Beyond Endoscopes: Pilot Study of Surgical Instrument Lumen Inspection.

Objective: Borescope examinations of endoscope channels are commonly described in literature, but no studies on surgical instrument lumen inspection have been published recently. Inadequately processed surgical instruments have been implicated in patient infections. This study assessed the utility of borescopes for inspecting surgical instruments. Methods: The study team inspected and photographed sterilized, patient-ready arthroscopic shaver handpieces and suction tips using a tablet camera and borescopes to characterize internal anatomy, defects found in lumens, and the impact of recleaning on debris or residues. Results: Ten suctions and eight shavers were inspected. All suctions had internal ridges and suction holes that were perpendicular to the lumen. All shavers had visible ridges, elbows, and lever mechanisms inside lumens. Of the 18 instruments, 16 (88%) had internal features that appeared rough or jagged and 17 (94%) had visible debris or discoloration in the lumens. Recleaning efforts generally were effective for suctions, but multiple rounds of recleaning with enhanced steps were less effective for shavers, which were replaced. Researchers documented retained soil and brush bristles in several new shavers despite following manufacturer instructions for cleaning and found visible damage and discoloration within five uses. Discussion: This study demonstrated the value of borescope examinations for surgical instrument lumens. Visual inspections identified anatomical features that could influence cleaning effectiveness and detected residual soil, discoloration, and debris in most instruments. The findings suggested that manufacturer cleaning instructions were insufficient and additional cleaning was not always effective. In response, the site's multidisciplinary team strengthened risk assessment protocols and enhanced their cleaning practices.

A Case Report of Primary Malignant Melanoma of the Gallbladder with Multiple Metastases.

Primary malignant melanoma of the gallbladder is an extremely rare tumor with approximately 39 cases described in the literature so far. However, since the first case was reported in 1907, it remains controversial whether gallbladder involvement in malignant melanoma is primary or metastatic. Here, we report a case of primary malignant melanoma of the gallbladder. A 52-year-old male presented to the emergency department with right upper quadrant abdominal pain and was found to have tumefactive sludge filling the majority of the gallbladder with possible gallbladder wall thickening on ultrasonography. A laparoscopic cholecystectomy was performed for presumed acute cholecystitis. Histopathologic examination of the gallbladder revealed malignant melanoma arising from the mucosa of the gallbladder. Further clinical investigation excluded other primary sites, supporting a diagnosis of primary malignant melanoma of the gallbladder.

Using Google Trends to Estimate the Geographic Distribution of Soil-Transmitted Helminthiasis in the United States from 2016 to 2021.

Soil-transmitted helminth infections are assumed to be uncommon in the US, despite numerous studies in the past few decades showing high burdens in Appalachia and the southern states. We assessed trends of interest in the Google search engine to gauge spatiotemporal patterns of potential soil-transmitted helminth transmission. We conducted a further ecological study comparing Google search trends to risk factors for soil-transmitted helminth transmission. Google search trends for terms related to soil-transmitted helminths were clustered in Appalachia and the south, with seasonal surges suggestive of endemic transmission for hookworm, roundworm (Ascaris), and threadworm. Furthermore, lower access to plumbing, increased septic tank use, and more rural environments were associated with increased soil-transmitted helminth-related Google search terms. Together, these results suggest that soil-transmitted helminthiasis remains endemic in parts of Appalachia and the south.

Global DNA methylation profiling reveals chromosomal instability in IDH-mutant astrocytomas.

Diffusely infiltrating gliomas are among the most common central nervous system tumors in adults. Over the past decade, the subcategorization of these tumors has changed to include both traditional histologic features and more recently identified molecular factors. However, one molecular feature that has yet to be integrated is the presence/absence of chromosomal instability (CIN). Herein, we use global methylation profiling to evaluate a reference cohort of IDH-mutant astrocytomas with and without prior evidence of CIN (n = 42), and apply the resulting methylation-based characteristics to a larger test cohort of publicly-available IDH-mutant astrocytomas (n = 245). We demonstrate that IDH-mutant astrocytomas with evidence of CIN cluster separately from their chromosomally-stable counterparts. CIN cases were associated with higher initial histologic grade, altered expression patterns of genes related to CIN in other cancers, elevated initial total copy number burden, and significantly worse progression-free and overall survival. In addition, in a grade-for-grade analysis, patients with CIN-positive WHO grade 2 and 3 tumors had significantly worse survival. These results suggest that global methylation profiling can be used to discriminate between chromosomally stable and unstable IDH-mutant astrocytomas, and may therefore provide a reliable and cost-effective method for identifying gliomas with chromosomal instability and resultant poor clinical outcome.

