Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care.

BACKGROUND: Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures, with predictable indications, techniques, and outcomes. As a result, this surgical procedure is an ideal choice for studying value. The purpose of this study was to perform patient-level value analysis (PLVA) within the setting of RCR over the 1-year episode of care. METHODS: Included patients (N = 396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode of care was defined as 1-year following surgery. The Western Ontario Rotator Cuff index was collected at both the initial preoperative baseline assessment and the 1-year postoperative mark. The total cost of care was determined using time-driven activity-based costing (TDABC). Both PLVA and provider-level value analysis were performed. RESULTS: The average TDABC cost of care was derived at $5413.78 ± $727.41 (95% confidence interval, $5341.92-$5485.64). At the patient level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient (0.82; analysis-of-variance F test, P = .01). There was a poor correlation between the change in the 1-year Western Ontario Rotator Cuff score and the TDABC cost of care (r2 = 0.03). Provider-level value analysis demonstrated significant variation between the 8 providers evaluated (P < .01). CONCLUSION: RCR is one of the most common orthopedic procedures, yet the correlations between cost of care and patient outcomes are unknown. PLVA quantifies the ratio of functional improvement to the TDABC-estimated cost of care at the patient level. This is the first study to apply PLVA over the first-year episode of care. With health care transitioning toward value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode of care.

Complicated Chikungunya Infection in Tertiary ICU in Western India - A Prospective Study Over 3 Years.

BACKGROUND: Chikungunya is a globally spreading infectious arboviral disease transmitted from a diurnal bite of the Aedes aegypti and Aedes albopictus Mosquitoes. It is a disease with sporadic outbreaks. It is now resurfacing in South East Asia especially in India, where it is found to have high mortality and morbidity and presenting with atypical presentation, especially with the neurotropic presentation. OBJECTIVE: To review clinical profile of patients who required admission in the Intensive care unit with atypical presentation of Chikungunya and to study their clinical spectrum and outcome over a course of three years in India. METHOD AND FINDINGS: Using Established guidelines, we conducted a prospective study in a Tertiary care center where we identified patients who required intensive care admissions and were admitted with complicated chikungunya infection and then evaluated their clinical progression of the disease. CONCLUSION: CHIKV infection is rapidly emerging in more than 100 countries and more and more atypical serious neurological manifestations are seen in elderly populations. Many of these patients have high morbidity and mortality.

Immediate Weightbearing After Operative Treatment of Bimalleolar and Trimalleolar Ankle Fractures: Faster Return to Work for Patients with Nonsedentary Occupations.

The goal of this study was to compare immediate weightbearing (IWB) and traditional weightbearing (TWB) postoperative protocols in unstable ankle fractures, as this has not been compared in prior works. We hypothesize that an immediate weightbearing protocol after ankle fracture fixation will lead to an earlier return to work. An ankle fracture registry was reviewed for operatively treated unstable bimalleolar and trimalleolar ankle fractures at an ambulatory surgery center and followed up at associated outpatient clinics. All fracture cases reviewed occurred from 2009 to 2015. Immediate weightbearing patients were placed into a controlled ankle motion (CAM) boot and allowed to fully bear weight the day of surgery. Traditional weightbearing patients were placed into a CAM boot with 6 weeks of non-weightbearing. Demographics, fixation technique, and injury characteristics were surveyed. Physical job demand was stratified for 69 patients meeting the inclusion criteria (34 IWB and 35 TWB). The main outcome of this study was measured as the time to return to work. Subgroup analysis of patients with nonsedentary jobs demonstrated a significantly earlier return to work for the IWB group (5.7 versus 10.0 weeks, p = .04). Multivariate regression analysis identified a statistically significant 2.25-week (p = .05) earlier return to work for the IWB group after adjustment for occupational physical demand, demographics, fracture characteristics, and participation in a light work period before full work return. In patients with nonsedentary jobs, an IWB protocol after operative management of bimalleolar and trimalleolar ankle fractures resulted in an earlier return to work compared with traditional protocols.

Corridor-diameter-dependent angular tolerance for safe transiliosacral screw placement: an anatomic study of 433 pelves.

