Guidelines on retention of pathology records and materials (Version 2/2022).

No abstract available.

Strain coupling of ferroelastic domains and misfit dislocations in [101]-oriented ferroelectric PbTiO3 films.

High-index perovskite ferroelectric thin films possess excellent dielectric permittivity, piezoelectric coefficient, and exotic ferroelectric switching properties. They also exhibit complications in the ferroelastic domains, misfit dislocations, and strain-relaxation behaviors. Exploring the relationship of the ferroelastic domains and misfit dislocations may be of benefit for promoting the high-quality growth of these thin films. Here, the strain field of the ferroelastic domains and misfit dislocations in [101]-oriented PbTiO3/(La, Sr)(Al, Ta)O3 epitaxial thin films were investigated by advanced aberration-corrected (scanning) transmission electron microscopy (TEM) combined with geometry phase analysis (GPA). Two types of misfit dislocations with projected Burgers vectors of a[001] or a[100] on the (010) plane were elucidated, whose strain fields included in-plane strain and lattice rotation coupled with the c domains above them. Besides, it was demonstrated that the coupling was kept inside the PbTiO3 films when the film thickness was increased. Furthermore, the polarization rotation was observed in both narrow c domains and around the misfit dislocation cores, which may be attributed to the flexoelectric effect. These results are expected to provide useful information for understanding the nucleation and propagation mechanism of ferroelastic domains and for further modifying the growth of high-index ferroelectric thin films.

[Comparative study of decentration, tilt and visual quality after implantation of aspherical intraocular lenses].

Objective: To compare the difference of decentration and tilt among 4 kinds of aspherical intraocular lenses (IOLs), and to analyze their objective visual quality. Methods: Prospective non-randomized controlled clinical trial. Age-related cataract patients who planned to undergo phacoemulsification and IOL implantation in the Affiliated Hospital of North Sichuan Medical College from April to June in 2020 were divided into ZCB00 group, SN60WF group, A1-UV group, and AO group according to IOL types. Thirty right eyes and thirty left eyes were selected in each group. Before operation and at 1 day, 1 week and 1 month postoperatively, decentration and tilt values were measured by a new swept-source anterior-segment optical coherence tomography device (CASIA2), and wavefront aberrations, objective scatter index (OSI), modulation transfer function cut off frequency (MTF cut off) and Strehl ratio (SR) were also examined. Values of decentration, tilt and visual quality compared among 4 groups were took from the right eye. One-way analysis of variance was used for inter-group comparison, and repeated measurement one-way analysis of variance was used for intra-group comparison. Data between right eyes and left eyes from all the individuals were compared by independent sample t-test. Results: A total of 181 patients (240 eyes) were enrolled, and 169 patients (224 eyes) completed the follow-up (114 right eyes and 110 left eyes). There were 77 males and 92 females, with an age of (69±9) years. There was no significant difference in gender, age, axial length, decentration and tilt of crystalline lens and IOL power among 4 groups (all P>0.05). At 1 day, 1 week and 1 month postoperatively, there was significant difference in decentration value among 4 groups (F=7.11, 6.12, 4.66; all P<0.05). For further pairwise comparison, the decentration value of SN60WF group was higher than that of the other 3 groups at 1 day and 1 week postoperatively, and the decentration value of SN60WF group was (0.259±0.101) mm at 1 month postoperatively, which was higher than that of ZCB00 group (0.177±0.099) mm and AO group (0.163±0.122) mm, and the differences were statistically significant (using SNK-q test, both P<0.05). The IOL tilt value in the ZCB00 group, SN60WF group, A1-UV group, and AO group at 1 month postoperatively were (4.806±1.129)°, (5.080±1.309)°, (4.586±1.338)°, (5.112±1.406)°, respectively. No significant difference in tilt value among 4 groups was found at any time after surgery (all P>0.05). In each group, there was no significant difference in decentration and tilt value at different postoperative time points (all P>0.05). At 1 month postoperatively, there was no significant difference in decentration and tilt at horizontal and vertical directions respectively among 4 groups (all P>0.05), and in each group, there was no significant difference in decentration and tilt value between right eyes and left eyes (all P>0.05), and IOLs tended to tilt towards the inferonasal or inferotemporal direction in both eyes. With 4-mm and 6-mm pupil diameter, there was significant difference in internal (F=131.32, 85.17) and ocular (F=46.64, 47.55) spherical aberration among 4 groups (all P<0.01). For further pairwise comparison, the spherical aberration of AO group was higher than that of the other 3 groups, and the difference was statistically significant (using SNK-q test, all P<0.05). There was no significant difference in OSI, MTF cut off and SR among 4 groups (all P>0.05). Conclusions: The four types of IOLs show decentration and tilt in varying degrees after implantation in the capsular bag, but this difference do not lead to clinical significance. Human eyes have tolerance to mild decentration and tilt of aspheric IOLs, showing good visual quality.

