A Rare Case of Duodenal Adenocarcinoma With Brain Metastasis.

Small bowel malignancies are relatively rare, accounting for only 3% of all gastrointestinal cancers. Duodenum is the most common location among small bowel cancers, followed by Jejunum and then Ileum. Duodenal adenocarcinoma produces vague symptoms, leading to late presentation and a poor prognosis compared to similarly staged colon cancer. It is rare to have brain metastasis in duodenal adenocarcinoma, and not many case reports have been reported. Only approximately 6% of patients with gastrointestinal malignancy have brain metastasis. Here, we present a case of a 64-year-old female patient diagnosed initially with stage IV duodenal adenocarcinoma presenting with duodenal mass, abdominal lymphadenopathy, and liver metastasis. She had excellent systemic control for over two years with systemic chemotherapy, with a close to complete response on follow-up imaging. She presented with a 2 cm left frontal mass biopsy consistent with duodenal adenocarcinoma metastasis. She underwent resection of the left frontal tumor and gamma knife to the resection cavity. She continues to have good systemic control of disease. This case highlights the rare possibility of brain metastasis with duodenal adenocarcinoma, especially in patients who have good systemic control with chemotherapy.

Declutter and Focus: Empirically Evaluating Design Guidelines for Effective Data Communication.

Data visualization design has a powerful effect on which patterns we see as salient and how quickly we see them. The visualization practitioner community prescribes two popular guidelines for creating clear and efficient visualizations: declutter and focus. The declutter guidelines suggest removing non-critical gridlines, excessive labeling of data values, and color variability to improve aesthetics and to maximize the emphasis on the data relative to the design itself. The focus guidelines for explanatory communication recommend including a clear headline that describes the relevant data pattern, highlighting a subset of relevant data values with a unique color, and connecting those values to written annotations that contextualize them in a broader argument. We evaluated how these recommendations impact recall of the depicted information across cluttered, decluttered, and decluttered+focused designs of six graph topics. Undergraduate students were asked to redraw previously seen visualizations, to recall their topics and main conclusions, and to rate the varied designs on aesthetics, clarity, professionalism, and trustworthiness. Decluttering designs led to higher ratings on professionalism, and adding focus to the design led to higher ratings on aesthetics and clarity. They also showed better memory for the highlighted pattern in the data, as reflected across redrawings of the original visualization and typed free-response conclusions, though we do not know whether these results would generalize beyond our memory-based tasks. The results largely empirically validate the intuitions of visualization designers and practitioners. The stimuli, data, analysis code, and Supplementary Materials are available at https://osf.io/wes9u/.

Pathologist Concordance for Ovarian Carcinoma Subtype Classification and Identification of Relevant Histologic Features Using Microscope and Whole Slide Imaging.

CONTEXT.­: Despite several studies focusing on the validation of whole slide imaging (WSI) across organ systems or subspecialties, the use of WSI for specific primary diagnosis tasks has been underexamined. OBJECTIVE.­: To assess pathologist performance for the histologic subtyping of individual sections of ovarian carcinomas using a light microscope and WSI. DESIGN.­: A panel of 3 experienced gynecologic pathologists provided reference subtype diagnoses for 212 histologic sections from 109 ovarian carcinomas based on optical microscopy review. Two additional attending pathologists provided diagnoses and also identified the presence of a set of 8 histologic features important for ovarian tumor subtyping. Two experienced gynecologic pathologists and 2 fellows reviewed the corresponding WSI images for subtype classification and feature identification. RESULTS.­: Across pathologists specialized in gynecologic pathology, concordance with the reference diagnosis for the 5 major ovarian carcinoma subtypes was significantly higher for a pathologist reading on a microscope than each of 2 pathologists reading on WSI. Differences were primarily due to more frequent classification of mucinous carcinomas as endometrioid with WSI. Pathologists had generally low agreement in identifying histologic features important to ovarian tumor subtype classification with either an optical microscopy or WSI. This result suggests the need for refined histologic criteria for identifying such features. Interobserver agreement was particularly low for identifying intracytoplasmic mucin with WSI. Inconsistencies in evaluating nuclear atypia and mitoses with WSI were also observed. CONCLUSIONS.­: Further research is needed to specify the reasons for these diagnostic challenges and to inform users and manufacturers of WSI technology.

