Diagnosing and Treating Blastic Plasmacytoid Dendritic Cell Neoplasm in a Resource-Limited Setting.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and aggressive hematological malignancy with limited treatment options and poor prognosis. This case report presents the clinical course and management of a 62-year-old man with BPDCN in a resource-limited setting. The patient presented with constitutional symptoms and abnormal complete blood count findings. Initial treatment was performed with an acute lymphoblastic leukemia-based chemotherapy regimen, and the patient achieved complete remission, but the disease recurred 7 months after the initial diagnosis was confirmed in April 2022. The subsequent therapy was not effective, and the patient died during treatment. This case highlights the challenges in managing BPDCN and the need for further research to improve outcomes.

Time series analysis and short-term forecasting of monkeypox outbreak trends in the 10 major affected countries.

BACKGROUND: Considering the rapidly spreading monkeypox outbreak, WHO has declared a global health emergency. Still in the category of being endemic, the monkeypox disease shares numerous clinical characters with smallpox. This study focuses on determining the most effective combination of autoregressive integrated moving average model to encapsulate time dependent flow behaviour of the virus with short run prediction. METHODS: This study includes the data of confirmed reported cases and cumulative cases from eight most burdened countries across the globe, over the span of May 18, 2022, to December 31, 2022. The data was assembled from the website of Our World in Data and it involves countries such as United States, Brazil, Spain, France, Colombia, Mexico, Peru, United Kingdom, Germany and Canada. The job of modelling and short-term forecasting is facilitated by the employment of autoregressive integrated moving average. The legitimacy of the estimated models is argued by offering numerous model performance indices such as, root mean square error, mean absolute error and mean absolute prediction error. RESULTS: The best fit models were deduced for each country by using the data of confirmed reported cases of monkeypox infections. Based on diverse set of performance evaluation criteria, the best fit models were then employed to provide forecasting of next twenty days. Our results indicate that the USA is expected to be the hardest-hit country, with an average of 58 cases per day with 95% confidence interval of (00-400). The second most burdened country remained Brazil with expected average cases of 23 (00-130). The outlook is not much better for Spain and France, with average forecasts of 52 (00-241) and 24 (00-121), respectively. CONCLUSION: This research provides profile of ten most severely hit countries by monkeypox transmission around the world and thus assists in epidemiological management. The prediction trends indicate that the confirmed cases in the USA may exceed than other contemporaries. Based on the findings of this study, it remains plausible to recommend that more robust health surveillance strategy is required to control the transmission flow of the virus especially in USA.

The Impact of Short Intensive Care Rotation on Residents' Experience in the COVID-19 Pandemic: A Mixed-Methods Study.

Objectives: To assess the impact and utility of an intensive care unit (ICU) rotation during the coronavirus disease 2019 (COVID-19) pandemic and the need for mandatory ICU rotations in training for all clinical specialties. Methods: A mixed methods study was conducted from January to September 2021 at the Aga Khan University Hospital, including resident doctors who rotated through COVID ICU between May and September 2020. An online survey was undertaken, followed by two focused group discussions (FGDs). Results: Fifty-nine complete responses out of a total of 86 were analyzed. Around 42.3% (n = 25) of doctors belonged to medicine/allied specialties and 57.6% (n = 34) had previous ICU experience. Both groups, with and without prior ICU experience, found the rotation equally challenging (82.3% (n = 28) versus 84% (n = 21), P = .776) and gained similar practical skills (35.3% (n = 12) versus 16% (n = 4), P = .072), however, those with experience gained significantly more knowledge (58.5% (n = 20) versus 32% (n = 8), P = .047). On opinion regarding mandatory ICU rotation, the majority agreed to have a mandatory rotation (82% (n = 28) versus 72% (n = 18), P = .421)) with an optimal duration of 1 to 2 months. The FGDs found that all residents encouraged the idea of mandatory training in ICU which must be tailored to their training specialty and suggested extending the duration beyond 1 week to ensure learning. Conclusions: COVID ICU rotation was a good avenue for learning and the idea of mandatory ICU training was supported. Mandating ICU rotation might theoretically enhance response to emergencies. More research is needed to understand for feasible incorporation of ICU training in the curriculum.

