Metastatic Breast Cancer to the Cervix Presenting with Abnormal Vaginal Bleeding During Chemotherapy: A Case Report and Literature Review.

The most common sites of invasive breast cancer metastasis are the lungs, liver, bones and brain. Less frequent sites include the gastrointestinal tract, pancreas, spleen, thyroid, adrenals, kidneys, heart and female genital tract. The uterus is reported as a rare site for metastasis, and even more so for an isolated metastasis. Other sites of extra-genital sources for uterine metastases include the colon, stomach, pancreas, gallbladder, lung, cutaneous melanoma, urinary bladder and thyroid. The rarity of breast cancer metastasis to the uterine cervix could be explained by the fact that the cervix has a small blood supply and an afferent lymph drainage system alone. It is rare to diagnose a cervical metastasis prior to eliciting the primary breast disease. Invasive lobular carcinoma metastasises to the female reproductive system more frequently than invasive ductal carcinoma. This paper presents a case of breast cancer metastasis to the cervix.

Burden of depressive disorders in Vietnam from 1990 to 2019: A secondary analysis of the Global Burden of Disease Study 2019.

Depressive disorders are among the leading causes of disability globally. However, information on the burden of depressive disorders in Vietnam is limited. We aimed to analyse the burden of depressive disorders in Vietnam from 1990 to 2019. Using data from the Global Burden of Disease Study 2019, prevalence and disability-adjusted life-years (DALYs) were used as indicators to analyse the burden of depressive disorders by age and sex. In 2019 in Vietnam, depressive disorders comprised 2629.1 thousand (95% uncertainty interval (UI): 2233.3-3155.9) estimated cases and 380.6 thousand (95% UI: 258.9-533.8) estimated DALYs. The crude prevalence rate of depressive disorders was higher among females than among males. The DALYs of depressive disorder accounted for a higher percentage of the total all-cause DALYs in the 10-64-year age group than in other age groups. Major depressive disorder was the largest contributor to the burden of depressive disorders. From 1990 to 2019, the crude prevalence and DALY rates per 100 000 population due to depressive disorders increased significantly, whereas age-standardised rates of prevalence and DALYs decreased significantly; the respective average annual percent changes were 0.88% (95% confidence interval: 0.87 to 0.89), 0.68% (0.66 to 0.70), -0.20% (-0.21 to -0.19), and -0.27% (-0.28 to -0.25). Although the age-standardised prevalence rate was lower than that seen globally, depressive disorders were considerable mental health issues in Vietnam. This study will help governments and policymakers to establish appropriate strategies to reduce the burden of these disorders by identifying the priority areas and individuals.

Trends in Head and Neck Cancer Mortality from 1999 to 2019 in Japan: An Observational Analysis.

Globally, the numbers of head and neck cancer (HNC) cases and related deaths have recently increased. In Japan, few studies have examined crude or age-adjusted HNC mortality rates. Therefore, this study aimed to determine the trends in crude and age-adjusted mortality rates for HNC per million individuals in Japan from 1999 to 2019. Data on HNC-associated deaths were extracted from the national death certificate database using the International Classification of Diseases, Tenth Revision (n = 156,742). HNC mortality trends were analysed using joinpoint regression models to estimate annual percentage change (APC) and average APC (AAPC). Among men, no significant change was observed in the age-adjusted death rate trend from 1999 to 2014; however, a marked decrease was observed from 2014 to 2019. No changing point was observed in women. Age-adjusted mortality rates continuously decreased over the 21-year period, with an AAPC of -0.7% in men and -0.6% in women. In conclusion, the overall trend in age-adjusted rates of HNC-associated deaths decreased, particularly among men, in the past 5 years. These results will contribute to the formulation of medical policies to develop targeted screening and prevention programmes for HNC in Japan and determine the direction of treatment strategies.

International consensus on patient-centred outcomes in eating disorders.