[Effect of endoplasmic reticulum stress induced by all-trans retinoic acid on apoptosis of FLT3-ITD mutated leukemia cells by activating autophagy in FLT3-ITD mutated protein].

Objective: Endoplasmic reticulum stress(ERS)was used as the research emphasis to further investigate the mechanisms of apoptosis of FLT3-ITD-mutated leukemia cells and decreased expression of FLT3-ITD mutated protein induced by all-trans retinoic acid(ATRA). Methods: FLT3-ITD-mutated leukemia cell lines(MV4-11 and MOLM13)were treated with ATRA. Flow cytometry was conducted to assess cell apoptosis. Real-time fluorescent quantitative PCR(RT-qPCR)and Western blot were used to detect the expression of ERS-related and autophagy-related genes and protein, respectively. Results: A low-dose ATRA further increased FLT3-ITD cells and ERS levels. ATRA acted on the ERS-related PERK/eif2ɑ signaling pathway and continued to increase the ERS of FLT3-ITD cells, resulting in an upregulation of apoptotic gene CHOP expression. After the treatment with ATRA, FLT3-ITD protein in FLT3-ITD cells was decreased. Of the two main ERS-related protein degradation pathways, ER-associated degradation(ERAD)and ER-activated autophagy(ERAA), the expression of ERAD-related protein ATF6 in FLT3-ITD cells was not significantly changed on ATRA, whereas the expression of ERAA-related proteins Atg7 and Atg5 were significantly increased. Conclusions: ATRA further raises the ERS level of FLT3-ITD cells continuously by activating the ERS-related PERK/eif2ɑ signal pathway and induces FLT3-ITD protein autophagy degradation through ERAA pathway, which induces apoptosis of FLT3-ITD-mutated leukemia cells. These results provide preliminary evidence on the use of ATRA in the treatment of refractory leukemia with FLT3-ITD.

Extramedullary CD20-positive B-lymphoblastic lymphoma in a 5-year-old child: A diagnostic challenge.

INTRODUCTION: Lymphoblastic leukaemia/lymphoma may present as an isolated extramedullary mass, which includes the musculoskeletal region involvement with normal or near-normal blood counts. The tumour may be in the form of B or T-lymphoblastic leukaemia/lymphoma. The clinical features and histological morphology of extramedullary B-lymphoblastic lymphoma (B-LBL) may mimic mature B-cell neoplasms, thus posing a diagnostic challenge. Arriving at the right diagnosis is crucial because these two diseases differ in their prognosis and management. A high index of suspicion is therefore important so as not to miss the correct diagnosis. The diagnosis may be overlooked because the clinical presentation may not be typical of B-LBL or the blood counts do not show any abnormalities. In this report, we highlight one such case where the diagnosis of B-LBL was missed because of its atypical presentation.

Polar meron lattice in strained oxide ferroelectrics.

A topological meron features a non-coplanar structure, whose order parameters in the core region are perpendicular to those near the perimeter. A meron is half of a skyrmion, and both have potential applications for information carrying and storage. Although merons and skyrmions in ferromagnetic materials can be readily obtained via inter-spin interactions, their behaviour and even existence in ferroelectric materials are still elusive. Here we observe using electron microscopy not only the atomic morphology of merons with a topological charge of 1/2, but also a periodic meron lattice in ultrathin PbTiO3 films under tensile epitaxial strain on a SmScO3 substrate. Phase-field simulations rationalize the formation of merons for which an epitaxial strain, as a single alterable parameter, plays a critical role in the coupling of lattice and charge. This study suggests that by engineering strain at the nanoscale it should be possible to fabricate topological polar textures, which in turn could facilitate the development of nanoscale ferroelectric devices.