Intranodal Neurofibroma: A Case Report and Literature Review.

PURPOSE: To report a case of neurofibroma involving the lymph nodes and to perform a literature review on this topic. OBSERVATIONS: A 72-year-old woman with a history of neurofibromatosis and biopsy-proven malignant melanoma of the left forearm underwent wide local excision of the malignant lesion along with sentinel axillary lymph node biopsy. Histological examination of axillary nodes revealed diffuse neurofibromatosis within 2 lymph node capsules. A thorough review of the English literature pertaining to intranodal neurofibroma was performed by querying Google Scholar and PubMed. Only 5 cases of intranodal neurofibroma have been described until now. CONCLUSIONS AND IMPORTANCE: Neurofibroma involving the lymph nodes is rare and this is the first reported case that is shown to diffusely involve the intracapsular space. Furthermore, intranodal neurofibroma can represent a diagnostic pitfall in the evaluation of sentinel lymph nodes for metastatic melanoma.

Review of IgG4-related Hashimoto Thyroiditis With Best Practice Recommendations for Diagnosis and Reporting.

Found in virtually any organ system, immunoglobulin (Ig) G4-related disease (RD) is a recently recognized immune-mediated, systemic, a fibroinflammatory disease characterized histologically by storiform fibrosis, obliterative phlebitis, and lymphoplasmacytic infiltrate with IgG4-positive plasma cells (PCs). IgG4-related Hashimoto thyroiditis (IgG4-RHT), also called IgG4-related thyroiditis, shares many features with IgG4-RD but is distinct in several ways. A case of IgG4-RHT in a 51-year-old African American female is assembled together with a literature review which uncovered 82 cases of IgG4-RHT. The findings and criteria which the respective authors used to reach their diagnoses are analyzed. Findings common to all studies are lymphoplasmacytic infiltration and IgG4-positive staining, while most describe follicular atrophy (95.2%, 79/83). Stromal fibrosis involving >33% of thyroid architecture was reported in 74% (58/78) of cases. While few reports observed storiform fibrosis, all describe lack of obliterative phlebitis or systemic involvement. Discrepancies between reports exist in immunostaining thresholds, as well as grading systems for stromal fibrosis. Based on our review of the literature and experience, we propose a set of best practice recommendations for the diagnosis of IgG4-RHT. Our diagnostic criteria are (1) lack of extrathyroidal IgG4-RD, (2) the fibroinflammatory process should not extend beyond the thyroid capsule, (3) stromal fibrosis comprises at least 30% of the involved tissue, (4) >30% IgG4/IgG ratio, with absolute immunostaining cutoffs varying by the degree of stromal fibrosis: for >50% stromal fibrosis use >20 IgG4+PCs/HPF, for 30% to 50% fibrosis use >30 IgG4+PCs/HPF, (5) fibrosis infiltrates the interlobular/interfollicular space, (6) features of follicle injury, and (7) obliterative phlebitis is not required.

Lichen simplex chronicus of the eyelid: A case report and literature review.

PURPOSE: To report a case of lichen simplex chronicus (LSC) of the eyelid and to perform a literature review on this topic. OBSERVATIONS: A 59-year-old African American man presents with chronic and recalcitrant recurrent chalazion of both upper eyelids despite aggressive medical management. An incision and drainage procedure was performed along with biopsy of the eyelid, which was found to be consistent with LSC. A thorough review of the English literature pertaining to LSC of the eyelids was performed by querying PubMed and Google Scholar. Though two clinical reports of LSC of the eyelid were found in older literature, only one such case confirmed by biopsy has been reported until now. CONCLUSIONS: LSC of the eyelid is rare and this is the first reported case that is associated with chronic and recalcitrant chalazion.

Rat bite fever with osteomyelitis and discitis: case report and literature review.

