detected on X-ray. Computed tomography (CT) showed multiple vertebral metastases later confirmed to be metastasized from the breast by biopsy. Tumor cells were progesterone receptor (PR) positive, estrogen receptor (ER) negative, and human epidermal growth factor receptor 2 (HER2) negative. The fracture was treated and the patient was kept on Tamoxifen. On follow-up after four months, the patient is doing well with relief of back pain. Clinical discussion: Despite mastectomy and the histopathological diagnosis of pure DCIS, distant metastases can occur even in absence of locoregional recurrence. Therefore, the aggressive phenotype of DCIS rather than diagnostic or treatment variables can be thought to bring worse outcome in the form of metastases. Early hormonal status identification and hormone therapy could result in a better outcome. Conclusion: Skeletal metastases should be strongly suspected in patients presenting with bone pain and having a history of DCIS of the breast, even after mastectomy. Even though distant metastasis after mastectomy is rare, regular follow-up and surveillance is necessary.

Hemophagocytic Lymphohistiocytosis After Greenlight Laser Prostate Surgery.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening systemic inflammatory disease. Multiple risk factors have been defined for the manifestation of HLH. While infection remains the top risk factor, having multiple surgical procedures has also been suggested as a potential risk factor for HLH. Our patient presented with generalized weakness, weight loss, and fatigue after having a greenlight laser prostatectomy for benign prostate hypertrophy; the patient deteriorated rapidly and was found to fulfill the HLH 2004 and modified criteria. We believe this patient had a rare bone marrow disorder with a rare complicated clinical and laboratory presentation.

Enhancing the bioavailability of mebendazole by integrating the principles solid dispersion and nanocrystal techniques, for safe and effective management of human echinococcosis.

The method based on integrating the principles of solid dispersion and nanocrystal techniques was developed to prepare polymer crystals (PCs) of mebendazole (MBZ) and polyethylene glycol (PEG). Powder X-Ray diffraction (PXRD) of the PC crystals shows the required integrated crystalline and amorphous regions. The in vitro solubility studies showed a 32-fold increase in the solubility of the drug. Tests of dissolution of the PCs showed that the crystals have an enhanced dissolution rate in comparison to those in the MF. The results of the pharmacokinetic study showed a 2.12-fold increase in the bioavailability of the drug. Thus, the present study has proved the potential in enhancing solubility, dissolution, and bioavailability of the drug.

Delayed presentation of a bowel Bovie injury after laparoscopic ventral hernia repair.

INTRODUCTION: Bowel injury during laparoscopic surgery is a rare but serious complication. A Bovie injury to the bowel can cause delayed perforation of the viscus, thus increasing the possibility of a preventable morbidity. Patients presenting with perforation peritonitis within 24 hours and up to 2 to 3 weeks after laparoscopic Bovie injury to the bowel have been reported in the literature. CASE DESCRIPTION: A 74-year-old woman underwent a laparoscopic ventral hernia mesh repair. Intraoperatively, a small area of superficial Bovie injury to the small bowel was repaired with Lembert sutures and tissue glue. Postoperatively, the patient recovered well, but she presented with perforation peritonitis 3 months after surgery. An exploratory laparotomy showed a jejunal perforation in the same area that was injured with cautery and repaired during the previous surgery. The patient was only using inhaled steroids for asthma on and off but had a remote history of chemotherapy and radiation for colorectal cancer. CONCLUSION: Bovie injury to the bowel has a hidden depth, causing a slow transmural tissue necrosis, and it might also impair local healing and eventually lead to perforation. Thus, the patient may present later than the usual period for wound healing and remodeling as previously reported. Given the disastrous consequence, it is imperative to perform a good surgical repair of even a minor Bovie injury to the bowel. This is the first report of a delayed presentation (>1 month) of a Bovie injury of the bowel.

Single-incision laparoscopic cholecystectomy (SILC) using non-articulating instruments and conventional trocars-single surgeon experience.

PURPOSE: Single-incision laparoscopic cholecystectomy (SILC) was first described in 1999. Many techniques using newer instruments have emerged but none has been standardized. We describe our technique and experience, using non-articulating instruments with conventional trocars. METHOD: Patients who underwent SILC over 2 years (July 2009-July 2011) were included in the study group. All consecutive laparoscopic cholecystectomies done during the same period by the same surgeon were included in the control group. Demographic data, previous abdominal surgeries, bile spillage, conversion, and duration of surgery were analyzed. RESULTS: Seventy patients underwent SILC while 115 patients had laparoscopic cholecystectomy. Ninety-three percent of SILCs were done in women as compared to 68 % in the control group (p < 0.0001). More SILC patients were younger (65 % were 30-50 years old) as compared to control patients (40 % were 50-70 years old, p < 0.001). The mean duration of SILC was 68 ± 2.15 min as compared to 66 ± 6.27 min in controls (p < .0001). Of the initial 20 SILC, nine required insertion of additional instruments and one was converted to conventional laparoscopic cholecystectomy. The subsequent 50 cases of SILC had only one conversion (p = 0.001). In the first 20 SILC, one patient (out of three) with BMI above 35 kg/m(2) required conversion to laparoscopic cholecystectomy and one required insertion of an additional instrument. In the subsequent 50 cases, all the six patients with BMI above 35 (up to 40) were operated on successfully without any additional instrument insertion or conversion. CONCLUSIONS: SILC has a learning curve. Patients with symptomatic cholelithiasis, biliary dyskinesia, and cholecystitis, age less than 75 years, and BMI <40 can undergo SILC. With experience, SILC using conventional laparoscopy instruments has comparable outcomes to laparoscopic cholecystectomy in properly selected patients and is economical.

