Mini-commentary on BJOG-20-0442.R2: Impact of hysterectomy on analgesic, psychoactive and neuroactive drug use in women with endometriosis: nationwide cohort study

Chylothorax is a well-recognized but uncommon complication during the postoperative period following the repair of left congenital diaphragmatic hernia. Conservative management with close monitoring of chylothorax output and patient status seems superior to surgery in managing this complication.

Laryngeal injury is a life-threatening risk in contact sports. Exercise-induced laryngeal obstruction (EILO) can occur as a result of trauma. Athletes can return to monitored training within weeks of laryngeal surgery. Due to the rarity and complexity of laryngeal trauma in sport, effective management requires a multidisciplinary approach.

DS-ALL patients have a higher rate of relapse and treatment-related mortality. We describe a DS-ALL patient with late bone marrow relapse who was treated per British ALL R3 reinduction chemotherapy. The patient remained in remission for approximately two years after therapy was discontinued due to severe systemic infections.

Carotid artery dissection should be considered in the differential diagnosis when a clinician face with a case presenting with an unilateral Purtscher-like retinopathy.

IgG4-related disease (IgG4RD) with intracranial involvement is rare. We report a 56-year-old male who had an excellent response to rituximab and dexamethasone after going undiagnosed for 5 years. After 3 years of rituximab maintenance, he has no evidence of disease on brain MRI.

In this paper, we study a mixed problem for the nonlinear hyperbolic equation with a strong dissipation and a dynamical transmission condition. The existence and uniqueness theorems of local and global solutions are proved

Dear Editor, First we would like to thank Dr Lopez de la Cruz for her comments and interest about our recently published article “the odyssey of suturing cardiac wounds: lessons from the past”. We highly appreciated and agree with the complements she made especially about Larrey and Milton role in this field. One should also note Theodore Tuffier’s attempt at cardiac resuscitation in 1898 in a young man dying on the wards at La Pitié Hospital (Paris)¹. Although this act was performed on an unwounded heart it adds information about the history of surgical approach in such dramatic condition. We do recognize left anterolateral thoracotomy as the gold standard in an emergency room to treat a penetrating cardiac injury. However a median longitudinal sternotomy may be discussed in our opinion if the patient arrived directly in a cardiac surgery operating theater. The patent presented in our paper was directly brought in our operative theater of cardiac surgery and managed immediately by cardiac surgeons and cardiac anesthesiologists, with a cardiopulmonary bypass ready, dedicated scrub nurses and perfusionist. In such specific conditions a sternotomy may be discussed, depending on the context and the anatomical suspected lesions (it was the option retained in the presented case and the surgical procedure was safely performed with good outcome). Clearly, in a peripheral hospital or at the emergency room sternotomy is not an option to be considered and we agree with Dr Lopez de la Cruz.

Jones et al. have given us an excellent guide for the management of symptomatic osteonecrosis in children and young adults with ALL. (1) I would like to present our 10 year retrospective concurrent control evaluation of pamidronate for reducing the incidence of symptomatic osteonecrosis which may be of interest.Patients aged 10-28 years at time of ALL diagnosis were given intravenous pamidronate (1 mg/kg IV over 2 hours) monthly for one year at the discretion of the primary oncologist, starting as early as possible after diagnosis.Concurrent controls age 10-28 did not receive pamidronate. All were treated according to the concurrent COG protocols with intermittent dexamethasone during delayed intensification.(2) Imaging was performed if osteonecrosis was suspected based on symptoms. Patients with BCR-ABL ALL were excluded, as dasatinib may increase the risk of osteonecrosis. (3,4)Patients were diagnosed between January 2010 and March 2018. They were censored at relapse (n=4; 2 controls) bone marrow transplant (n=4; 3 controls) or at last follow up. Data was analyzed 6/1/2020. The median follow up is 3.3 years from diagnosis to event or censoring. This retrospective study was approved by Children’s Minnesota IRB. Data was entered into excel and transferred to SPSS version 23 for analysis.There were 65 patients, 38 males, 27 females, of which 49 had B-lineage and 16 T-lineage ALL. Pamidronate was started during induction in 63% of patients, and before delayed intensification in 85%. The mean, median and interquartile range for the number of pamidronate doses was 11.6, 12, 10.8 to 12. Pamidronate was used in 26 patients, with four subsequently developing symptomatic osteonecrosis. There were 39 concurrent controls who did not receive pamidronate with 14 developing osteonecrosis. Five from this group have since received joint replacements. There were no short or long term side-effects from pamidronate infusions including osteonecrosis of the jaw or hypocalcemia.The incidence of symptomatic osteonecrosis by Kaplan-Meier analysis with was 16% with pamidronate vs. 39% in controls (figure 1). P-value is significant at 0.043 (Breslow Generalized Wilcoxan). There was no significant difference in the leukemia lineage, gender distribution or Body Mass Index (BMI) at diagnosis between groups. For all patients the mean, median, and interquartile range for BMI was 25.8; 22.0; 14.2 to 28.8 Kg/m2.The age at diagnosis was significantly greater in the pamidronate group with a mean, median and Interquartile range 18.4; 18.6; 13.8 to 23.4 years for pamidronate patients vs. 15.6; 15.7; 11.5 to 19.9 in concurrent controls (independent means t-test p = 0.01). Age was not significant for osteonecrosis in Cox Proportional Hazard analysis (p=0.10).Study limitations include small numbers of patients from a single institution and lack of a randomized control group. Strengths of the study are the long duration of followup, as most of the patients are beyond the peak risk time for osteonecrosis. We hope these results even with its limitations would spark interest in a randomized trial of pamidronate in patients at high risk of symptomatic osteonecrosis.Author Contributions and Disclosures: Bruce Bostrom was the sole contributor to this submission and has no conflict-of-interest to disclose. Jack Knutson assisted with data collection as part of a high school senior mentor connection project. Char Bostrom provided invaluable editorial assistance.Figure 1 legend : Incidence of symptomatic osteonecrosis from time of ALL diagnosis in patients who received prophylactic pamidronate and concurrent controls.