BACKGROUND: The purpose of this study was to determine the angular tolerance of the S1 and S2 segments to accommodate a transiliosacral screw across both sacroiliac joints. HYPOTHESIS: We hypothesized that the angular tolerance for transiliosacral screw placement would be more constrained than the angular tolerance for iliosacral fixation in pelves where a safe osseous corridor was measured. MATERIALS AND METHODS: The cortical boundaries of the S1 and S2 sacral segments in 433 pelvic CTs were digitally mapped. A straight-line path was placed within each osseous corridor and extended across both SI joints past the outer iliac cortices. The diameter of the path was increased until it breached the cortex, geometrically determining maximum diameter (Dmax). Angular tolerance for screw placement was calculated with trigonometric analysis of the Dmax value of the corridor, and the average distance from the termination of the osseous corridor to the site of percutaneous insertion. Gender, age, and BMI were evaluated as independent predictors using binomial logistic regression. RESULTS: The transiliosacral angular tolerance for the S1 and S2 osseous corridors was 1.53 ± 0.57 degrees and 1.02 ± 0.33 degrees, respectively. 68.9% of S1 corridors and 81.1% of S2 corridors had a safe zone (corridor diameter ≥ 10 mm) for transiliosacral placement, 48.3% of the pelves had a safe zone for both corridors, while 5.1% had no safe zones. Females had a less frequent Dmax ≥ 10 mm at S1, 52% vs 67% (p = 0.001), and at S2, 64% vs 86% (p < 0.001). DISCUSSION: In conclusion, the angular tolerance of 1.53 and 1.03 degrees for the S1 and S2 segments, respectively, creating a narrow interval for safe passage of the trans-iliac and trans-sacral, with approximately 31.1% of patients not having a viable corridor for screw passage. A correlation exist between S1 and S2 corridors with Dmax ≥ 10 mm and the resulting increase in angular tolerance for safe passage of a transilioscral screw. LEVEL OF EVIDENCE IV: Level Retrospective Cohort.

Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study.

BACKGROUND: Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. METHODS: This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). RESULTS: Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7 days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. CONCLUSION: An immediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level III.

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA. METHODS: Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model. RESULTS: More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P < .01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P < .01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%. CONCLUSION: People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation. LEVEL OF EVIDENCE: Diagnostic Level III.

Working memory in action: inspecting the systematic and unsystematic errors of spatial memory across saccades.

Our ability to interact with the world depends on memory buffers that flexibly store and process information for short periods of time. Current working memory research, however, mainly uses tasks that avoid eye movements, whereas in daily life we need to remember information across saccades. Because saccades disrupt perception and attention, the brain might use special transsaccadic memory systems. Therefore, to compare working memory systems between and across saccades, the current study devised transsaccadic memory tasks that evaluated the influence of memory load on several kinds of systematic and unsystematic spatial errors, and tested whether these measures predicted performance in more established working memory paradigms. Experiment 1 used a line intersection task that had people integrate lines shown before and after saccades, and it administered a 2-back task. Experiments 2 and 3 asked people to point at one of several locations within a memory array flashed before an eye movement, and we tested change detection and 2-back performance. We found that unsystematic transsaccadic errors increased with memory load and were correlated with 2-back performance. Systematic errors produced similar results, although effects varied as a function of the geometric layout of the memory arrays. Surprisingly, transsaccadic errors did not predict change detection performance despite the latter being a widely accepted measure of working memory capacity. Our results suggest that working memory systems between and across saccades share, in part, similar neural resources. Nevertheless, our data highlight the importance of investigating working memory across saccades.

An ensemble micro neural network approach for elucidating interactions between zinc finger proteins and their target DNA.

BACKGROUND: The ability to engineer zinc finger proteins binding to a DNA sequence of choice is essential for targeted genome editing to be possible. Experimental techniques and molecular docking have been successful in predicting protein-DNA interactions, however, they are highly time and resource intensive. Here, we present a novel algorithm designed for high throughput prediction of optimal zinc finger protein for 9 bp DNA sequences of choice. In accordance with the principles of information theory, a subset identified by using K-means clustering was used as a representative for the space of all possible 9 bp DNA sequences. The modeling and simulation results assuming synergistic mode of binding obtained from this subset were used to train an ensemble micro neural network. Synergistic mode of binding is the closest to the DNA-protein binding seen in nature, and gives much higher quality predictions, while the time and resources increase exponentially in the trade off. Our algorithm is inspired from an ensemble machine learning approach, and incorporates the predictions made by 100 parallel neural networks, each with a different hidden layer architecture designed to pick up different features from the training dataset to predict optimal zinc finger proteins for any 9 bp target DNA. RESULTS: The model gave an accuracy of an average 83% sequence identity for the testing dataset. The BLAST e-value are well within the statistical confidence interval of E-05 for 100% of the testing samples. The geometric mean and median value for the BLAST e-values were found to be 1.70E-12 and 7.00E-12 respectively. For final validation of approach, we compared our predictions against optimal ZFPs reported in literature for a set of experimentally studied DNA sequences. The accuracy, as measured by the average string identity between our predictions and the optimal zinc finger protein reported in literature for a 9 bp DNA target was found to be as high as 81% for DNA targets with a consensus sequence GCNGNNGCN reported in literature. Moreover, the average string identity of our predictions for a catalogue of over 100 9 bp DNA for which the optimal zinc finger protein has been reported in literature was found to be 71%. CONCLUSIONS: Validation with experimental data shows that our tool is capable of domain adaptation and thus scales well to datasets other than the training set with high accuracy. As synergistic binding comes the closest to the ideal mode of binding, our algorithm predicts biologically relevant results in sync with the experimental data present in the literature. While there have been disjointed attempts to approach this problem synergistically reported in literature, there is no work covering the whole sample space. Our algorithm allows designing zinc finger proteins for DNA targets of the user's choice, opening up new frontiers in the field of targeted genome editing. This algorithm is also available as an easy to use web server, ZifNN, at http://web.iitd.ac.in/~sundar/ZifNN/ .