BACKGROUND: Rat bite fever (RBF) is a rare systemic febrile illness transmitted by rats. Streptobacillus moniliformis is a pleomorphic Gram-negative bacillus which is the usual etiologic organism for rat bite fever in the United States. CASE PRESENTATION: Here we present a case of rat bite fever complicated by vertebral osteomyelitis and discitis. The patient revealed an exposure history of being bitten by pet rats. The patient's symptoms dramatically improved with a six-week course of cephalexin therapy. CONCLUSIONS: It is important to obtain a thorough zoonotic exposure history and maintain rat bite fever in the differential when considering potential causes of discitis and osteomyelitis.

Glycogenic Hepatopathy Masquerading as Acute Pancreatitis.

Glycogenic hepatopathy (GH), defined histologically by hepatocytic glycogen accumulation without fatty change or fibrosis, is a benign reversible condition. It presents clinically as hepatomegaly with elevated liver enzymes in young diabetic (type 1) patients with poor glycemic control. We report a case of a 20-year-old female with a history of poorly controlled type 1 diabetes mellitus (T1DM) and prior pancreatitis who presented with sharp epigastric pain and hepatomegaly. She was found to have diabetic ketoacidosis with elevated lipase and amylase. Though at first her symptoms were erroneously attributed to pancreatitis, a liver biopsy showing glycogenated nuclei led to a diagnosis of GH.

Hematoma as a cause of a febrile and inflammatory response after tibial fractures.

After incurring bilateral tibial fractures and developing sizable hematomas at the trauma sites, a child experienced 4 days of fever with an elevated C-reactive protein level and sedimentation rate. As thrombotic and infectious etiologies were ruled out, the patient's febrile and inflammatory response was likely attributable to hematoma formation. Hematomas are a recognized cause of noninfectious fever. Local release of pyrogenic cytokines within the hematoma may be the source for elevation in temperature and inflammatory markers.

Molecular Correlates of Long Survival in IDH-Wildtype Glioblastoma Cohorts.

IDH-wildtype glioblastoma is a relatively common malignant brain tumor in adults. These patients generally have dismal prognoses, although outliers with long survival have been noted in the literature. Recently, it has been reported that many histologically lower-grade IDH-wildtype astrocytomas have a similar clinical outcome to grade IV tumors, suggesting they may represent early or undersampled glioblastomas. cIMPACT-NOW 3 guidelines now recommend upgrading IDH-wildtype astrocytomas with certain molecular criteria (EGFR amplifications, chromosome 7 gain/10 loss, and/or TERT promoter mutations), establishing the concept of a "molecular grade IV" astrocytoma. In this report, we apply these cIMPACT-NOW 3 criteria to 2 independent glioblastoma cohorts, totaling 393 public database and institutional glioblastoma cases: 89 cases without any of the cIMPACT-NOW 3 criteria (GBM-C0) and 304 cases with one or more criteria (GBM-C1-3). In the GBM-C0 groups, there was a trend toward longer recurrence-free survival (median 12-17 vs 6-10 months), significantly longer overall survival (median 32-41 vs 15-18 months), younger age at initial diagnosis, and lower overall mutation burden compared to the GBM-C1-3 cohorts. These data suggest that while histologic features may not be ideal indicators of patient survival in IDH-wildtype astrocytomas, these 3 molecular features may also be important prognostic factors in IDH-wildtype glioblastoma.

IgA negative immunofluorescence in diagnoses of adult-onset Henoch-Schönlein purpura.

We describe two cases of young adult men presenting with diffuse petechial rash and gastrointestinal disturbances. They were found to have leukocytoclastic vasculitis without immunoglobulin A findings under direct immunofluorescence on skin biopsy histopathology performed over a week after the appearance of lesions. Henoch Schönlein purpura (HSP) was diagnosed based upon the clinical presentation as well as the leukocytoclastic vasculitis biopsy findings.

A Case of Attempted Suicide by Cerbera odollam Seed Ingestion.

We report a case of attempted suicide by Cerbera odollam seed ingestion by a transgender patient who was successfully treated at our hospital. While the C. odollam plant has multiple practical and ornamental functions, its seeds have traditionally been utilized for suicidal and homicidal purposes in many parts of the world. Physicians should be aware of the presentation, diagnosis, and treatment of C. odollam ingestion given the current ease of availability of these seeds in the United States and the increased reports of suicide attempts.