Objectives To report changes in practice brought about by COVID-19 and the implementation of new guidelines for the management of tonsillitis and peritonsillar abscess (PTA), and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). Design Prospective multicentre national audit over 12 weeks from 6th April 2020. Setting UK secondary care ENT departments Participants Adult patients with acute tonsillitis and PTA Main outcome measures Re-presentation within 10 days for patients discharged from the ED. Results 83 centres submitted 765 tonsillitis and 416 PTA cases. 54.4% (n=410) of tonsillitis cases and 45.3% (187/413) of PTA were discharged directly from the ED. 9.6% (39/408) of tonsillitis and 10.3% (19/184) of PTA discharges re-presented within 10 days, compared to 9.7% (33/341) and 10.6% (24/224) for those initially admitted from ED. The subsequent admission rate of those initially discharged from ED was 4.7% for tonsillitis and 3.3% for PTA. IV steroids were given to 67.0% of tonsillitis patients (n=505/754) and 73.6% of PTA (n=304/413). 77.2% of PTA patients underwent drainage during their initial presentation (n=319/413), but there was no significant difference in re-presentation rate in those drained Vs not-drained (10.6% vs 9.5%, n=15/142 vs 4/42, p=0.846). Univariable logistic regression showed no significant predictors of re-presentation within 10 days. Conclusions Management of tonsillitis and PTA was affected during the initial peak of the pandemic, with a shift towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.

Isoprene (2-methyl-1, 3-butadiene (C5H8)) is one of the most prominent and abundant non-methane hydrocarbon existing in the lower level of the troposphere. In this work, possible reaction mechanism of chlorine (Cl) radical initiated isoprene and its subsequent reactions are investigated using quantum chemical methods. The calculated thermodynamic result shows that the reaction of isoprene with the Cl radical at the terminal C=C bond position plays an important role to predict the end products. The calculated rate coefficient for the reaction between isoprene and Cl radicals (Cl addition at C1, C3, C4 and C5 positions) is found to be 4.89⨯10-11, 6.91⨯10-10, 1.63⨯10-10 and 8.12⨯10-10 cm3/molecule/sec at 298K. The branching ratio and atmospheric lifetime have been calculated from the reaction rate coefficient values of isoprene+Cl. The reaction force analysis predicts Cl radical addition at the terminal C=C bond position plays a dominant role by structural rearrangement. The kinetic and thermodynamic results reveal that the electrophilic addition of Cl radical to the terminal carbon atom plays the dominant role in the marine boundary. Further, the subsequent reaction of Cl-isoprene adduct radical helps for the development of ozone layer during daytime.

Electrochemotherapy is an effective strategy for the treatment of solid tumors by exposing tumor cells to electric fields to enhance the bioactivity of non-permeable or low permeable anticancer drugs, such as cisplatin. To understand the improved efficiency of cisplatin in electrochemotherapy, the effects of oriented external electric fields (OEEFs) on the geometric structures and relevant electronic properties of cisplatin have been systemically investigated by density functional theory (DFT) computations in this work. Our results reveal that the presence of positive OEEFs on cisplatin can not only weaken its Pt-Cl bonds, but also enhance the intramolecular charge transfer in it, which effectively accelerates the critical hydrolysis step involved in the mechanism of its biological activity. Moreover, the positive OEEFs can facilitate the attack of the singly aquated cis-[Pt(NH3)2(H2O)Cl]+ on DNA, and enlarge the dipole moments and water solubility of cisplatin and its aquated product. Consequently, this work provides a deeper insight into the higher efficacy of electrochemotherapy than traditional chemotherapy from a molecular point of view.

