Mandibular Mucormycosis: A Report of Four Cases and a Discussion on Their Management.

Mucormycosis of the mandible (MOM) is a rare fungal infection, and only 23 cases had been reported during the last 50 years worldwide, from seven different countries. Most of the cases were reported in India (n=8, 34%), followed by the United States (n=5, 22%). It is usually associated with an immunocompromised state and generally occurs after tooth extraction. Radiographically, it presents with the characteristic sign of osteomyelitis. Most of the previous case reports/series on MOM described successful outcomes with the resection of the involved segment. However, our experience in managing these cases was quite different and it was observed that resection is seldom required. It was seen that MOM rarely causes cortical perforation. One of the probable reasons is the thicker cortical bone and well-confined boundary of the mandible. Another reason could be the fulminating nature of the disease that leads it to rapidly spread in less resistant medullary bone before perforating cortical bone. During surgery, a clear line was seen separating necrotic medullary bone from healthy cortical bone. The thicker cortical bone of the mandible was found to be resistant to fungal invasion; however, the medullary bone was rapidly invaded. Therefore, the healthy cortical bone could be saved. The preservation of the cortical parts thus helps in maintaining the continuity of the bone. Surgical curettage of necrotic medullary bone is usually the optimal method to manage MOM affecting the mandibular body or ramus region.

Hysterectomies for endometrial hyperplasia decreased during the first year of the COVID-19 pandemic: where have all the patients gone?

Objectives: To determine change in number of hysterectomies (hyst) and levonorgestrel intrauterine device (IUD) placements as treatment for endometrial hyperplasia (EH), and in the number of diagnostic procedures for abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB) performed during the first year of the COVID-19 pandemic compared to pre-pandemic levels. Method(s): Hospitals submitting data to the Vizient database for the period 2/1/19 through 2/1/21 provided the study population. We queried Vizient to identify patients undergoing (1) hyst, (2) IUD placement for EH, and (3) endometrial biopsy (EMB) or dilation and curettage (D&C) for AUB or PMB by month (mo.). We defined the pre-pandemic period as 2/1/19 through 1/31/20;2/1/20 began the pandemic period. Mean number/mo of EH hyst, EH IUD placement, and EMB or D&C for AUB or PMB for the pre-pandemic period established a baseline for comparison to mos during the first pandemic year. Result(s): 314 hospitals reported data on 2,374 EH hysts, 2,006 EH IUD placements, and 99,782 diagnostic procedures for AUB and PMB. The mean number of EH hysts was 118/mo pre-pandemic and 79.9/mo during the pandemic;the mean difference was 38.2/mo (95%CI 23.2- 53.1, p=0.00015). Mean EH IUD placements pre-pandemic were 87.6/ mo, and 79.6/mo during the pandemic;mean difference was 8/mo (95%CI -11-27, p=0.37). The mean number of combined EMBs and D&Cs pre-pandemic was 4,547/mo and 3,768/mo during the pandemic;mean difference was 778/mo (95%CI 80-1477, p=0.032).[Formula presented] Conclusion(s): During the first year of the COVID-19 pandemic, the number of EH hysts performed per mo decreased. We found no increase in EH IUD placement. Although Vizient does not report the number of patients prescribed oral progesterone as an alternative treatment, we found that the total number of patients undergoing diagnostic procedures for AUB and PMB decreased significantly during the pandemic period, suggesting that the deficit in hysts performed for EH is due, in part, to fewer patients presenting for workup of abnormal bleeding. Together with our earlier report that 20% fewer hysts for EC were done during the first pandemic year, our findings suggest a meaningful delay in care. More research is needed to determine if this delay will impact stage, treatment and outcome. Data for the 2nd pandemic year will be analyzed in time for the meeting.Copyright © 2022 Elsevier Inc.