Stevens-Johnson syndrome: a case report of possible cephalosporin-induced cutaneous adverse reaction.

A severe medical condition known as Stevens-Johnson syndrome (SJS) is marked by a cutaneous and mucosal reaction from the use of specific medications. The prodromal illness is followed by severe mucocutaneous symptoms in this immune-mediated disease. We describe the clinical history of a 55-year-old Caucasian woman who was exposed to cephalosporins. In resource-constrained countries and hospitals where cutaneous biopsy is not readily available, it is not easy to diagnose Steven Johnson Syndrome. This is particularly true in countries where the incidence of infectious diseases such as scarlet fever and measles is high and the early symptoms of SJS can be mistaken for these conditions. We used the Naronjo scale to confirm the probable association of the drug with the syndrome. Physicians while writing prescriptions for their patients need to warn them of potential side effects and they should keep in mind conditions like Stevens-Johnson syndrome. This case report highlights the need for improved knowledge and understanding of SJS among healthcare practitioners in resource-limited communities where the prevalence of infectious diseases is high.

Knowledge and Attitude of Inflammatory Bowel Disease Patients Toward Colorectal Cancer Risk, Its Management, and the Role of Healthcare Providers: A Cross-Sectional Study in the UK.

Background: Inflammatory bowel disease (IBD) increases the risk for colorectal cancer (CRC). Limited literature exists on patients' knowledge of CRC risk and management. Attitude toward doctor-recommended management and the role of healthcare providers (HCPs) in CRC risk awareness remain unexplored. This study aimed to fill the gap in knowledge about CRC risk awareness and management in IBD patients in the UK. Methods: This cross-sectional internet-based study was conducted in April-July 2019. Adult (>18 years) IBD patients with a confirmed diagnosis for 2 years and adequate command of English language were invited from non-Natinal Health Services sources. A self-designed and piloted questionnaire with open- and closed-ended questions was used. Closed-ended data were analyzed using descriptive statistics and open-ended responses were analyzed using content analysis. Results: Ninety-two participants (52.5% Crohn's disease and 67.5% females) responded. Around 88% knew that IBD increased CRC risk. Only 20.7% were aware of colonoscopy as the best screening tool; 88% were unaware of screening initiation time. Almost 90% would agree to a doctor's recommendation of colonoscopy. For dysplasia with 10% risk of CRC, 46.7% would not agree with colectomy. Some 48% reported to have never had a discussion about the risk of CRC in IBD with their HCPs, while 58% were not informed of the role of screening and surveillance in managing CRC risk. Conclusions: IBD patients were poorly aware of CRC risk management and had mixed willingness to comply with a doctor's recommendation. HCP's role in cancer knowledge dissemination was suboptimal and patients desired more information.

Uncovering the Hidden Threat: A Case Report of Suspected Dengue Fever in Armenia.

Dengue is a viral infection transmitted by mosquitoes that causes fever, headache, joint pain, nausea, vomiting, and pain behind the eyes. In severe cases, it can progress to dengue hemorrhagic fever and dengue shock syndrome, which can be life-threatening. Armenia has not reported a single case of dengue to date and is non-endemic for this disease. However, it has been found that the vector of the disease, Aedes albopictus, is present in Armenia since 2016. The aim of this report is to present the imported case of suspected dengue hemorrhagic fever. A 23-year-old female who was admitted to the University Hospital experienced symptoms of general weakness, fever, joint pain, and chills after her return from Bali and had a three-day febrile period. A thorough examination revealed mosquito bites on her skin. On the fourth day of hospitalization, the patient's condition deteriorated. She started experiencing vaginal bleeding. On the same day, the patient noted a small petechiae rash sized 1-2 mm in diameter in the upper and lower extremities. The patient deteriorated, with progressive leukopenia and thrombocytopenia, and hypertransaminasemia. Screening tests for HIV and hepatitis A, B, C, and E were performed, and the results showed that the anti-hepatitis C antibody was positive, while the hepatitis C virus polymerase chain reaction was negative. The case was reported to the National Center for Disease Control and Prevention as an imported case of hemorrhagic fever. Unfortunately, no lab test was available there for confirmation of the diagnosis. The patient received IV infusion and symptomatic treatment. Her condition improved, and upon discharge, she was in a state of recovery. This case report highlights the importance of early diagnosis and appropriate treatment for hemorrhagic fevers, particularly dengue fever. The unavailability of diagnostic kits for dengue in Armenia highlights the need to invest in improving their availability. It also emphasizes the importance of maintaining dengue surveillance in non-endemic nations and carefully evaluating and monitoring febrile patients who have returned from dengue-endemic countries.