The effectiveness of mental health care can be improved through coordinated and wide-scale outcome measurement. The International Consortium for Health Outcomes Measurement has produced collaborative sets of outcome measures for various mental health conditions, but no universal guideline exists for eating disorders. This Position Paper presents a set of outcomes and measures for eating disorders as determined by 24 international experts from professional and lived experience backgrounds. An adapted Delphi technique was used, and results were assessed through an open review survey. Final recommendations suggest outcomes should be tracked across four domains: eating disorder behaviours and cognitions, physical health, co-occurring mental health conditions, and quality of life and social functioning. Outcomes are collected using three to five patient-reported measures. For children aged between 6 years and 12 years, the measures include the Children's Eating Attitude Test (or, for those with avoidant restrictive food intake disorder, the Eating Disorder in Youth Questionnaire), the KIDSCREEN-10, and the Revised Children's Anxiety and Depression Screener-25. For adolescents aged between 13 years and 17 years, the measures include the Eating Disorder Examination Questionnaire (EDE-Q; or, for avoidant restrictive food intake disorder, the Nine-Item Avoidant Restrictive Food Intake Disorder Screener [NIAS]), the two-item Patient Health Questionnaire (PHQ-2), the nine-item Patient Health Questionnaire (PHQ-9), the two-item Generalised Anxiety Disorder (GAD-2), the seven-item Generalised Anxiety Disorder (GAD-7), and the KIDSCREEN-10. For adults older than 18 years, measures include the EDE-Q (or, for avoidant restrictive food intake disorder, the NIAS), the PHQ-2, the PHQ-9, the GAD-2, the GAD-7, the Clinical Impairment Assessment, and the 12-item WHO Disability Assessment Schedule 2.0. These questionnaires should be supplemented by information on patient characteristics and circumstances (ie, demographic, historical, and clinical factors). International adoption of these guidelines will allow comparison of research and clinical interventions to determine which settings and interventions work best, and for whom.

Identification of mineral deposits in the brain on radiological images: a systematic review.

OBJECTIVES: MRI has allowed the study of mineral deposition in the brain throughout life and in disease. However, studies differ in their reporting of minerals on MRI for reasons that are unclear. METHODS: We conducted a systematic review from 1985 to July 2011 to determine the appearance of iron, calcium, copper and manganese on MRI and CT and their reliability. We assessed which imaging investigations provided the most consistent results compared with histology. RESULTS: Of 325 papers on minerals imaging, we included 46 studies that confirmed findings either directly or indirectly using a non-imaging method such as histology. Within this group, there was inconsistency in the identification of iron probably because of changes in its paramagnetic properties during its degradation. Iron appeared consistently hypointense only on T2*-weighted MRI, and along with calcified areas, hyperattenuated on CT. Appearance of copper, calcium and manganese, although consistently reported as hyperintense on T1-weighted MRI, was confirmed histologically in few studies. On T2-weighted imaging, calcified areas were always reported as hypointense, while the appearance of iron depended on the concentration, location and degradation stage. CONCLUSIONS: More work is required to improve the reliability of imaging methods to detect and differentiate brain mineral deposition accurately. KEY POINTS: There is inconsistency in reporting the appearance of minerals on radiological images. • Only 46 studies confirmed mineral appearance using a non-imaging method. • Iron is the mineral more widely studied, consistently hypointense on T2*-weighted MRI. • T1-weighted MRI consistently reported copper, calcium and manganese hyperintense. • Calcium is consistently reported hypointense on T2-weighted MRI and hyperattenuating on CT.

Efficacy of perineural versus intravenous dexamethasone in prolonging the duration of analgesia when administered with peripheral nerve blocks: a systematic review and meta-analysis.

BACKGROUND: Perineural dexamethasone has been regarded as a promising adjunct for prolonging the duration of nerve blocks. However, it is uncertain whether its effects are due to local effects on the nerves or from systemic absorption. This systematic review aimed to compare the duration of postoperative analgesia associated with perineural versus intravenous dexamethasone as an adjunct to peripheral nerve blocks. METHODS: A total of 2,216 relevant academic articles were identified after a comprehensive search of PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from 1967 until 2020. All randomized controlled trials that compared perineural and intravenous dexamethasone as adjuncts to peripheral nerve limb blocks were included. RESULTS: Fifteen randomized controlled trials (1,467 cases; 738 perineural dexamethasone, 729 intravenous dexamethasone) were eligible. The primary outcome (duration of analgesia) was significantly longer in the perineural than in the intravenous dexamethasone group (mean difference [MD]: 2.72 h, 95% CI [1.42, 4.01], P < 0.001). Perineural dexamethasone was also found to prolong the sensory block (MD: 3.45 h, 95% CI [1.36, 5.54], P = 0.001) and lower 24 h postoperative pain scores (MD: -0.74 h, 95% CI [-1.40, -0.07], P = 0.03). CONCLUSIONS: This review confirms the greater efficacy of perineural compared to intravenous dexamethasone in prolonging the analgesic duration of peripheral nerve blocks. However, the extent of prolongation was small and may not represent a clinically meaningful difference.

Indeterminate (B3) Breast Lesions and the Ongoing Role of Diagnostic Open Biopsy.