Evaluation of coagulation factor activity and sterility of thawed fresh frozen plasma during storage up to 5 days at 4°C.

INTRODUCTION: Fresh frozen plasma (FFP) is a blood component containing functional quantities of all coagulation factors stored at -18°C or below. FFP has to be thawed and transfused as soon as possible to prevent the loss of certain coagulation factor activities and to minimise microbial contamination. MATERIALS AND METHODS: Thirty units of FFP kept at -20°C were thawed using a 37°C water bath and immediately sampled for baseline Factor II (FII), Factor VIII (FVIII) and fibrinogen activity levels and sterility testing. Each unit was then divided into two smaller bags (i.e. Bag I and Bag II) and kept at 4°C. At 6 hours and Day 3, representative samples were taken from Bag I for coagulation factor activity assays, while at Day 5 representative samples were taken from Bag II for coagulation factor activity assays and sterility testing. RESULTS: FII activities at the four time points were 73.43%, 73.73%, 71% and 69.8%, respectively, while FVIII activities were 177.63%, 144.37%, 80.8% and 70.97%, respectively. Fibrinogen levels at the four time points were 3.24 g/L, 3.24 g/L, 3.21 g/L and 3.20 g/L, respectively. All samples were free from microbial contamination even at Day 5. CONCLUSION: The mean reduction in FII and fibrinogen activities on Day 5 was 5% and 1%, respectively. However, FVIII activity declined significantly by approximately 60% at Day 5. Despite these reductions, thawed plasma stored for up to 5 days at 4°C is still suitable for use as the coagulation factor activity levels still exceed the minimum release criteria recommended in quality assurance regulations.

Integrated sensing layer of bacterial cellulose and polyethyleneimine to achieve high sensitivity of ST-cut quartz surface acoustic wave formaldehyde gas sensor.

Surface acoustic wave (SAW)-based formaldehyde gas sensor using bi-layer nanofilms of bacterial cellulose (BC) and polyethyleneimine (PEI) was developed on an ST-cut quartz substrate using sol-gel and spin coating processes. BC nanofilms significantly improve the sensitivity of PEI films to formaldehyde gas, and reduces response and recovery times. The BC films have superfine filamentary and fibrous network structures, which provide a large number of attachment sites for the PEI particles. Measurement results obtained using in situ diffuse reflectance Fourier transform infrared spectroscopy showed that the primary amino groups of PEI strongly adsorb formaldehyde molecules through nucleophilic reactions, thus resulting in a negative frequency shift of the SAW sensor due to the mass loading effect. In addition, experimental results showed that the frequency shifts of the SAW devices are determined by thickness of PEI film, concentration of formaldehyde and relative humidity. The PEI/BC sensor coated with three layers of PEI as the sensing layer showed the optimal sensing performance, which had a frequency shift of 35.6 kHz for 10 ppm formaldehyde gas, measured at room temperature and 30 % RH. The sensor also showed good selectivity and stability, with a low limit of detection down to 100 ppb.

An Audit on Overnight Transfusion Practice in A Teaching Hospital in Malaysia.

INTRODUCTION: Overnight transfusion (OT) is the blood transfusion taking place from 9pm to 8am. During this period, patients are exposed to increased risk of errors. This cross-sectional study aims to determine the incidence and practice of OT in Universiti Kebangsaan Malaysia Medical Centre. MATERIALS & METHODS: Data from all OT in June and mid-July 2017 were collected from recipients' cards, transfusion request forms and patient's case files, regarding discipline involved, indications, time intervals from request of blood transfusion to the completion of OT on patients, monitoring of patients and adverse reactions. RESULTS: A total of 1285 transfusion cases were identified during the study period. 216 (16.8%) cases were OT while the 1069 (83.2%) cases were non-OT. Surgery discipline has the highest (30.1%) OT. The indications of OT were acute clinical need: 82.9%, less acute clinical need: 13.9% and no clinical need: 3.2%. A huge delay (average: 5 hours 40 minutes) in starting transfusion after grouping and crossmatching (GXM) completion was noted. Besides, 25.9% cases took <4 hours to complete OT; 83.4% cases did not have proper transfusion monitoring and three transfusion reactions were reported. DISCUSSION: Although most of the OT cases had appropriate clinical indications, the transfusion can be commenced earlier at day time rather than overnight. Cases without absolute indication should avoid OT. The poor monitoring of patient during OT had posed risks to patients' life if an adverse transfusion reaction happened. The major reason for OTs was a huge delay in starting transfusion after the GXM completion. The contravention of 4-hour infusion rule increased the patients' risk of developing bacterial sepsis. The practice of OT should be discouraged wherever possible except for clinically indicated cases.