Successful treatment of viral warts with topical and intralesional cidofovir in an immunocompromised paediatric patient

Cidofovir is well described as an effective antiviral agent. It is reported to treat viral warts successfully in immunocompetent and immunocompromised individuals. Unfortunately, its use may be limited by the high cost and pain of treatment. We here report the successful treatment of multiple palmoplantar warts in an 8-year old male undergoing chemotherapy for relapsed acute lymphoblastic leukaemia. His most significant lesion was a 3 x 3 x 1.5 cm tumorous lesion on the central plantar forefoot that interfered with weight bearing. It had been resistant to over-the-counter treatments, cryotherapy, silver nitrate cautery, curettage and cautery, cantharadin and topical 5-fluorouracil. He was developing multiple satellite lesions and they had spread to the toes, the other foot and both hands, totalling more than 30 lesions. The first treatment session was during sedation for intrathecal chemotherapy. One millilitre of cidofovir (diluted to 15 mg mL-1) was instilled to the largest lesion (although solution was seen visibly escaping from the surface). The remainder of the vial was compounded to topical cidofovir 1% in Eucerin, which he applied once daily to remaining lesions. His postprocedure recovery was unremarkable, with no analgesia requirements or other complications. By the time of review 4 weeks later, the verruca that had received one session of intralesional treatment had completely resolved. Some of the smaller warts had shrunk in size. Despite reports of pain associated with intralesional cidofovir injections, our patient was keen for a repeated treatment to more lesions without sedation/anaesthetic. He tolerated the treatment of a number of remaining lesions without the need for topical or local anaesthesia. Treatments continued at 4-weekly intervals (to coincide with his chemotherapy regimen) with good response and no side-effects. After three treatment sessions most lesions had resolved with only some smaller lesions remaining. Unfortunately, his next treatments were suspended as he contracted COVID-19. In summary, we report the successful eradication of significant and widespread viral warts in an immunocompromised paediatric patient. Reports in patients under 10 years of age are scarce. We also confirm excellent tolerance of the procedure. Although the high cost of cidofovir may seem prohibitive, given that one vial could generate around 25 mL solution and 0.2-1 mL is needed per lesion, we would argue that it may be more costeffective than multiple sessions of other less/ineffective modalities. Furthermore, its antiviral mechanism of action is particularly beneficial in immunocompromised patients in comparison with other modalities, which require an efficient immune response in order to be successful.

IUGR And Preterm Labor Occurrence In Pregnant Women With Early Pregnancy Vaginal Bleeding And History Of COVID-19 Infection

Background Vaginal bleeding is a common complication that may occur at any time during pregnancy. Up to 22% of women asked at delivery reported that vaginal bleeding occurred at some time during pregnancy. Preterm delivery is the delivery before 37 weeks of gestation, which involves approximately 12% of all pregnancies. If vaginal bleeding happens during pregnancy, some adverse outcomes including mortality before and after birth, low birth weight and preterm delivery will be increased. Vaginal bleeding is associated with two-fold increased risk of preterm delivery. Methods This prospective cohort study included 60 cases of pregnant female with first or second trimester vaginal bleeding at Obstetrics& Gynecology Department, Faculty of Medicine, of Damanhur Medical National Institute. The duration of the study was from April 2021 to April 2022. In the study 4 cases refused to complete the study and other 56 completed. Results There was significant decrease in birth weight and Apgar score with increase severity of vaginal bleeding. There was significant increase in neonatal intensive care unit (NICU) admission, intrauterine growth restriction (IUGR) occurrence and preterm labor with increase severity of vaginal bleeding. There was significant positive correlation between vaginal bleeding and IUGR and NICU admission. There was significant negative correlation between vaginal bleeding and Birth weight and APGAR score. Conclusion It seems that previous COVID-19 infection does not affect greatly pregnancy outcomes associated with vaginal bleeding. Vaginal bleeding was the main parameter affecting pregnancy outcomes.Copyright © 2022 Authors. All rights reserved.