Sclerosing Mesenteritis Presenting With Small Bowel Obstruction in a Patient With Systemic Lupus Erythematosus: A Case Report.

Sclerosing mesenteritis (SM) is a rare inflammatory disorder characterized by chronic inflammation and fibrosis of the mesenteric adipose tissue. While SM can manifest with various gastrointestinal symptoms, its association with small bowel obstruction (SBO) is infrequent. We present a case of a 78-year-old male with a history of systemic lupus erythematosus (SLE) who presented with acute abdominal pain and distention. The patient had multiple admissions with the same symptoms. A CT scan showed swirling of the proximal central mesentery, small bowel malrotation with volvulus, and high-grade mechanical obstruction of the proximal jejunum. The patient underwent exploratory laparotomy, with findings significant for multiple inflammatory nodules in the mesentery. These were causing adhesions between the bowel and mesentery, resulting in a volvulus of the bowel. One segment was resected, and subsequent histopathological examination revealed subserosal fibrosis and chronic inflammation. The clinical scenario was consistent with a diagnosis of SM. This case highlights the challenges of diagnosing and managing SBO in the presence of SM and SLE. Further research is needed to understand the underlying pathophysiological mechanisms and improve management techniques for this rare clinical condition.

Socioeconomic and Demographic Determinants of Readmission Rates in Congestive Heart Failure Patients: Insights From the Nationwide Readmissions Database.

Background Congestive heart failure (CHF) is a leading cause of hospitalizations and readmissions, placing a significant burden on the healthcare system. Identifying factors associated with readmission risk is crucial for developing targeted interventions and improving patient outcomes. This study aimed to investigate the impact of socioeconomic and demographic factors on 30-day and 90-day readmission rates in patients primarily admitted for CHF. Methods The study was carried out using a cross-sectional study design, and the data were obtained from the Nationwide Readmissions Database (NRD) from 2016 to 2020. Adult patients with a primary diagnosis of CHF were included. The primary outcomes were 30-day and 90-day all-cause readmission rates. Multivariable logistic regression was used to identify factors independently associated with readmissions, including race, ethnicity, insurance status, income level, and living arrangements. Results A total of 219,904 patients with a primary diagnosis of CHF were used in the study. The overall 30-day and 90-day readmission rates were 17.3% and 23.1%, respectively. In multivariable analysis, factors independently associated with higher 30-day readmission risk included Hispanic ethnicity (OR 1.18, 95% CI 1.03-1.35), African American race (OR 1.15, 95% CI 1.04-1.28), Medicare insurance (OR 1.24, 95% CI 1.12-1.38), and urban residence (OR 1.11, 95% CI 1.02-1.21). Higher income was associated with lower readmission risk (OR 0.87, 95% CI 0.79-0.96 for highest vs. lowest quartile). Similar patterns were observed for 90-day readmissions. Conclusion Socioeconomic and demographic factors, including race, ethnicity, insurance status, income level, and living arrangements, significantly impact 30-day and 90-day readmission rates in patients with CHF. These findings highlight the need for targeted interventions and policies that address social determinants of health and promote health equity in the management of CHF. Future research should focus on developing and evaluating culturally sensitive, community-based strategies to reduce readmissions and improve outcomes for high-risk CHF patients.

Comprehensive Review of Mesothelioma Cases: From Diagnosis to Therapeutic Strategies.

Mesothelioma is a rare and aggressive malignancy typically associated with asbestos exposure. We present the clinical and diagnostic journey of a 63-year-old male carpenter, who presented with concerning symptoms of shortness of breath and total right lung "white-out" on imaging. Comprehensive medical evaluation revealed the presence of malignant pleural mesothelioma. This study underscores the importance of considering mesothelioma as a potential diagnosis in individuals with occupational asbestos exposure and highlights patterns in diagnosing and managing this devastating disease. Early recognition and intervention are essential in improving outcomes for patients diagnosed with mesothelioma.