Natural Language Processing Model for Identifying Critical Findings-A Multi-Institutional Study.

Improving detection and follow-up of recommendations made in radiology reports is a critical unmet need. The long and unstructured nature of radiology reports limits the ability of clinicians to assimilate the full report and identify all the pertinent information for prioritizing the critical cases. We developed an automated NLP pipeline using a transformer-based ClinicalBERT++ model which was fine-tuned on 3 M radiology reports and compared against the traditional BERT model. We validated the models on both internal hold-out ED cases from EUH as well as external cases from Mayo Clinic. We also evaluated the model by combining different sections of the radiology reports. On the internal test set of 3819 reports, the ClinicalBERT++ model achieved 0.96 f1-score while the BERT also achieved the same performance using the reason for exam and impression sections. However, ClinicalBERT++ outperformed BERT on the external test dataset of 2039 reports and achieved the highest performance for classifying critical finding reports (0.81 precision and 0.54 recall). The ClinicalBERT++ model has been successfully applied to large-scale radiology reports from 5 different sites. Automated NLP system that can analyze free-text radiology reports, along with the reason for the exam, to identify critical radiology findings and recommendations could enable automated alert notifications to clinicians about the need for clinical follow-up. The clinical significance of our proposed model is that it could be used as an additional layer of safeguard to clinical practice and reduce the chance of important findings reported in a radiology report is not overlooked by clinicians as well as provide a way to retrospectively track large hospital databases for evaluating the documentation of the critical findings.

Post-caesarean necrotizing soft tissue infection leading to maternal death: A case report.

Necrotizing soft tissue infection is lethal and can lead to sepsis, multi-organ failure, and death. Here we describe a case, which reported to us within 24 hours of Caesarean section, with acute abdominal pain, tachycardia, and tachypnoea. Local examination revealed a large area of necrotic subcutaneous tissue involving a Caesarean section scar. Immediate debridement was carried out and repeated twice after the initial procedure but she could not survive.

Female Representation in Academic Medicine in Pakistan: A 15-Year Overview.

OBJECTIVE: To determine the proportion of female authors publishing in Pakistan and their representation in academic anesthesiology. Design, place, and duration of study: This study was a cross-sectional retrospective analysis. We reviewed all volumes and issues of the Journal of the College of Physicians and Surgeons Pakistan (JCPSP) published from 2007 to 2021. All original articles, clinical practice articles (CPAs), reviews, and editorials were included. The first and last authors publishing in JCPSP were the study subjects. MAIN OUTCOME MEASURES: Gender of the first and last authors was determined by (a) a general review of the author's first, middle, and last names, (b) an internet search of the author's name, and a review of photographs on their social media, or (c) an online search of the author's first name for typical gender assignment. The research field of the first author was noted to determine the contribution of different medical specialties. Article type and the number of citations were noted to determine the relationship with the gender of the author. RESULTS: Around 1549 papers were published by Pakistani authors, of which, 82.6% were original articles, 9.8% were editorials, 5.5% were CPAs, and 2.1% were reviews. Around 56.2% of the first authors and 70.9% of the last authors were males. Most article types had a majority of male first and last authors (<0.001). The median (interquartile range) citation rate was two (0-19), with no difference in citations between gender. Male-male author pairing remained the most common (45.6%). The majority of the papers published belonged to the field of medicine (27.2%) and surgery (21%), with only 3.1% contributed by anesthesiology (females: 41.3%; males: 58.6%). CONCLUSION: Female representation in academia in Pakistan is at par with developed countries. The academic contribution from anesthesiology remains low, which corresponds to a lower percentage of the anesthesia workforce in the country. There is a need for a national indexed journal of anesthesia to evaluate the true representation of female authors in the country.