Virtual undergraduate dermatology teaching using headmount camera video

Undergraduate clinical dermatology teaching in our hospital was delivered pre-COVID-19 to fourth-year medical students via an objective structured clinical examination-style circuit education session, with preselected live patients displaying important clinical presentation signs. A combination of posters, quizzes and interactive stations (e.g. topical therapy application and cryotherapy demonstration) were also used. Feedback for this consultant-delivered clinical teaching session was always excellent. However, this format did not lend itself easily to virtual teaching when COVID-19 forced immediate changes to undergraduate teaching delivery. A particular, understandable anxiety specifically reported by students was the loss of 'hands-on' clinical teaching with patients. Despite COVID-19 restrictions, a significant number of our face-toface clinics continued and so to harness these clinical teaching opportunities, both live and recorded patient video interactions were arranged. With local university and health-board approval, we obtained written patient consent to record consultations and used secure portals offered by Microsoft Office 365 to display live videos or recorded consultations using a secure NHS Microsoft Teams group, which allowed storage of these teaching videos within its One Drive application. To mimic a 'hands-on' patient interaction, a head-mount (temporal), wireless, 4 K camera was used to mirror the view of the clinician. For skin lesion consultations, ring lamp and dermoscopy magnification examination could also be included (additional still images could also be added retrospectively to any offline video edit). Full-skin examination and general dermatology findings, such as rash pattern and distribution, were highlighted. Some surgical procedures were also recorded, including local anaesthesia infiltration, skin excisions and curettage, as well as cryotherapy administration and topical therapy application. Despite novice use of this teaching technique, video quality was good and feedback excellent, with students appreciating the efforts made to provide interactive clinical teaching during an unprecedented time. Limited existing literature highlighting the use of such teaching models has mainly come from its application in postgraduate surgical specialty intraoperative teaching. We hope the merits of these techniques can be applied to current undergraduate dermatology teaching methodology. We plan to continue to record further clinical consultations to expand our existing teaching video portfolio and are likely to continue to use this as an adjunct resource in our undergraduate teaching delivery. Depending on student feedback, we may consider future professional video recording methods from our university and medical illustration colleagues.

Silver nitrate-induced skin inflammation mimicking surgical infection

Silver has been in medicine for hundreds of years and has proven antimicrobial properties. It was widely used until the Second World War, when antibiotics emerged. Silver nitrate (SN) sticks (75% silver nitrate and 25% potassium nitrate) are currently employed as a topical haemostatic agent for various cutaneous surgical procedures. In the initial phase of the COVID-19 pandemic, faced with a limited supply of personal protective equipment, we used SN stick haemostasis for several skin surgical procedures (including excisions). COVID-19-related guidance from the Trust recommended the avoidance of electrocautery owing to the generation of surgical plume;hence, SN stick haemostasis seemed a pragmatic option. Four female patients with a mean age of 67 years (range 48-75) presented with swelling, erythema and pain at the surgical site within a week of the procedure. Three had ellipse excisions for suspected melanoma and squamous cell carcinomas, and one had a shave excision for possible seborrhoeic keratosis. Postsurgical wound infection was suspected, but repeated microbiological swabs did not grow any pathogens. All patients failed to respond to broad-spectrum oral antibiotics, even after two courses. The inflammatory changes took up to 4 weeks to settle, with topical corticosteroids used for wound healing. On contact with moisture, SN sticks deliver free silver ions that form an eschar as they bind to the tissue and occlude vessels. The longer the tip contacts the tissue, the greater the degree of the resultant caustic action. It is widely used in clinical practice, especially wound care (overgranulation, epibole and delayed healing). A 2020 review found an increased incidence of postoperative pain along with pigmentary changes in surgical wounds treated with SN sticks vs. aluminium chloride hexahydrate and ferric subsulfate. In skin surgery, SN is used to cauterize superficial wounds after curettage and shave excision. It does not generate aerosol and, in a pandemic setting, this particular feature can be valuable. However, the potential to cause aseptic skin inflammation that mimics postoperative infection is noteworthy. There are no evidence-based guidelines for its use in dermatology. We believe that the SN is an effective haemostatic agent but can induce significant tissue inflammation in some patients, particularly if it is used in excisions when the cauterized tissue is closed. If SN-induced haemostasis for excision was to be adopted in clinical practice, our experience suggests that larger studies and guidelines are recommended.