Intratumoral acetic acid injection eradicates human prostate cancer tumors in a murine model.

INTRODUCTION: To treat localized prostate cancer without substantial morbidity, an ideal treatment would be an effective local therapy with minimal morbidity. Direct injections have been used to treat benign prostatic hyperplasia without major complications, but in limited cases. We evaluated the local oncotoxic effects of acetic acid in a prostate cancer xenograft murine model. MATERIALS AND METHODS: PC3 and LNCaP human prostate cancer cell lines were used to grow subcutaneous tumors in SCID mice. For each cell line, 14 mice underwent intratumor injection with 25% acetic acid (0.05 ml/100 cm3 of tumor) after the tumor was >300 mm3. Post-treatment one mouse/group was euthanized after 2 h, 24 h, 1 and 2 weeks; remaining mice (n = 10) were killed at 120 days. Control mice (8/group) were euthanized after they met the humane criteria for tumor burden and overall health. RESULTS: Tumor necrosis was noted immediately post-injection; by 24 h, ulceration and crusting of overlying skin were noted, which healed into scars by 23 ± 5 days. Histological examination showed tumor degeneration and necrosis with blood vessel obstruction. Ten treated mice in both groups survived for 120 days, which was much longer than the mean survival of PC3 (40 ± 9 days) and LNCaP (56 ± 10) control mice. CONCLUSIONS: Direct injection of acetic acid successfully eradicated both tumors. This treatment option could potentially be used in humans for treatment of early localized prostate cancer and nonoperative management of locally advanced cases. This is the first report of successful local chemical therapy for prostate cancer.

Hematocele after laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy is one of the most common laparoscopic surgeries performed. We report an unusual complication of hematocele after laparoscopic appendectomy. CASE DESCRIPTION: A 48-y-old male presented with swelling and discomfort in his right scrotum 11 d after he underwent laparoscopic appendectomy for acute appendicitis. Before the surgery, he had no scrotal swelling or inguinal hernia.

Trauma care - a participant observer study of trauma centers at Delhi, Lucknow and Mumbai.

BACKGROUND: Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years. AIM: To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India - Delhi (2 centres), Lucknow and Mumbai. SETTING AND DESIGN: Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers. MATERIAL AND METHODS: Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables. RESULTS: Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning - anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute. CONCLUSION: Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.

Esophageal injuries due to aluminum phosphide tablet poisoning in India.

Aluminum phosphide is a lethal systemic poison with 80%-90% mortality. Survivors have taken either a very small amount or the tablet had been exposed to air, rendering it less toxic, but often causing severe esophageal injuries. The presentation and treatment of 11 cases of esophageal injury due to aluminum phosphide are described. Ten patients had esophageal stricture, and 1 had tracheoesophageal fistula with stricture. Endoscopic bougie dilatation was sufficient in 7 patients, and surgical intervention was required in 4 who underwent definitive repair via gastric tube or feeding jejunostomy with a 2(nd) stage repair planned in 2. There was no mortality but significant morbidity. Mortality and morbidity might be prevented by withdrawing this pesticide from the market, making its sale difficult, or modifying the packaging.

A study of knowledge, attitude and practice of hospital consultants, resident doctors and private practitioners with regard to pre-hospital and emergency care in Lucknow.

BACKGROUND: Burden of death and disability resulting from lack of emergency medical system (EMS) and emergency care is very high in low and middle income countries (LMIC). AIM: To study the knowledge, attitudes and practices of pre-hospital care and emergency services among health care providers of Lucknow SETTING AND DESIGN: Cross-sectional survey, 200 residents, 104 hospital consultants and 108 private practitioners MATERIAL AND METHODS: A close ended, self administered questionnaire based on 5-point Likert scale with 30 items of knowledge, attitude and practice of pre-hospital and emergency care RESULTS: Median scores of knowledge (26/50), attitude (41/50) and practices (27/50) showed less than adequate knowledge and practices. However, a positive attitude was seen in all the 3 group of respondents i.e. resident doctors, hospital consultants and private practitioners. CONCLUSION: Lucknow is the capital city of Indian largest state - Uttar Pradesh with over 100 years of established medical education. The results of the study in this town are applicable to most developed cities in India. Lack of adequate knowledge and practices in emergency medical system (EMS) at Lucknow represent a dismal situation and require continuing medical education in this area.