Mickey Mouse Sign on Bone Scan: This Mouseketeer Rebels Against Paget Disease.

ABSTRACT: An 81-year-old man with prostate adenocarcinoma demonstrated interval progression of the osteoblastic metastatic disease on surveillant bone scan with a new lumbar lesion resembling the configuration of Mickey's head (Mickey Mouse sign), a sign considered to be specific for Paget disease, even in the presence of malignancy. However, our case demonstrates that this appearance can be caused by other etiologies. In the era of SPECT/CT and MRI, it is prudent to obtain further cross-sectional correlation at the time of radionuclide bone scintigraphy to clarify the underlying cause for "Mickey Mouse sign" to prevent misinterpretation, allowing for efficient and accurate patientcare.

Balancing the Scales: An Analysis of Social Determinants of Health, Radiology Report Acuity, and Radiology Staffing Models in an Academic Health System.

PURPOSE: Social determinants of health, including race and insurance status, contribute to patient outcomes. In academic health systems, care is provided by a mix of trainees and faculty members. The optimal staffing ratio of trainees to faculty members (T/F) in radiology is unknown but may be related to the complexity of patients requiring care. Hospital characteristics, patient demographics, and radiology report findings may serve as markers of risk for poor outcomes because of patient complexity. METHODS: Descriptive characteristics of each hospital in an urban five-hospital academic health system, including payer distribution and race, were collected. Radiology department T/F ratios were calculated. A natural language processing model was used to classify multimodal report findings into nonacute, acute, and critical, with report acuity calculated as the fraction of acute and critical findings. Patient race, payer type, T/F ratio, and report acuity score for hospital 1, a safety net hospital, were compared with these factors for hospitals 2 to 5. RESULTS: The fraction of patients at hospital 1 who are Black (79%) and have Medicaid insurance (28%) is significantly higher than at hospitals 2 to 5 (P < .0001), with the exception of hospital 3 (80.1% black). The T/F ratio of 1.37 at hospital 1 as well as its report acuity (28.9%) were significantly higher (P < .0001 for both). CONCLUSIONS: T/F ratio and report acuity are highest at hospital 1, which serves the most at-risk patient population. This suggests a potential overreliance on trainees at a site whose patients may require the greatest expertise to optimize care.

Management of uncomplicated total knee arthroplasty chronic pain and stiffness utilizing cooled radiofrequency ablation: a single institution pilot study.

OBJECTIVE: The objective of this study is to introduce cooled radiofrequency ablation technical feasibility as an alternative percutaneous image-guided treatment of chronic pain and stiffness in the setting of uncomplicated total knee arthroplasty. MATERIAL AND METHOD: This retrospective pilot study includes a total of 19 consecutive patients experiencing persistent chronic pain after total knee arthroplasty, without underlying hardware complications who had failed conservative care. Patients initially underwent anesthetic blocks of the genicular nerve branches to determine C-RFA candidacy. After adequate response to the anesthetic blocks (> 50% immediate pain relief), patients were subjected to cooled radiofrequency ablations 2-3 weeks later. Treatment response was evaluated utilizing clinically validated questionnaires (KOOS, the Knee Injury and Osteoarthritis Outcome Score) and visual analog scale (VAS) to assess pain severity, stiffness, functional activities of daily living, and use of pain medication. Follow-up outcome scores were collected up to 1 year after C-RFA procedure. RESULT: A total of 21 knees were treated consecutively between 4/2019 and 1/2020 (mean age 70.5 years; 5 M:14F). The mean total KOOS score improved significantly from baseline at 35.0 ± 14.0 to 64.2 ± 14.7 at a mean of 10.2 months after treatment (p < 0.0001), with significant improvement in mean stiffness score from 44.8 ± 16.7 to 68.8 ± 20 (p < 0.0001). The mean VAS score improved significantly from baseline at 8.30 ± 1.1 to 2.45 ± 1.8 (p < 0.0001). No major complications were encountered. No patients went on to receive re-treatment, surgical revision, or other intervention. CONCLUSION: Image-guided genicular nerve cooled radiofrequency ablation offers a promising alternative in treating chronic pain/stiffness in the setting of uncomplicated TKA.