INTRODUCTION: Due to their uncertain malignant potential, indeterminate breast lesions on core needle biopsy (CNB) require diagnostic open biopsy (DOB). This study evaluated DOB results given largely benign pathology. Lesions included are atypical papilloma, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and radial scar/complex sclerosing lesions (RS/CSL). Methodology. A retrospective audit from 2010 to 2017 analysed patients with a screen-detected suspicious lesion and indeterminate (B3) CNB diagnosis. Primary outcome was the malignancy upgrade rate, with secondary evaluation of patient factors predictive of malignancy including age, symptoms, mammogram characteristics, lesion size, biopsy method, and past and family history. RESULTS: 152 patients (median age 57 years) were included, with atypical papillomas being the largest subgroup (44.7%). On DOB histology, 99.34% were benign, resulting in a 0.66% malignancy upgrade rate. Patient characteristic analysis identified 86.84% of B3 lesions were in patients greater than 50 years old. 90.13% were asymptomatic, whilst 98.68% and 72.37% had a negative past and family history. Majority 46.71% of lesions had the mammogram characteristic of being a mass. However, with 57.89% of the lesion imaging size less than 4 mm, a corresponding 60.5% of core needle biopsies were performed stereotactically. The small malignant subgroup limited predictive factor evaluation. CONCLUSION: Albeit a low 0.66% malignancy upgrade rate in B3 lesions, no statistically significant patient predictive factors were identified. Until predictive factors and further assessment of vacuum-assisted excision (VAE) techniques evolve, DOB remains the standard of care.

Reported outcomes for planned caesarean section versus planned vaginal delivery: A systematic review.

BACKGROUND: There is currently no consensus regarding the outcomes and outcome measures that should be reported in studies assessing planned mode of birth. OBJECTIVE: To develop an inventory for reported outcomes for studies comparing planned caesarean section (CS) and planned vaginal delivery (VD) for women age 18-45. METHODS: A systematic review of outcomes reported in prospective studies investigating planned CS and planned VD was conducted. Three online databases, Ovid SP version of MEDLINE and EMBASE and the Cochrane Pregnancy and Childbirth Group's Trials Register, were searched from 2011 to June 2019. The inclusion criteria were: prospective studies evaluating planned mode of birth, age 18-45, singleton pregnancy, gestational age 37-40 weeks, >100 participants, middle or high income countries. No language restrictions were applied. Two researchers independently screened titles and abstracts, and subsequently reviewed the full text of each selected study to assess for eligibility. Discrepancies were resolved by discussion with a third author. The selected studies were evaluated using the MOMENT criteria. Outcomes and outcome measures were systematically extracted and organised into an inventory. RESULTS: 63 prospective studies comparing planned CS versus planned VD including data from 6,397,310 women were included. 37 studies (59%) investigating planned CS versus planned VD fulfilled four or more MOMENT criteria. In total, 43 different primary outcomes and 79 different primary outcome measures, and 12 different secondary outcomes and 31 secondary outcome measures were identified from studies investigating planned CS versus planned VD. CONCLUSION: The findings of this study will contribute to the development of a core outcome set for planned mode of birth in the future. Standardising outcomes will aid comparison and interpretation of data pertaining to planned CS versus planned VD. PROSPERO registration: CRD42019133104.

Isolated abducens nerve palsy in a patient with asymptomatic SARS-CoV-2 infection.

The neuro-ophthalmological complications of SARS-CoV-2 infection are emerging but the spectrum of presentations and pathophysiological mechanism underpinning the association remains to be fully determined. We describe the case of a 44-year-old female who presented with a 12-hour history of diplopia preceded by a mild headache and found to have an isolated right abducens nerve palsy. Initial vital signs were normal but she developed a fever and nasopharyngeal swab confirmed SARS-CoV-2 infection by RT-PCR. All other investigations returned normal including blood tests, chest X-ray, MRI brain and cerebrospinal fluid analysis. She remained systemically well, and there was complete resolution of the abducens palsy and diplopia at two week follow up. In the absence of an alternative underlying cause or risk factors identified, the aetiology was presumed to be microvascular and potentially related to the viral infection. We add to the evolving literature of neuro-ophthalmological associations of SARS-CoV-2, discuss possible causal mechanisms and suggest considering asymptomatic SARS-CoV-2 infection in cases of isolated abducens palsy without clear risk factors.

Occipital encephalocele in a neonate: a case successfully managed by excision and formation of a reverse visor scalp flap.