Anti-NMDAR-Positive Small-Cell Lung Cancer Paraneoplastic Limbic Encephalitis: A Case Report and Literature Review.

INTRODUCTION: Paraneoplastic limbic encephalitis (PLE) is a rare disease that presents as rapid onset dementia characterized by short-term memory loss (STM), anxiety, and behavioral changes. Anti-NMDAR antibodies are unfrequently reported in PLE associated with small-cell lung cancer (SCLC). Given that PLE can precede the diagnosis of cancer, it is very important that once infectious, metabolic, nutritional, or structural disorders associated with short-term memory loss are ruled out that vigorous effort must be made to rule out underlying malignancy. CASE: We report a rare case of PLE as the presenting symptom of SCLC. A 72-year-old male with history of COPD was brought to the ED by his wife after he was found to have short-term memory loss, including forgetfulness of his wedding anniversary the day before, and anxiety. Neurological exam showed impaired short-term recall on MOCA. CT head showed no evidence of infarct. Lumbar puncture was performed which showed lymphocytic pleocytosis, a nonspecific inflammatory change. CSF panel was negative for HSV, Neisseria, Hemophilus, E. coli, and HIV. Initial EEG was unremarkable, though a repeat EEG showed mild slowing of the posterior dominant rhythm consistent with mild encephalopathy. MRI showed equivocal increased FLAIR on T2-weighted images in the bilateral temporal lobes, left greater than right. CTA thorax showed bulky mediastinal and right hilar LAD. FNA of the R4 lymph node revealed SCLC. The NM bone scan showed no osteoblastic lesions. While the serum autoantibody panel was positive for anti-NMDAR, the CSF autoantibody panel returned entirely negative. Chemotherapy with etoposide and cisplatin was started on Day 4 of admission. The patient's neurological symptoms showed improvement following chemotherapy. CONCLUSION: This case highlights the importance of recognizing short-term memory loss as a feature of PLE.

Historical analysis of inverse correlation between soil-transmitted helminthiasis and pancreatic cancer.

In this descriptive epidemiological study, the soil-transmitted helminth (STH) burden and pancreatic cancer (PC) mortality rates of different countries and peoples are compared to demonstrate an inverse correlation. Formerly ubiquitous helminth infection possibly played a significant role in defending the human host against PC until the advancement of modern hygiene, with helminth eradication in recent times in developed countries and urban centers. It is posited that a high rate of infection by STH in developing countries and rural areas protects the human host from the development of PC, possibly by immune modulation. This hypothesis is used to explain increased PC rates in minority groups in the United States who had decreased helminth exposure in the late 20th century.

γδ T Cells Promote Steatohepatitis by Orchestrating Innate and Adaptive Immune Programming.

BACKGROUND AND AIMS: The recruitment and activation of inflammatory cells in the liver delineates the transition from hepatic steatosis to steatohepatitis (SH). APPROACH AND RESULTS: We found that in SH, γδT cells are recruited to the liver by C-C chemokine receptor (CCR) 2, CCR5, and nucleotide-binding oligomerization domain-containing protein 2 signaling and are skewed toward an interleukin (IL)-17A+ phenotype in an inducible costimulator (ICOS)/ICOS ligand-dependent manner. γδT cells exhibit a distinct Vγ4+ , PD1+ , Ly6C+ CD44+ phenotype in SH. Moreover, γδT cells up-regulate both CD1d, which is necessary for lipid-based antigens presentation, and the free fatty acid receptor, CD36. γδT cells are stimulated to express IL-17A by palmitic acid and CD1d ligation. Deletion, depletion, and targeted interruption of γδT cell recruitment protects against diet-induced SH and accelerates disease resolution. CONCLUSIONS: We demonstrate that hepatic γδT cells exacerbate SH, independent of IL-17 expression, by mitigating conventional CD4+ T-cell expansion and modulating their inflammatory program by CD1d-dependent vascular endothelial growth factor expression.

Passage survival of European and American eels at Francis and propeller turbines.