Complex Tunneling Perirectal Abscess: Intra-abdominal and Extraperitoneal Extension of a Persistent Perirectal Abscess.

Deep-tissue extension of perianal and perirectal abscesses, while rare, requires timely diagnosis and emergent surgical intervention to prevent serious secondary complications. This report evaluates a case of intra-abdominal and extraperitoneal extension of a persistent perirectal abscess that required comprehensive irrigation, drainage, and debridement of multiple abscess-associated cavities. This report follows the case of a 24-year-old African-American female presenting to the ED with mild fevers, nausea, abdominal distension, and lower abdominal pain following a persistent perirectal abscess that had not resolved following conservative outpatient antibiotic management one week prior. Clinical examination revealed abdominal guarding with CT imaging demonstrating extraluminal air pockets in multiple intra-abdominal and extraperitoneal compartments. The patient underwent emergent surgical irrigation, drainage, and debridement of multiple abscess cavities extending from the original perirectal abscess. This report provides a comprehensive overview of the diagnosis, surgical approach, and postoperative management in a patient presenting with a complex tunneling perirectal abscess forming intra-abdominal and extraperitoneal abscesses.

Two Cases of Malpositioning of Internal Jugular Central Venous Catheters: A Review of Literature and Current Treatment Recommendations.

Percutaneous central venous catheterization, despite ultrasound guidance, is known to carry significant risks. While central venous catheters are widely used in clinical practice, they are also associated with various complications, including incorrect positioning during insertion. Arterial puncture is a well-recognized complication, and although unintended subclavian or carotid artery cannulation is rare, it can lead to serious consequences. We present two cases, in which a dual-lumen, non-tunneled temporary hemodialysis catheter was inadvertently inserted into the left common carotid artery and in the left innominate vein.

A Displaced Intrauterine Device Eroding Into the Sigmoid Colon.

A 36-year-old female presented to the gynecology office eight weeks after the placement of a ParaGard intrauterine device (IUD). Upon gynecologic examination, the strings of the IUD were not found. Magnetic resonance imaging was performed which reported the IUD embedded in the sigmoid colon. Initial diagnostic laparoscopy was done without bowel preparation and revealed an IUD embedded within the sigmoid colon and mesocolon. Colonoscopy did not reveal any breach of the colonic lumen. A second diagnostic laparoscopy was planned with the robotic-assisted technique after bowel preparation. Intraoperative findings during the second operation identified the IUD embedded in the antimesenteric side of the sigmoid colon with surrounding scar tissue to the uterus. The IUD was sharply freed using robotic scissors and the resulting serosal defect was sutured in layers with buttress made of appendices epiploica. The patient recovered well and had an excellent outcome. Our article highlights the minimally invasive method of dealing with a displaced IUD. The use of the robotic technique was helpful in our case to achieve an excellent outcome.

How many patients do you need? Investigating trial designs for anti-seizure treatment in acute brain injury patients.

BACKGROUND/OBJECTIVES: Epileptiform activity (EA), including seizures and periodic patterns, worsens outcomes in patients with acute brain injuries (e.g., aneurysmal subarachnoid hemorrhage [aSAH]). Randomized control trials (RCTs) assessing anti-seizure interventions are needed. Due to scant drug efficacy data and ethical reservations with placebo utilization, and complex physiology of acute brain injury, RCTs are lacking or hindered by design constraints. We used a pharmacological model-guided simulator to design and determine the feasibility of RCTs evaluating EA treatment. METHODS: In a single-center cohort of adults (age >18) with aSAH and EA, we employed a mechanistic pharmacokinetic-pharmacodynamic framework to model treatment response using observational data. We subsequently simulated RCTs for levetiracetam and propofol, each with three treatment arms mirroring clinical practice and an additional placebo arm. Using our framework, we simulated EA trajectories across treatment arms. We predicted discharge modified Rankin Scale as a function of baseline covariates, EA burden, and drug doses using a double machine learning model learned from observational data. Differences in outcomes across arms were used to estimate the required sample size. RESULTS: Sample sizes ranged from 500 for levetiracetam 7 mg/kg versus placebo, to >4000 for levetiracetam 15 versus 7 mg/kg to achieve 80% power (5% type I error). For propofol 1 mg/kg/h versus placebo, 1200 participants were needed. Simulations comparing propofol at varying doses did not reach 80% power even at samples >1200. CONCLUSIONS: Our simulations using drug efficacy show sample sizes are infeasible, even for potentially unethical placebo-control trials. We highlight the strength of simulations with observational data to inform the null hypotheses and propose use of this simulation-based RCT paradigm to assess the feasibility of future trials of anti-seizure treatment in acute brain injury.