Encephaloceles are one form of neural tube defect and are associated with partial absence of skull bone fusion, with an incidence of 1-4 cases for every 10 000 live births. We report the case of a neonate born at term, with an antenatal diagnosis of occipital encephalocele, which was successfully managed with excision and formation of a reverse visor scalp flap on day 2 of life.Surgery was performed in a single stage, involving a multidisciplinary approach between neurosurgery and plastic surgery teams, with wider management involving neonatal intensive care, paediatric, obstetric and anaesthetic teams.The patient had no early postoperative complications, and we use this case report to demonstrate that a reverse visor scalp flap is a good option to cover full-thickness defects in patients with encephaloceles.Furthermore, we advocate early repair and a multidisciplinary approach to minimise the morbidity associated with occipital encephaloceles.

High-Frequency Jet Ventilation for a Patient With Tracheomediastinal Fistula, Tension Pneumomediastinum, and Pneumothorax: A Case Report.

Tracheomediastinal fistula (TMF) is an uncommon condition and carries a high mortality. We report the anesthetic management of a patient with TMF using stent insertion via rigid bronchoscopy. The TMF was a complication of double-lumen endotracheal tube insertion resulting in a tension pneumomediastinum. Initial intraoperative attempts to ventilate the lungs and overcome the air leak with high gas flow of 45 L/min via the side port of the bronchoscope resulted in a pneumothorax. This case report demonstrates that high-frequency jet ventilation can minimize the air leak and avoid barotrauma during anesthesia for TMF repair.

Characterisation of recent trends in cardiovascular risk factors in young and middle-aged patients with ischaemic stroke and/or transient ischaemic attack.

BACKGROUND: Strokes in the young and middle-aged are associated with a disproportionately large economic and social impact in addition to their clinical effects. Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes mellitus and smoking) are key drivers of cardiovascular disease including strokes, however recent temporal trends in the younger stroke population have not been well characterised. We aimed to evaluate recent trends of SMuRFs in a cohort of younger patients with ischaemic stroke. METHODS: Consecutive patients aged <65 years with clinical and/or radiological diagnosis of ischaemic stroke or transient ischaemic attack in a tertiary referral centre (2013-2017) were retrospectively appraised. The demographic and clinical comorbidities of these patients were assessed including their SMuRF profile. The prevalence over time and clinical associations of patients with no SMuRFs were studied and compared to patients with SMuRFs. RESULTS: Of 487 patients (53.49 ± 9.13 yrs., 60% men) analysed, 23% did not have SMuRFs. The proportion of "non-SMuRF" patients increased over time (p < 0.01) and this trend was not influenced by age (p = 0.48) or gender (p = 0.68). The presence of SMuRFs was not associated with in-hospital outcomes, however patients without SMuRFs were significantly less likely to be discharged on blood pressure (p < 0.01) and lipid-lowering therapies (p = 0.03). CONCLUSIONS: The proportion of younger stroke patients without SMuRFs is substantial and has increased over time. Our findings highlight the need for further research to better understand the mechanisms underlying stroke development in this population and whether less risk factor treatment in this population could impact longer term outcomes.

Urinary catheterization 2: technique and managing failure.

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic is discussed over two articles: the first article focused on indications, and this second discusses techniques and managing failure. Good technique is essential to prevent complications and if problems do occur, these must be managed efficiently to prevent long-term consequences. In some situations, this may require referral to the urology team for more specialized intervention. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

Urinary catheterization 1: indications.

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic will be discussed over two articles: this first article will focus on indications, and the second on techniques and managing failure. There are multiple indications for urethral catheter insertion and a range of catheter types and sizes. The choice of catheter is dependent on the patient and indication. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

Comparison of Formulae for Orotracheal Intubation Depth in the Paediatric Population.

INTRODUCTION: Multiple formulae have been proposed for calculating orotracheal depth for paediatric intubation. However, literature on the validation of these formulae in the emergency department setting is limited. Three methods described in the local Advanced Paediatric Life Support curriculum include the Broselow tape, endotracheal tube (ETT) size x 3, and the age-based formula of age divided by 2, add 12. We aimed to determine their accuracy. MATERIALS AND METHODS: Patients with intubation performed in the Children's Emergency from 1 January 2009 to 31 December 2013 were included in this retrospective observational study. The depths of ETT placement based on the formulae were calculated from the actual depth of ETT. ETT position between T2 to T4 vertebral bodies of the chest radiograph was taken as the reference position for radiological accuracy. RESULTS: ETT size x 3 has the highest accuracy of 76.5%, as compared to 67.9% for age-based formula and 63.5% for Broselow tape. When the formulae were inaccurate, Broselow tape often predicted a depth that was too shallow as compared to ETT size x 3 (P = 0.006) and age-based formula (P = 0.011). The accuracy of Broselow tape was not uniform across the age groups, with highest accuracy in patients 1 to 8 years old. ETT size x 3 had the highest accuracy in patients weighing more than 25 kg. CONCLUSION: ETT size x 3 was superior for determining orotracheal intubation depth but cannot preclude the confirmation of appropriate placement of ETT by auscultation and chest radiograph.