Observation of room-temperature polar skyrmions.

Complex topological configurations are fertile ground for exploring emergent phenomena and exotic phases in condensed-matter physics. For example, the recent discovery of polarization vortices and their associated complex-phase coexistence and response under applied electric fields in superlattices of (PbTiO3)n/(SrTiO3)n suggests the presence of a complex, multi-dimensional system capable of interesting physical responses, such as chirality, negative capacitance and large piezo-electric responses1-3. Here, by varying epitaxial constraints, we discover room-temperature polar-skyrmion bubbles in a lead titanate layer confined by strontium titanate layers, which are imaged by atomic-resolution scanning transmission electron microscopy. Phase-field modelling and second-principles calculations reveal that the polar-skyrmion bubbles have a skyrmion number of +1, and resonant soft-X-ray diffraction experiments show circular dichroism, confirming chirality. Such nanometre-scale polar-skyrmion bubbles are the electric analogues of magnetic skyrmions, and could contribute to the advancement of ferroelectrics towards functionalities incorporating emergent chirality and electrically controllable negative capacitance.

Long noncoding RNA-JPX predicts the poor prognosis of ovarian cancer patients and promotes tumor cell proliferation, invasion and migration by the PI3K/Akt/mTOR signaling pathway.

OBJECTIVE: To investigate the clinical functions and the detailed mechanism of long noncoding RNA (lncRNA) JPX in human ovarian cancer cell lines. PATIENTS AND METHODS: The expression of JPX in ovarian cancer tissues and cell lines was detected by Real-time polymerase chain reaction (RT-PCR). The correlation between JPX expression and prognosis was analyzed by follow-up data. The OVCAR-3 cell proliferation, invasion and migration were measured by methyl thiazolyl tetrazolium (MTT) assay, cloning formation assay and scratch assay. The cell apoptosis was detected by Bcl-2, Bax, and Caspase-3 activity. PI3K/mTOR inhibitor treatment and Western blot proved that JPX functions associated with PI3K/Akt/mTOR signaling and test the protein levels of p-PI3K, p-Akt, p-mTOR. RESULTS: RT-PCR results showed that the expression of JPX was upregulated in ovarian cancer tissues and ovarian cancer cell lines (p < 0.05), and it was significantly increased in large tumor tissues and metastatic lymph nodes (p < 0.05). The survival rate of high JPX expression patients was much lower than low JPX expression patients (p < 0.05), indicating that high expression of JPX predicted poor prognosis in patients with ovarian cancer. MTT assay, colony formation and scratch assay showed the repression of JPX and resulted with significantly decreased in cell proliferation, invasion and migration of OVCAR-3 cells compared with the control (p < 0.05). PI3K/mTOR inhibitor treatment showed overexpression of JPX could activate the PI3K/Akt/mTOR signaling pathway. Western blot assay showed that the expressions of p-PI3K, p-Akt, p-mTOR were significantly increased after overexpression of JPX (p < 0.05), and after the inhibition of PI3K/Akt/mTOR signaling pathway and overexpression of JPX, the tumor cell proliferation, invasion and migration were significantly repressed, compared with the control (p < 0.05). CONCLUSIONS: JPX could predict the poor prognosis in patients with ovarian cancer, which could promote the tumor cell proliferation, invasion and migration in human ovarian cancer cell lines and inhibited the cell apoptosis through activating PI3K/Akt/mTOR signaling pathway.

[Application of self-made stretch pants in patients with burn in special sites].

The change and fixation of dressing are difficult in patients with burn in special sites of perineum, buttocks, and bilateral thighs. Therefore, we designed and made stretch pants by ourselves for dressing fixation after dressing change in patients with burns in abdomen, buttocks, and bilateral thighs. The stretch pants are made by cutting and splicing elastic fabric according to perimeters of abdomen and legs. The stretch pants are used after wound dressing change, which can fix the dressing stably, accelerate wound healing, and reduce the medical workers' labor intensity of dressing change and economic burden of patients. And patients can walk out of bed early. It's especially suitable for dressing fixation of infants and other patients who are unwilling to cooperate. Besides, it's easy to make with low cost and suitable for clinical promotion.