A Case Report of Non-puerperal Uterine Inversion

Objective: Non-puerperal uterine inversion is a rare occurrence. The common etiology for this condition is uterine sarcoma, endometrial carcinoma, and myoma. Case Presentation: This case is a 44-year-old woman with a protruding malodorous vaginal mass, abdominal pain, and urinary retention. Total hysterectomy with bilateral salpingectomy was per-formed. Conclusion: Diagnosis of uterine inversion might be difficult and requires a high index of suspicion. © 2023 Bentham Science Publishers.

The effect of online video-assisted teaching program on medical students learning procedure of fractional curettage.

OBJECTIVES: Since 2020, with the entire world in crisis over the coronavirus pandemic (COVID-19), medical students have adapted to hybrid and distance learning. This study aims to compare the learning outcomes of students learning the procedure of fractional curettage in an online video-assisted teaching program to those of students learning the procedure in a traditional class. METHODS: A quasi-experimental study was conducted among fourth-year medical students who rotated to Obstetrics and Gynecology courses between April 2021 and October 2021. Participants in the first two rotations were enrolled in traditional classes, and the online video-assisted teaching program was introduced in the subsequent two rotations. Both study groups took OSCEs (objective structured clinical examinations), a pre-test and post-test with MCQs (multiple choice questions), and a confidence and satisfaction level questionnaire. RESULTS: A total of 106 fourth-year medical students, 54 in the traditional group and 52 in the online video-assisted teaching program, were recruited. The online video-assisted group showed a statistically better mean OSCE score (85.67 ± 11.29 vs. 73.87 ± 13.01, p < 0.001) and mean post-test MCQ score than the traditional group (4.21 ± 0.87 vs. 3.80 ± 0.98, p = 0.0232). Moreover, the mean difference between the two groups' pre and post-test MCQ scores was significantly different (0.96 ± 1.37 vs. 1.79 ± 1.50 in traditional and online video-assisted teaching program groups, respectively, P = 0.0038). The participants in the experimental group reported significantly greater confidence (P < 0.001) in performing the fractional curettage procedure. However, the mean satisfaction score was significantly higher in the control group (p = 0.0053). CONCLUSION: The online video-assisted teaching program on the fractional curettage procedure, a necessary and skill-demanding procedure, is an effective and advantageous education tool that improves skills, knowledge, and confidence in fourth-year medical students. We recommend that the video-assisted teaching program is another effectively procedural teaching method for medical students.

Diagnostic delay due to COVID-19 pandemic: a case of uncontrolled growth of peripheral giant cell granuloma

COVID-19 pandemic had several consequences including reduced access to public health care service that led to significant delays in screenings, diagnosis, and treatments. Peripheral giant cell granuloma (PGCG) is a benign exophytic lesion of reactive nature, affecting gingiva and alveolar ridge. Recent studies report its highest prevalence in 5th-6th decade of age, occurring mainly in mandible with an average size of 1.3-1.7 cm. We aimed to show the impact of pandemic on diagnosis delay in a patient with peripheral giant cell granuloma that reached unusual dimensions. ACaucasian 61-year-old male referred to our observation for the presence of an exophytic lesion on edentulous alveolar crest of the mandible. He was an edentulous patient, that developed a lesion of unusual dimensions of 7x4.5x3.5 cm. The soft consistency, slow exophytic growth and bluish-red color suggested an inflammatory hyperplastic nature of the lesion. An excisional biopsy was performed in association with curettage of underlying periosteum. Histological examination revealed presence of spindle-shaped mononuclear cells and multiple multinucleated giant cells in a well vascularized stromal tissue. No calcifications were found. Clinical and histological features suggested the diagnosis of PGCG. This case is clinical evidence of the delays induced by the COVID-19 emergency, which negatively affected all health care and suggests that the PGCG, albeit benign in nature, may have an uncontrolled and non-self-limiting growth, making its surgical removing and healing process more complicated. Copyright © 2022 Edizioni Minerva Medica. All rights reserved.