A cross-sectional survey on cold chain management of vaccines in Cebu, Philippines.

BACKGROUND: Appropriate cold chain management is the foundation of safety and quality of vaccines. OBJECTIVES: This cross-sectional study was conducted to assess the cold chain management of the rural health units of Consolacion and Liloan, Cebu, Philippines on August to September 2017. METHODS: Data was collected using a structured questionnaire, which was developed based on previous studies of cold chain survey. The questionnaire was administered to one personnel who is responsible for the storage and maintenance of vaccines in each public health center (PHC). RESULTS: Of 42 targeted PHCs, only 52.4% (n=22) agreed to join in the study. The results of the study indicated that storage units and equipments were available in all 22 PHCs, even though only five of them (22.7%) stored vaccines. The majority of PHCs (90.9%, n=20) did not have access to a generator and only 9% (n=2) had a voltage stabilizer connected to the refrigerator. Refrigerators that were equipped with thermometer were only found in 68.2% (n=15) PHCs. No statistically significant relationship was found (p=0.159) between the statuses of PHCs to store vaccine and the level of knowledge of health professionals assigned to manage the vaccine. CONCLUSIONS: Primary health centers that store vaccines have at least one functional refrigerator and freezer and alternative power sources. Contingency plans in the event of mechanical and power failure as well as proper temperature monitoring are needed. Personnel handling vaccines must be updated on proper storage and transport of such like the use of cold boxes and ice packs to maintain cold chain. Improvement of cold-chain management for vaccines in Cebu City's PHCs was necessary.

Improving the patient booking service to reduce the number of missed appointments at East London NHS Foundation Trust Community Musculoskeletal Physiotherapy Service.

The East London National Health Service Foundation Trust (ELFT) Community Musculoskeletal (MSK) Physiotherapy Service had reported a high rate of non-attendance at scheduled appointments. This was leading to delayed access to treatment for patients and a reduced capacity for service users, as well as a waste of clinical resources. The aim of this quality improvement project was therefore to reduce the percentage of missed appointments within this department. This study was undertaken by the ELFT community MSK service, with support from the ELFT Quality Improvement team. To begin with, patient complaints were explored; these indicated that the main reason for missing appointments was due to issues with the patient booking service. Baseline data were initially collected for both new referrals and follow-up patients. The proposed changes were then introduced, which included text message reminders, first via a manual platform and then via an automated system. Ongoing data were recorded to note the effectiveness of these changes. Following the intervention, non-attendance of newly referred patients reduced by 43.35% (23.76%-13.46%) after both cycles. Non-attendance of follow-up patients reduced by 44.14% (23.74%-13.26%) after the second cycle alone. By listening to the opinions of service users, it was possible to improve the patient booking system and the flexibility of appointments. This resulted in a reduction in the percentage of appointments missed. These changes will continue to be monitored within this department to ensure sustainability but there is also now potential for similar interventions to be trialled in other health service departments.

Development of an Atlantic salmon heart endothelial cell line (ASHe) that responds to lysophosphatidic acid (LPA).

As diseases and abnormalities of the heart can interfere with the aquaculture of Atlantic salmon, the heart was investigated as a source of cell lines that could be used to study the cellular basis of these conditions. An Atlantic salmon heart endothelial cell line, ASHe, was developed and characterized for growth properties, endothelial cell characteristics, and responsiveness to lysophosphatidic acid (LPA). AHSe cells stained negative for senescence associated ß-galactosidase and grew well in 10 and 20% FBS/L15 at high cell density, but not in L15 medium supplemented with calf serum. It displayed many endothelial cell-like characteristics including a cobblestone morphology, capillary-like structures formation on Matrigel, and expression of von Willebrand factor and endothelial cell-related tight junction proteins ZO-1, claudin 3, and claudin 5. ASHe cells responded to the cardiovascular modulator, LPA, in two contrasting ways. LPA at 5 and 25 µM inhibited the ability of ASHe cells to heal a wound but stimulated their proliferation, especially as evaluated by colony formation in low-density cultures. The enhancement of proliferation by LPA parallels what has been observed previously in mammalian endothelial cell cultures exposed to LPA, whereas the LPA slowing of ASHe cell migration contrasted with the LPA-enhanced migration of some mammalian cells. Therefore, this cell line is a potentially useful model for future comparative studies on piscine and mammalian cardiovascular cell biology and for studies on diseases of Atlantic salmon in aquaculture.