Query bot for retrieving patients' clinical history: A COVID-19 use-case.

OBJECTIVE: With increasing patient complexity whose data are stored in fragmented health information systems, automated and time-efficient ways of gathering important information from the patients' medical history are needed for effective clinical decision making. Using COVID-19 as a case study, we developed a query-bot information retrieval system with user-feedback to allow clinicians to ask natural questions to retrieve data from patient notes. MATERIALS AND METHODS: We applied clinicalBERT, a pre-trained contextual language model, to our dataset of patient notes to obtain sentence embeddings, using K-Means to reduce computation time for real-time interaction. Rocchio algorithm was then employed to incorporate user-feedback and improve retrieval performance. RESULTS: In an iterative feedback loop experiment, MAP for final iteration was 0.93/0.94 as compared to initial MAP of 0.66/0.52 for generic and 1./1. compared to 0.79/0.83 for COVID-19 specific queries confirming that contextual model handles the ambiguity in natural language queries and feedback helps to improve retrieval performance. User-in-loop experiment also outperformed the automated pseudo relevance feedback method. Moreover, the null hypothesis which assumes identical precision between initial retrieval and relevance feedback was rejected with high statistical significance (p â‰ª 0.05). Compared to Word2Vec, TF-IDF and bioBERT models, clinicalBERT works optimally considering the balance between response precision and user-feedback. DISCUSSION: Our model works well for generic as well as COVID-19 specific queries. However, some generic queries are not answered as well as others because clustering reduces query performance and vague relations between queries and sentences are considered non-relevant. We also tested our model for queries with the same meaning but different expressions and demonstrated that these query variations yielded similar performance after incorporation of user-feedback. CONCLUSION: In conclusion, we develop an NLP-based query-bot that handles synonyms and natural language ambiguity in order to retrieve relevant information from the patient chart. User-feedback is critical to improve model performance.

Dietary interventions and nutritional supplements for heart failure: a systematic appraisal and evidence map.

AIMS: To appraise meta-analytically determined effect of dietary interventions and nutritional supplements on heart failure (HF)-related outcomes, and create an evidence map to visualize the findings and certainty of evidence. METHODS AND RESULTS: Online databases were systematically searched for meta-analyses of randomized controlled trials (RCTs) evaluating the effect of dietary interventions and nutritional supplements on HF outcomes and incidence. These were then updated if new RCTs were available. Estimates were pooled using a random-effects model and reported as risk ratios (RRs) or mean differences with 95% confidence intervals. We identified 14 relevant meta-analyses, to which 21 new RCTs were added. The total evidence base reviewed included 122 RCTs (n = 176 097 participants) assessing 14 interventions. We found that coenzyme Q10 was associated with lower all-cause mortality [RR 0.69 (0.50-0.96); I2  = 0%; low certainty of evidence] in HF patients. Incident HF risk was reduced with Mediterranean diet [RR 0.45 (0.26-0.79); I2  = 0%; low certainty of evidence]. Vitamin E supplementation was associated with a small but significant increase in the risk of HF hospitalization [RR 1.21 (1.04-1.40); I2 = 0%; moderate certainty of evidence]. There was moderate certainty of evidence that thiamine, vitamin D, iron, and L-carnitine supplementation had a beneficial effect on left ventricular ejection fraction. CONCLUSION: Coenzyme Q10 may reduce all-cause mortality in HF patients, while a Mediterranean diet may reduce the risk of incident HF; however, the low certainty of evidence warrants the need for further RCTs to confirm a definite clinical role. RCT data were lacking for several common interventions including intermittent fasting, caffeine, DASH diet, and ketogenic diet. More research is needed to fill the knowledge gap.

Association of Apgar Score With Meconium Staining of Amniotic Fluid in Labor.