[A family with Allan-Herndon-Dudley syndrome due to SLC16A2 gene mutation].

Objective: To report a family diagnosed with Allan-Herndon-Dudley syndrome (AHDS) due to SLC16A2 gene mutation and to summarize the phenotypes, genotypes, diagnosis, treatment, and prognosis. Methods: The clinical features of a family of AHDS diagnosed in Xiangya Hospital of Central South University in November 2017 were analyzed. Related literature was searched at Online Mendelian Inheritance in Man (OMIM), PubMed, CNKI and Wanfang database (from the establishment of databases to June 2018) by using "Allan-Herndon-Dudley syndrome" , and "AHDS" as keywords and the case reports from April 2013 to June 2018 were reviewed. Results: The proband was a boy aged 8 months who presented with global developmental retardation, inability to hold up the head, disability to sit independently or grab, no language development, elongated face, big ears, esotropia, scoliosis, hypotonia in the trunk, hypertonia in extremities, and hyperreflexia. Brain magnetic resonance imaging (MRI) showed widening of the extracerebral space and delayed myelination. Thyroid function tests revealed increased FT3, decreased FT4 and normal TSH. Whole exome sequencing (WES) revealed the SLC16A2 gene c.431-1 (IVS1) G>C hemizygous mutation. The infant's mother and grandmother are carriers, but whose father had no related mutation. One uncle from maternal side had severe psychomotor retardation as well as dystonia and died at one year of age with unknown etiology. A total of 97 articles were retrieved in which 19 case reports were reviewed. Forty-two cases (22 from 8 families and 20 sporadic) were reported. Among these 42 cases (all males), all of them presented with moderate to severe cognitive dysfunction, 15 with seizures; 36 were bedridden, only 4 could walk; 31 had no language development, 2 could speak sentences, 4 could speak few words, 1 had babbling sounds. Furthermore,16 had microcephaly, 18 had facial dysmorphism, 6 had esotropia, 2 had hearing loss,14 had scoliosis, 11 had joint contracture, 30 had low body weight/muscle wasting, 37 had hypotonia in trunk or extremities, 32 had progressive spastic paraplegia or hypertonia. In terms of thyroid function, 33 had abnormal results, within whom 30 had increased T3, 25 had decreased T4 and 3 had increased TSH. Brain MRI showed delayed myelination in 22 cases, within which one normalized with development. Genetic tests showed that 31 had missense mutation (14 sporadic), 5 had deletion mutation (3 sporadic, and 1 due to frameshift mutation), 5 had insertion mutation (2 sporadic), and 1 had repeated mutation. The prognosis was poor as patients often died of recurrent respiratory tract infection. Conclusions: The main clinical manifestations of AHDS are severe global developmental retardation, hypotonia, spastic paraplegia, abnormal serum levels of thyroid hormone and delayed brain myelination. SLC16A2 c. 431-1 (IVS1) G > C mutation is accountable for this disease.

Myelodysplastic syndrome with fibrosis and complex karyotype arising in a patient with essential thrombocythaemia.

INTRODUCTION: Essential thrombocythaemia (ET) is a chronic myeloproliferative neoplasm (MPN) characterised by persistent thombocytosis. It is an indolent disorder but transformation to myelofibrosis (MF), acute myeloid leukaemia (AML) or myelodyplastic syndrome (MDS) has been reported. CASE REPORT: We described a patient with ET whose disease evolved into MDS with fibrosis and complex karyotype after 15 years of stable disease. She was asymptomatic and was on hydroxyurea (HU) treatment until recently when she presented with worsening anaemia. Physical examination showed mild splenomegaly. Full blood picture showed leukoerythroblastic picture with presence of 3% circulating blasts and background of dysplastic features such as hypogranular cytoplasm and nuclear hyposegmentation of neutrophils. The bone marrow aspiration was haemodiluted but revealed presence of 6% blast cells, trilineage dysplasia and predominant erythroid precursors (60%). Trephine biopsy showed no excess of blast cells and normal quantity of erythroid precursors, but there was increased in fibrosis (WHO grade 2) and presence of dysmegakaryopoeisis such as nuclear hypolobation, multinucleation and micromegakaryocytes. Cytogenetic study showed complex karyotype; monosomy of chromosome 2, chromosome 5, chromosome 18 and presence of a marker chromosome (42~44, XX,-2,-5,-18,+mar). Fluorescence in situ hybridisation (FISH) showed 5q deletion (CSF1R and EGR1). CONCLUSION: The findings were consistent with transformation of ET to MDS with fibrosis and complex karyotype. ET progression to MDS is considered rare. The presence of complex karyotype and fibrosis in MDS are associated with unfavourable outcome.