We present the magnitude of losses of European eel Anguilla anguilla and American eel A. rostrata in passage through propeller and Francis turbines at hydroelectric projects. Survival and injury rates and types were turbine type related. Overall, eel survival was higher (mean ± 90% CI = 95.1 ± 5.3%,) and injury rate lower (12.5 ± 10.5) at Francis than propeller turbines (survival = 80.7 ± 6.4%; injury rate = 25.7 ± 7.9%). The common injury type at Francis turbines was bruises and at propeller turbines was severance. Blade shape and thickness of the leading edge of the blades (rounded, thick buckets of Francis turbines v. flatter, sharper edged blades in propeller turbines); eel entry routes into the turbines; their flexible, cylindrical body shape and orientation probably contributed to these differences. Relationship between survival and injury and turbine characteristics was turbine specific. For Francis turbines, one negative correlation (r = -0.986, P < 0.01) between survival and runner speed was found and two positive correlations between injury rates and fish length (r = 0.740, P < 0.10) and number of blades (r = 0.835, P < 0.05) were noted for propeller turbines. Several severely injured eels remained active 48 h after turbine passage suggesting caution is warranted when using telemetric movement for estimating eel survival. We conclude there is a need to (a) better understand travel paths and approach orientation of eels through turbines; (b) determine where only eel passage is of concern at hydropower plants that have both turbine types and therefore preferential operation of Francis turbines may be considered; (c) inform hydropower plant operators where turbine replacement is being considered and downstream eel passage is of concern that replacement by Francis or bulb turbines may prove beneficial for eel passage.

Chilaiditi's Sign: A Case Report.

Chilaiditi's sign refers to the interposition of the colon (usually the transverse colon) between the diaphragm and the liver. When associated with abdominal pain it is referred to as Chilaiditi's syndrome. Chilaiditi's sign is rare entity with an estimated incidence of 0.025 to 0.28% worldwide. The sign occurs more frequently in males, with a male to female ratio of 4:1. Apparent pneumoperitoneum seen on imaging below the right hemidiaphragm, a life-threatening condition, may in fact be merely Chilaiditi's sign. Awareness of this phenomenon and its consideration as a differential diagnosis is essential to prevent unnecessary laparoscopic intervention. Here we present a case of a 74-year-old male who was incidentally found to have free air under the diaphragm without symptoms of abdominal pain. After further evaluation by the radiologists and surgeons it was concluded that he had Chilaiditi's sign and no further intervention was required. However, due to the lack of awareness of this radiographic finding patients can be subjected to unnecessary surgical intervention.

Practice question.

A hospital admission can be bewildering for people with dementia or delirium. Staff can have difficulty managing what they perceive to be unsafe behaviour and so adopt one-to-one nursing to minimise risk. However, one-to-one nursing is often applied haphazardly or is not managed robustly enough to ensure efficacy and cost effectiveness. Some organisations have policies to guide staff about when and how to apply observation, but these are often in place to minimise organisational risk rather than to consider the needs of the person experiencing distress.

Oxygen rotational temperature determination using empirical analyses of C(3)Π(v' = 2) ← X(3)Σ(v'' = 0) transitions.

The spectra of molecular oxygen through C(3)Π(v' = 2) ← X(3)Σ(v'' = 0) transitions have been obtained by coherent microwave Rayleigh scattering (radar) from resonance-enhanced multiphoton ionization (REMPI). Measurements of rotational temperatures of molecular oxygen have been demonstrated based on the empirical analyses of the O2 spectra without the requirement of highly resolved rotational features. Three methods, including (1) linewidth fitting, (2) linear fitting, and (3) area fitting have been investigated for temperature measurements within pure oxygen, ambient air, and H2-air and CH4-air flame environments. The first two methods were applied in a moderately low temperature environment with measurement uncertainties less than 11% and 26%, respectively. The area fitting method covered a wider temperature range, from room temperature (~300 K) to flame temperature (~1700 K), with minimal dependence on the fine structures of the O2 spectra. Less elaborate than Boltzmann plot analyses of ultrafine rotational lines from congested upper rotational energy levels in O2(C(3)Π(v' = 2)), these empirical analyses are predictably sensitive to the thermal distribution of molecular oxygen and have been successfully demonstrated as simple and quick methods for remote gas-phase temperature measurement.