Communicative Visualizations as a Learning Problem.

Significant research has provided robust task and evaluation languages for the analysis of exploratory visualizations. Unfortunately, these taxonomies fail when applied to communicative visualizations. Instead, designers often resort to evaluating communicative visualizations from the cognitive efficiency perspective: "can the recipient accurately decode my message/insight?" However, designers are unlikely to be satisfied if the message went 'in one ear and out the other.' The consequence of this inconsistency is that it is difficult to design or select between competing options in a principled way. The problem we address is the fundamental mismatch between how designers want to describe their intent, and the language they have. We argue that visualization designers can address this limitation through a learning lens: that the recipient is a student and the designer a teacher. By using learning objectives, designers can better define, assess, and compare communicative visualizations. We illustrate how the learning-based approach provides a framework for understanding a wide array of communicative goals. To understand how the framework can be applied (and its limitations), we surveyed and interviewed members of the Data Visualization Society using their own visualizations as a probe. Through this study we identified the broad range of objectives in communicative visualizations and the prevalence of certain objective types.

An Evaluation of Semantically Grouped Word Cloud Designs.

Word clouds continue to be a popular tool for summarizing textual information, despite their well-documented deficiencies for analytic tasks. Much of their popularity rests on their playful visual appeal. In this paper, we present the results of a series of controlled experiments that show that layouts in which words are arranged into semantically and visually distinct zones are more effective for understanding the underlying topics than standard word cloud layouts. White space separators and/or spatially grouped color coding led to significantly stronger understanding of the underlying topics compared to a standard Wordle layout, while simultaneously scoring higher on measures of aesthetic appeal. This work is an advance on prior research on semantic layouts for word clouds because that prior work has either not ensured that the different semantic groupings are visually or semantically distinct, or has not performed usability studies. An additional contribution of this work is the development of a dataset for a semantic category identification task that can be used for replication of these results or future evaluations of word cloud designs.

Extramedullary haematopoiesis presenting with cardiac tamponade in a patient with polycythaemia vera.

A 71-year-old man with a history of polycythaemia vera, diagnosed 4 years ago, presented to the emergency room with shortness of breath. A bedside echocardiogram revealed a large pericardial effusion with features concerning for pericardial tamponade. A left anterior thoracotomy and a pericardial window were emergently performed in the operating room and relieved the patient's symptoms. Histology evaluation of the pericardial fragments and pericardial fluid revealed the presence of trilineage haematopoietic elements without any increase in the blasts. A bone marrow core biopsy revealed an increase in reticulin fibre and increase in the number of blasts of 5%-10%, whereas peripheral blood testing was positive for JAK2 V617F mutation. This case report reviews the literature for cases of extramedullary haematopoiesis associated with myeloproliferative neoplasms.

Discordance Between Cobas BRAF V600 Testing and VE1 Immunohistochemistry in a Melanoma Patient With Bone Marrow Metastases.

False negative result remains an ongoing problem in direct gene sequencing of cancers. It is important to use the appropriate mutation detection method most appropriate to each circumstance and the available tissue. Here, we report a patient with melanoma of unknown primary with metastases to spleen and bone marrow, who was tested negative for Cobas BRAF V600E mutation, whose cancer progressed on antiprogrammed death 1 (PD1) receptor monoclonal antibody therapy. Subsequent VE1 immunohistochemistry was positive for BRAF V600E mutation, and the tumor responded dramatically to v-Raf murine sarcoma viral oncogene homolog B (BRAF)/Mitogen-activated protein kinase inhibitor combination therapy. This demonstrates how alternative BRAF testing methodology could produce results that can influence treatment choice and the outcome.

Fatalities associated with the 2009 H1N1 influenza A virus in New York city.