[Design and manufacture of a utility artificial hand for a burned child by three-dimensional printing technology and its application].

In May 2015, a child with absence of most of the five fingers with scar formation after healing of a left hand burn wound hospitalized in our burn ward. According to the free online design program for making artificial limbs using three-dimensional printing technology on the internet, a utility artificial hand, most of which made of plastic parts, was designed for the child and printed by a three-dimensional printer. The child was instructed to wear and use the utility artificial hand, including driving the finger part of the utility artificial hand to make a grasping action by flexing the wrist joint. On the first day of using the utility artificial hand, the time the right hand and the utility artificial hand took to finish the Nine-Hole Peg Test (NHPT) was 24 and 325 s, respectively. After training, the child could grab some light and rough objects. After 3 months of follow-up, the child could use the utility artificial hand to cooperate with the upper limb of the healthy side to make the movements of picking up the basketball and keeping the balance of body on the bicycle. The time the right hand and the utility artificial hand took to finish NHPT was 21 and 193 s, respectively. The time the utility artificial hand took increased by 40.6% compared with the initial period. By assembling the three-dimensionally printed utility artificial hand, the partial appearance image of the child was restored, and some of the hand functions were compensated, which improved the self-care ability of the child in daily life and was beneficial to his physical and mental development.

Multiple strains and polar states in PbZr0.52Ti0.48O3/PbTiO3 superlattices revealed by aberration-corrected HAADF-STEM imaging.

Tuning multiple strain and polar states of ferroelectrics by using strain engineering is an essential approach for designing multifunctional electric devices such as multiple state memories. However, integrating multiple strain states is still a challenge, and in addition, revealing such strains and the resultant polar behaviors on the atomic level remains difficult. In this work we prepare PbZr0.52Ti0.48O3/PbTiO3 (PZT/PTO) superlattices on SrRuO3-buffered SrTiO3(001) substrates. Aberration-corrected high angle annular dark field scanning transmission electron microscopy (HAADF-STEM) reveals that the superlattice is coherent in both c (out-of-plane polar direction) and a (in-plane polar direction) domains. We find that the strain states of both PZT and PTO in c and a domains are variant, leading to four special strain states. For example, the tetragonality for PTO in c and a domains is 1.061 and 1.045, respectively. In contrast, PZT in c domains displays a tetragonality as giant as 1.107, which corresponds to 110 µC cm-2 spontaneous polarization, much larger than the bulk PZT; while PZT in a domains exhibits 1.010 tetragonality with about 70 µC cm-2 polarization. This study reveals a practical way to integrate multiple strain states and enhanced polarizations in ferroelectric films, which could be used as multifunctional electric elements.

The crucial role of molecular testing to facilitate the diagnosis of pneumocystis pneumonia during pregnancy.

Pneumocystis pneumonia is an important human immunodeficiency virus (HIV)-associated opportunistic infection, and especially so in pregnant HIV-positive patients. We report a case of a 40-year-old woman in her first trimester of pregnancy who initially presented with acute gastroenteritis symptoms but due to a history of high-risk behaviour and the observation of oral thrush, she was worked up for HIV infection. Her retroviral status was positive and her CD4+ T cell count was only 8 cells/µL. She was also worked up for pneumocystis pneumonia due to the presence of mild resting tachypnoea and a notable drop in oxygen saturation (from 100% to 88%) following brief ambulation. Her chest radiograph revealed bilaterally symmetrical lower zone reticular opacities and Giemsa staining of her bronchoalveolar lavage (BAL) was negative for Pneumocystis jirovecii cysts. However, real-time P. jirovecii polymerase chain reaction (PCR) testing on the same BAL specimen revealed the presence of the organism. A course of oral co-trimoxazole plus prednisolone was commenced and her clinical condition improved.