Objectives: To report changes in practice brought about by COVID-19 and the implementation of new guidelines, and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). Design: Prospective multicentre national audit over 12 weeks from 6th April 2020. Setting: UK secondary care ENT departments. Participants: Adult patients with acute epistaxis Main outcome measures Re-presentation within 10 days for patients discharged from the ED. Results: 83 centres from all four UK nations submitted 2,631 valid cases. The majority of cases were ED referrals (89.7%, n=2,358/2,631). 54.6% were discharged from the ED following ENT review (n=1,267/2,322), of whom 19.5% re-presented within 10 days (n=245/1,259) and 6.8% were ultimately admitted (n=86/1,259). 46.7% of patients had a non-dissolvable pack inserted by ED prior to referral to ENT (n=1,099/2,355). The discharge rates for ED patients and their subsequent re-presentation rates were as follows: non-dissolvable packs, 29.5% discharged (n=332/1125), 18.2% re-presented (n=60/330); dissolvable products, 71.1% discharged (n=488/686), 21.8% re-presented (n=106/486); cautery only, 89.2% discharged (n=247/277), 20.0% re-presented (n=49/245); and no intranasal intervention, 85.5% discharged (n=200/234), 15.2% re-presented (n=30/198). Univariable logistic regression showed that not being packed by ED, antiplatelet medications, failed cautery and recent epistaxis treatment were significant predictors of re-presentation within 10 days. Conclusions: Management of acute epistaxis was notably affected during the initial peak of the pandemic, with a shift towards reduced admissions. This national audit highlights that many patients who may previously have been admitted to hospital may be safely discharged from the ED following acute epistaxis.

Background and purpose: Increasing evidence has shown that human cholestasis is closely related to hepatic macrophage accumulation and activation. Research has indicated that peroxisome proliferator-activated receptor-g (PPARg) activation exerts liver protection in cholestatic liver disease (CLD), particularly by ameliorating inflammation and fibrosis, thus limiting disease progression. However, existing PPARg agonists, such as troglitazone and rosiglitazone, have significant side effects that impede their clinical application in the treatment of CLD. In this study, we found that tectorigenin (TEC) can alleviate intrahepatic cholestasis in mice by activating PPARg. Experimental approach: Wild-type mice received intragastric administration of a-naphthylisothiocyanate (ANIT) or were fed a diet containing 0.1% 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) to establish an experimental intrahepatic cholestasis model and TEC intervention simultaneously, followed by determination of intrahepatic cholestasis and the involved mechanisms. In addition, PPARg deficient mice were administered ANIT and/or TEC to determine whether TEC exerts its liver protection effect by activating PPARg. Key results: Our results demonstrated that TEC intervention alleviated intrahepatic cholestasis by inhibiting hepatic macrophage recruitment and activation as well as promoting the expression of bile transporters through activating PPARg. Furthermore, our results show that TEC increased bile salt export pump (Bsep) expression through enhanced PPARg binding to the Bsep promoter. We also demonstrated that PPARg deficiency blocked the hepatocyte protective effect of TEC during cholestasis. Conclusions and implications: In conclusion, TEC reduced hepatic macrophage recruitment and activation, and enhanced bile acid export by activating PPARg. Taken together, our results suggest that TEC is a potential drug for the prevention of CLD.

A 13-month-old healthy patient without COVID-compatible symptoms and no known sick contacts presented to the emergency department with an esophageal coin. New institutional policy requiring pre-operative SARS-CoV-2 testing was positive for the virus. Additional precautions were taken in the operating room to successfully prevent transmission of the virus.

The atrial septal aneurysm is a rare cardiac abnormality that is usually detected during routine echocardiography or evaluation of cases with thromboembolism. We report a 62 years old male who presented with abdominal pain and bleeding per rectum found to have ischemic colitis and atrial septal aneurysm on transesophageal echocardiogram.

Aims of the study Patient comprehension is a critical part of meeting standards of informed consent in study designs. The aim of the study was to determine if extant literature exists to require clinicians to disclose the specific risk that COVID-19 vaccines could worsen disease upon exposure to challenge or circulating virus. Methods used to conduct the study Published literature was reviewed to identify extant preclinical and clinical evidence that COVID-19 vaccines could worsen disease upon exposure to challenge or circulating virus. Results of the study Based on the history of coronavirus vaccine development, COVID-19 vaccines designed to elicit neutralizing antibodies may sensitize vaccine recipients to more severe disease than if they were not vaccinated. Vaccines for SARS, MERS and RSV have never been approved, and the data generated in the development and testing of these vaccines suggest a serious mechanistic concern: that vaccines designed empirically using the traditional approach (consisting of the unmodified or minimally modified coronavirus viral spike to elicit neutralizing antibodies), be they composed of protein, viral vector, DNA or RNA and irrespective of delivery method, may worsen COVID-19 disease via antibody-dependent enhancement (ADE) of either infection or disease. Conclusions drawn from the study and clinical implications The specific and significant COVID-19 risk of ADE should have been and should be clearly and emphatically disclosed to research subjects currently in vaccine trials, as well as those being recruited for the trials and future patients after vaccine approval, in order to meet the medical ethics standard of patient comprehension.

Reimplantation of the supra-aortic vessels can be challenging with Thoraflex Hybrid. A device modification made the vessel lengths more appropriate and the position of the neo-vessels in the chest avoided malpositioning and kinking and facilitated sternum closure; this may improve operating times as well as allowing complete and continuous cerebral trivascular perfusion and corrects positioning of the intrathoracic vessels.