BACKGROUND. When the 2009 H1N1 influenza A virus emerged in the United States, epidemiologic and clinical information about severe and fatal cases was limited. We report the first 47 fatal cases of 2009 H1N1 influenza in New York City. METHODS. The New York City Department of Health and Mental Hygiene conducted enhanced surveillance for hospitalizations and deaths associated with 2009 H1N1 influenza A virus. We collected basic demographic and clinical information for all patients who died and compared abstracted data from medical records for a sample of hospitalized patients who died and hospitalized patients who survived. RESULTS. From 24 April through 1 July 2009, 47 confirmed fatal cases of 2009 H1N1 influenza were reported to the New York City Department of Health and Mental Hygiene. Most decedents (60%) were ages 18-49 years, and only 4% were aged 65 years. Many (79%) had underlying risk conditions for severe seasonal influenza, and 58% were obese according to their body mass index. Thirteen (28%) had evidence of invasive bacterial coinfection. Approximately 50% of the decedents had developed acute respiratory distress syndrome. Among all hospitalized patients, decedents had presented for hospitalization later (median, 3 vs 2 days after illness onset; P < .05) and received oseltamivir later (median, 6.5 vs 3 days; P < .01) than surviving patients. Hospitalized patients who died were less likely to have received oseltamivir within 2 days of hospitalization than hospitalized patients who survived (61% vs 96%; P < .01). CONCLUSIONS. With community-wide transmission of 2009 H1N1 influenza A virus, timely medical care and antiviral therapy should be considered for patients with severe influenza-like illness or with underlying risk conditions for complications from influenza.

agr function in clinical Staphylococcus aureus isolates.

The accessory gene regulator (agr) of Staphylococcus aureus is a global regulator of the staphylococcal virulon, which includes secreted virulence factors and surface proteins. The agr locus is important for virulence in a variety of animal models of infection, and has been assumed by inference to have a major role in human infection. Although most human clinical S. aureus isolates are agr(+), there have been several reports of agr-defective mutants isolated from infected patients. Since it is well known that the agr locus is genetically labile in vitro, we have addressed the question of whether the reported agr-defective mutants were involved in the infection or could have arisen during post-isolation handling. We obtained a series of new staphylococcal isolates from local clinical infections and handled these with special care to avoid post-isolation mutations. Among these isolates, we found a number of strains with non-haemolytic phenotypes owing to mutations in the agr locus, and others with mutations elsewhere. We have also obtained isolates in which the population was continuously heterogeneous with respect to agr functionality, with agr(+) and agr(-) variants having otherwise indistinguishable chromosomal backgrounds. This finding suggested that the agr(-) variants arose by mutation during the course of the infection. Our results indicate that while most clinical isolates are haemolytic and agr(+), non-haemolytic and agr(-) strains are found in S. aureus infections, and that agr(+) and agr(-) variants may have a cooperative interaction in certain types of infections.

Invasive group A streptococcal infection in high school football players, New York City, 2003.

After being notified that 2 high school football teammates from New York City were hospitalized with confirmed or suspected invasive group A streptococcal infections, we conducted an investigation of possible spread among other team members. This investigation highlights a need for guidelines on management of streptococcal and other infectious disease outbreaks in team sport settings.

Linezolid-associated toxic optic neuropathy: a report of 2 cases.

We describe 2 cases in which the prolonged use of linezolid to treat complicated methicillin-resistant Staphylococcus aureus infections was followed by acutely developed blurred vision and progressive loss of vision and color perception during the ensuing few weeks. Both patients received a diagnosis of toxic optic neuropathy, and linezolid therapy was stopped. The patients experienced an initial rapid partial improvement and a subsequent gradual, almost complete, recovery over many months.

Evolution and current use of the tuberculin test.

Since it was first introduced in the late 1800s, the tuberculin test has undergone continual refinement in its formulation, standardization, and dosage, as well as its interpretation and indications for use. New guidelines have replaced universal screening with targeted testing and rigid definitions of positivity with individualized criteria formulated from a Bayesian approach. This review summarizes the evolution of the test and provides information to help gauge its predictive value.