Objective This study aimed to determine the association of Apgar score with meconium staining of amniotic fluid in labor. Methodology A retrospective observational study was carried out through the non-probability convenient sampling technique at the Department of Obstetrics and Gynecology for a duration of six months. Only those women were selected who had more than 24 weeks of gestation period. The women were excluded on the basis of risk factors for fetal distress and breech in late labor. Results A total of 216 pregnant women were selected from the labor room in this study. The mean age of the women was 26.57±4.28 years. The gestational age of the women was 36.09±4.11 weeks. Moreover, the mean parity of pregnant women was 1.68±2.53. It has been observed that the women who had meconium staining, the neonates of 144(77.4%) women showed the Apgar score of less than six at one minute. However, for the women without meconium staining, the neonates of only 15(50%) women showed the Apgar score of less than six at the one-minute interval with a significant association (p=0.02). With respect to age groups, a significant association of meconium staining with Apgar score was noted in the 21-30 years age group, whereas, no significant association was seen in other age groups. Similarly, a significant association of meconium staining and Apgar score was noted in primiparous women, whereas, no significant association was noted in multiparous women. No significant association of Apgar score and meconium staining was seen with respect to the mode of delivery. Conclusion The study has found a relation between the Apgar score and meconium staining of amniotic fluid and reported that the Apgar score of less than six at one minute was significantly associated with meconium staining of amniotic fluid.

Patients with falls from standing height and head or neck injury may not require body CT in the absence of signs or symptoms of body injury.

PURPOSE: To determine the rate of clinically impactful body injury among patients who had a fall from standing height with an associated head/neck injury, but without evidence of body injury on physical exam or plain radiographs. We also examine surgical/endovascular intervention related to body injury and mortality rates for head/neck and body injury. METHODS: Retrospective study of 288 patients with CT evidence of acute head/neck injury that underwent body CT despite the absence of clinical or radiographic evidence of body injury. Predictor variables were age, sex, race/ethnicity, and body mass index (BMI). RESULTS: There were 11.5% (n = 33) with body injury on CT (n = 33). There were 3.1% (n = 9) with clinically impactful body injury. No patient had either surgical/endovascular intervention or mortality related to body injury. Additionally, 8.7% (n = 25) had mortality from head/neck injury. Increased age (OR = 1.05, 95% CI: 1.01, 1.08, p = 0.01) and overweight BMI (25-29.99 kg/m2) (OR = 2.85, 95% CI: 1.07, 7.62, p = 0.04) were each significantly associated with increased odds for mortality from head/neck injury. CONCLUSION: Patients with falls from standing height and known head/neck injury had a low rate of clinically impactful body injury. None of the studied variables were associated with increased risk of body injury in this patient population. The low rate of clinically impactful body injury and the lack of any mortality, procedure, or transfusion resulting from body injury suggest that body CT may not be necessary in patients with head/neck injury in the absence of clinical or radiographic evidence of body injury.

Prevalence and characteristics of resistant hypertensive patients in an Asian population.

BACKGROUND: Resistant hypertension is a well-recognized clinical challenge yet there are no reported data on its prevalence in Pakistan. These patients are subjected to a higher risk of developing hypertensive complications. The objective of our study was to evaluate the prevalence and determinants of resistant hypertension in an Asian cohort of hypertensive patients. METHODS: This cross-sectional study was carried out among hypertensive patients visiting a tertiary care hospital in Karachi from September-December 2015. Patient data and characteristics were recorded using a pre-coded questionnaire. Morisky and Berlin questionnaires were used to assess compliance to medications and determine the risk of developing obstructive sleep apnea, respectively. Pearson's chi-square test was used to analyze statistical differences between hypertensive patients and related factors. RESULTS: A total of 515 patients were included in the study. Overall, 12% of the total patients (n=62) were resistant hypertensives and 25% (n=129) had pseudo-resistant hypertension. Resistant patients were more often females, older and had a higher body mass index (all P<0.001). Use of painkillers and noncompliance to dietary recommendations were found to be significant determinants of resistant hypertension. Prevalence of comorbid conditions, including diabetes (p=0.33), hyperlipidemia (p=0.46), and chronic kidney disease (p=0.23), was not significantly higher in patients with resistant hypertension. CONCLUSION: Nearly one in ten hypertensive patients had true resistant hypertension, and twenty-five percent of patients had pseudo-resistance. Resistance hypertensions is significantly associated with female gender, older age, obesity, dietary noncompliance and increased use of NSAIDs.