People with cystic fibrosis do not show an increased interferonresponse transcriptomic signature in nasal epithelial cells

Objectives: People with CF (PwCF) are at increased risk of respiratory infections and chronic inflammation.We sought to determine whether the inflammatory response is different in nasal epithelium of PwCF compared to healthy volunteers (HV). Since Interferons can increase ACE2 expression, a protein required for SARS-CoV-2 entry,we focused our analysis on the the focusing on the interferon-response signature. Methods: We reanalysed nasal curettage sample bulk RNA-seq signatures of pilot and validation datasets for which the study methods and demographics of the recruited cohort have already been reported. For this analysis, we performed in-silico deconvolution of bulk RNA-seq data using publicly available single-cell RNA-seq data from nasal epitheliumas a reference to determine the abundance of the specific cell types in each sample. Results: Hierarchical clustering of the pilot and validation cohorts revealed 3 clusters. Analysis of the larger validation cohort revealed that Cluster A included HV (11 out of 11 subjects) and both homozygous (7 out of 13 subjects) and heterozygous (3 out of 10 subjects) PwCF. Subject cluster A was characterised by increased expression of genes related to secretory and ciliated epithelial cells, whereas Clusters B and C contained both homozygous and heterozygous PwCF only and were characterised by genes restricted to neutrophils and involved in immune responses. We then compared samples from cluster A that contained samples from HV (n = 11), PwCF homozygous (n = 7) and heterozygous (n = 3) for F508del. This analysis identified 379 genes upregulated in HV and 146 genes upregulated in PwCF homozygous for F508del and only 44 and 6 genes upregulated in HV and PwCF heterozygous for F508del, respectively (FDR q < 0.05). ACE2, TMPRS2 or other interferon-response genes were not deferentially expressed in either comparison of cluster A. Conclusion: PwCF do not have higher expression of interferon-response genes in nasal epithelial cells

BEDSIDE TEST TO RULE OUT AN ECTOPIC PREGNANCY USING A MODIFIED FDA APPROVED KIT

OBJECTIVE: To evaluate the accuracy of a modified bedside test in ruling out an ectopic pregnancy. The test is based on a lateral flow immunoassay for alpha-fetoprotein (AFP). It has been shown that a high AFP level in vaginal blood indicates the passage of fetal tissue, suggestive of a miscarriage [1].We hypothesized that high AFP levels in sampled intrauterine tissue, assuming non-heterotopic pregnancy, rules out the presence of an ectopic pregnancy. MATERIALS AND METHODS: This is a prospective cohort study. The study included pregnant women undergoing a dilation and curettage (D&C) for pregnancy loss or termination, women with pregnancy loss or an ectopic pregnancy presenting with vaginal bleeding, and non-pregnant women with vaginal bleeding. Vaginal blood was collected on gauzes, sanitary pads, and cotton swabs. Samples were then tested for AFP levels using a commercial kit (ROMplus, Laborie, USA) originally designed to detect leakage of amniotic fluid. This kit contains a lateral flow immunoassay strip capable of detecting the presence of AFP. Positive samples for AFP were retested at a later date (after 3 to 20 days) to ascertain the stability of AFP and reliability of the test. Official sonograms, pregnancy tests, and final pathology results were obtained to confirm pregnancy status as well as the presence or absence of fetal tissue in the vaginal blood. A sensitivity and specificity analysis was performed against these final results to validate the accuracy of the test strip in ruling out an ectopic pregnancy. RESULTS: A total of 30 vaginal blood samples were tested for AFP. All pregnant women who had a miscarriage or D&C had detectible AFP in their vaginal blood (n=13). On retesting the samples 3 to 20 days later, these results remained the same (positive test strip). The remaining 17 vaginal blood samples were from 4 women with ectopic pregnancies and from 13 non-pregnant women with vaginal bleeding. All 4 ectopic pregnancies had no AFP detected in the vaginal blood and only 1 out of 13 non-pregnant patient samples had AFP detected. The ROMplus test strip correctly detected AFP in all samples tested containing fetal tissue (n=13) resulting in a test sensitivity of 100%. ROMplus correctly identified the absence of AFP in 16 out of the 17 samples lacking fetal tissue, a 94% test specificity. CONCLUSIONS: ROMplus has the potential to accurately and reliably detect the presence of AFP, and hence fetal tissue, in vaginal blood samples. This could be a vital non-invasive aid in ruling out an ectopic pregnancy at the bedside (currently off-label use). Furthermore, it could limit the amount of invasive testing and visits needed in cases of pregnancies of unknown location. IMPACT STATEMENT: In light of the recent COVID-19 pandemic, a simple non-invasive bedside test to rule out an ectopic pregnancy is highly desired given its potential for reducing the number of visits, investigations performed, and personnel involved in the workup of a pregnancy of unknown location.