Audio Distraction for Traction Pin Insertion: A Prospective Randomized Controlled Study.

BACKGROUND: Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure. METHODS: A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale. RESULTS: A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69). CONCLUSIONS: AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Health Care Implications of the COVID-19 Pandemic for the Cardiovascular Practitioner.

There has been substantial excess morbidity and mortality during the COVID-19 pandemic, not all of which was directly attributable to SARS-CoV-2 infection, and many non-COVID-19 deaths were cardiovascular. The indirect effects of the pandemic have been profound, resulting in a substantial increase in the burden of cardiovascular disease and cardiovascular risk factors, both in individuals who survived SARS-CoV-2 infection and in people never infected. In this report, we review the direct effect of SARS-CoV-2 infection on cardiovascular and cardiometabolic disease burden in COVID-19 survivors as well as the indirect effects of the COVID-19 pandemic on the cardiovascular health of people who were never infected with SARS-CoV-2. We also examine the pandemic effects on health care systems and particularly the care deficits caused (or exacerbated) by health care delayed or foregone during the COVID-19 pandemic. We review the consequences of: (1) deferred/delayed acute care for urgent conditions; (2) the shift to virtual provision of outpatient care; (3) shortages of drugs and devices, and reduced access to: (4) diagnostic testing, (5) cardiac rehabilitation, and (6) homecare services. We discuss the broader implications of the COVID-19 pandemic for cardiovascular health and cardiovascular practitioners as we move forward into the next phase of the pandemic.

Atypical diffuse large B-cell lymphoma, primary splenic lymphoma variant; a case report.

INTRODUCTION AND IMPORTANCE: Primary splenic lymphoma (PSL) is characterized by lymphoma involvement confined to the spleen and hilar lymph nodes, without evidence of liver involvement or other sites. This condition is extremely uncommon, accounting for approximately 1 % of non- Hodgkin lymphomas (NHLs) and <2 % of all lymphomas. Diffuse large B-cell lymphoma (DLBCL) is the most common histological subtype of both PSLs and all NHLs. DLBCL encompasses an aggressive heterogeneous entity with distinct morphological variants. CASE PRESENTATION: A 68 year-old gentleman presented to the office with a 10-month history of vague left sided upper abdominal pain. Clinical examination revealed a tender left upper quadrant, evidenced with splenomegaly on radiological evaluation. The patient proceeded with a splenectomy with subsequent pathological and immunohistochemical analysis, confirming a final diagnosis of germinal center type DLBCL. CLINICAL DISCUSSION: Primary splenic DLBCL is a rare variant of DLBCL, characterized by exclusive involvement of the spleen. It requires a comprehensive diagnostic evaluation to exclude lymphoma involvement in other organs and lymph nodes. Splenectomy followed by appropriate adjuvant therapy has been demonstrated as the definitive treatment strategy. This case report emphasizes the importance of considering primary splenic DLBCL as a differential diagnosis in patients presenting with splenomegaly and highlights the significance of multidisciplinary collaboration for accurate diagnosis and optimal management of this uncommon entity. CONCLUSION: Primary Splenic DLBCL, an exceptionally rare B-Cell neoplasm variant, requires precise diagnosis due to its unique splenic involvement. Splenectomy's efficacy, adjuvant therapy, multidisciplinary collaboration, and ongoing research are crucial for optimal management.

Adult T-Cell Lymphoma (ATL) With Erythroderma in Indolent Human T-Lymphotropic Virus Type I (HTLV-1) Infection.

Adult T-cell lymphoma (ATL) is a hematological malignancy of CD4+ mature T-lymphocytes commonly associated with chronic human T-lymphotropic virus type I (HTLV-1) infection. Chronic HTLV-1 infection induces oncogenic mutations in CD4+ T-cells, leading to an acute malignant transformation of host cells. Atypically, ATL presents with dermatological and pulmonary symptoms consistent with a "smoldering" disease pattern. We present a case of a 78-year-old male patient with chronic generalized malaise, progressively worsening shortness of breath, and diffuse erythroderma, who was diagnosed with ATL secondary to chronic indolent HTLV-1 infection. We evaluate the multisystemic clinical signs associated with ATL, the comprehensive clinical investigations required to reach a conclusive diagnosis, and the options for long-term clinical management.