Understanding Predictors of Patient Follow-up in Tissue-Poor Endocervical Curettage (ECC) Specimens: A Single Center Experience

Background: Endocervical curettage (ECC) specimens routinely aid in diagnosis of cervical dysplasia. At our institution, we routinely use the words insufficient or scant/minute to convey inadequacy and under-sampling of a ECC specimen. Among patients with an inadequate ECC, conclusions are not possible in absence of a positive concurrent cervical biopsy (CCB). Though a repeat procedure is recommended for patients with inconclusive results, many are not followed in a timely fashion. The goals of this work are to identify predictors of follow-up within one year among patients with tissue-poor ECC, and to characterize the frequency of non-benign outcomes on repeat procedures among such patients for whom a follow-up procedure was actually performed. Design: We identified ECC specimens reported as insufficient or scant/minute in our pathology data system from April to September in 2018 and 2020. Age;HPV status;concurrent cervical biopsy;prior history of ASCUS, LSIL, and HSIL;and pathologic findings on follow-up procedures (if performed) were recorded. We used multivariate logistic regression to identify predictors of follow-up among patients with either no CCB performed or a benign CCB. Results: We identified 294 patients with inadequate ECC specimens. The mean age was 41.5 years (SD=12.3). A total of 173/294 (59%) patients had a CCB;64/173 (37%) had LSIL and 27/173 (16%) had HSIL. Among the 83 patients with a benign CCB, 51 (61%) were followed, and 12/51 (24%) had dysplasia/carcinoma reported on their follow up procedure. Among the 121 patients with no CCB, 68 (56%) were followed, and 22/68 (32%) had dysplasia/carcinoma reported on a follow up procedure. We identified HPV18 (aOR=6.3, 95% CI: [1.5, 26.3];p=0.01), prior HSIL (aOR=3.3, 95% CI: [1.2, 9.4];p=0.02), and prior ASCUS (aOR=2.1, 95% CI: [1.04, 4.1];p=0.04) as significant predictors of receiving a follow up procedure on an inadequate ECC. We further found that follow up was markedly lower during the COVID-19 pandemic (aOR=0.24, 95% CI: [0.12, 0.42];p<0.001). Additional odds ratios are reported in Table 1. Conclusions: The high rate of non-benign results on follow-up sampling to inconclusive prior results is alarming and critically important. This study highlights the need for more effective diagnostic verbiage on inadequate / poorly sampled ECC specimens, to ensure adequate follow-up. This study also supports the hypothesis that the COVID-19 pandemic has had an adverse role in longterm cancer prevention.