Establishment of a birth-to-education cohort of 1 million Palestinian refugees using electronic medical records and electronic education records.

Introduction: By linking datasets, electronic records can be used to build large birth-cohorts, enabling researchers to cost-effectively answer questions relevant to populations over the life-course. Currently, around 5.8 million Palestinian refugees live in five settings: Jordan, Lebanon, Syria, West Bank, and Gaza Strip. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides them with free primary health and elementary-school services. It maintains electronic records to do so.We aimed to establish a birth cohort of Palestinian refugees born between 1st January 2010 and 31st December 2020 living in five settings by linking mother obstetric records with child health and education records and to describe some of the cohort characteristics. In future, we plan to assess effects of size-at-birth on growth, health and educational attainment, among other questions. Methods: We extracted all available data from 140 health centres and 702 schools across five settings, i.e. all UNRWA service users. Creating the cohort involved examining IDs and other data, preparing data, de-duplicating records, and identifying live-births, linking the mothers' and children's data using different deterministic linking algorithms, and understanding reasons for non-linkage. Results: We established a birth cohort of Palestinian refugees using electronic records of 972,743 live births. We found high levels of linkage to health records overall (83%), which improved over time (from 73% to 86%), and variations in linkage rates by setting: these averaged 93% in Gaza, 89% in Lebanon, 75% in Jordan, 73% in West Bank and 68% in Syria. Of the 423,580 children age-eligible to go to school, 47% went to UNRWA schools and comprised of 197,479 children with both health and education records, and 2,447 children with only education records. In addition to year and setting, other factors associated with non-linkage included mortality and having a non-refugee mother. Misclassification errors were minimal. Conclusion: This linked open birth-cohort is unique for refugees and the Arab region and forms the basis for many future studies, including to elucidate pathways for improved health and education in this vulnerable, understudied population. Our characterization of the cohort leads us to recommend using different sub-sets of the cohort depending on the research question and analytic purposes.

[Conservative treatment of iatrogenic milk fistula].

A milk fistula is a rare condition, and only 27 cases have been reported in the latest systematic review from 2020. A fistula can be iatrogenic or spontaneous. The content of tissue factors in breast milk promotes granulation in wounds, which can lead to hypergranulation and lack of epithelialization. In this case report, a 29-year-old breastfeeding woman developed a milk fistula after surgical removal of a naevus on suspicion of being a melanoma. Hypergranulation of the wound was successfully treated with corticosteroid, which inhibits growth factor in breastmilk, and breastfeeding was continued during treatment.

Umbilical Endometriosis Disguised by Seborrheic Keratosis on Punch Biopsy.

ABSTRACT: Endometriosis is a benign condition of the female genital system, characterized by endometrial tissue external to the uterine cavity. Of all cases with endometriosis, the incidence of umbilical endometriosis is only 0.29%. Umbilical endometriosis typical presents with symptoms including cyclical pain, bleeding, and swelling of the nodule. Morphological changes in the epidermis, as in this case, simulating a seborrheic keratosis both clinically and microscopically, can initially mask the underlying endometriosis and prolong the course of treatment. A thorough anamnesis and examination revealing the characteristic symptoms and findings coupled with a representative biopsy is essential to correctly diagnose umbilical endometriosis.

Posterior reversible encephalopathy syndrome in a patient with Richter's syndrome on combination DA-R-EPOCH chemotherapy regimen: a case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiologic entity characterized by headaches, altered mental status, seizures, visual loss, and a characteristic imaging pattern in brain magnetic resonance images. The exact etiology and pathogenesis of this condition are not yet fully elucidated. CASE PRESENTATION: A 72-year-old White man presented with 2 weeks of low-grade fever and chills, night sweats, fatigue, dysphagia, and new-onset rapidly increasing cervical lymphadenopathy. He had a history of chronic lymphocytic leukemia with transformation to diffuse large B-cell lymphoma for which he was started on dose-adjusted rituximab, etoposide, prednisone vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH). Shortly after treatment initiation, the patient developed severe airway obstruction due to cervical lymphadenopathy that required emergency intubation. A few days later, the cervical lymphadenopathy and the status of the airway improved, and sedation was consequently weaned off to plan for extubation. However, the patient did not recover consciousness and developed generalized refractory seizures. Brain magnetic resonance imaging revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes, consistent with PRES. CONCLUSIONS: Posterior reversible encephalopathy syndrome refers to a neurological disorder and imaging entity characterized by subcortical vasogenic edema in patients who develop acute neurological signs and symptoms of a usually reversible nature in different settings, including chemotherapy. Despite its name, PRES is not always fully reversible, and permanent sequelae can persist in some patients. Clinicians should be aware of the possible association between chemotherapy and PRES to ensure early recognition and timely treatment.

[Artificial intelligence in Danish healthcare].

Artificial intelligence (AI) and machine learning have become important in medicine as shown in this review. Automatic tools can be trained to analyse patient data and thereby be a great asset to doctors when diagnosing and treating patients. Denmark is a leading country in collecting data. Having large amounts of stored data improves the quality when building a prediction tool. Due to the potential of building AI in the Danish healthcare sector, a significant amount of money has been allocated to foster new innovations in the field. Denmark could play a critical rule utilising data and implementing AI in medicine.

[Reconstruction by means of fillet flaps].

The purpose of this review is to summarise the literature and provide an overview of the topic and use of fillet flaps. Large and complex defects remain a reconstructive challenge balancing the benefits of reconstruction against donor-site morbidity. The spare-part concept involves using parts of amputated, non-salvageable or intact tissue for reconstruction. Fillet flaps are axial pattern flaps and can be harvested as pedicled-, island- or free flaps. Using fillet flaps for reconstruction is a valuable tool to obtain reconstruction in a one-stage procedure while minimising donor-site morbidity.

[Fillet flap used for reconstruction after hemipelvectomy and amputation of a lower extremity].

In this case report, a 67-year-old woman presented with increasing pain in the left side of the thigh and pelvis. A PET scan revealed a large malignant tumour in the left side of the pelvis and proximal left femur, and an ultrasound-guided biopsy diagnosed an undifferentiated pleomorphic sarcoma. Combined orthopaedic and plastic surgery resulted in a left-sided hemipelvectomy and amputation of the left leg. The amputated left leg was used as a free fillet flap for reconstruction of the pelvis. The patient healed without complications, and seven months post-operatively she was able to use a prosthesis.

Color Doppler ultrasonography targeted reconstruction using pedicled perforator flaps-a systematic review and meta-analysis.

BACKGROUND: Flaps are increasingly popularized in reconstructive surgery and there is need to test and increase their reliability. Color Doppler ultrasound has been stated to be valuable in flap planning. The aim of this study was to conduct a systematic review and meta-analysis of the literature of Color Doppler ultrasound targeted pedicled perforator flaps and provide information on outcomes and complication rates. METHOD: A systematic review and meta-analysis were conducted for articles published until April 2017 in PubMed and Embase. We aimed to include randomized clinical trials, meta-analysis, prospective studies, case-control studies, and cohort studies written in English. We included studies where CDU was used to identify the perforator(s) prior to surgery. We evaluated the quality of the included studies using checklists recommended by the Cochrane group. RESULTS: From the initial 219 studies, only 12 studies using Color Doppler targeted pedicled perforator flaps in 252 cases met the inclusion and exclusion criteria. Eleven of these were case series and one a prospective study. The incidence of major complications was 8% (21/252) and minor complications was 14%, comprising of mostly necrosis 8% (24/252) and venous congestion 8% (21/252). CONCLUSIONS: The reconstructive success rate following pedicled perforator flap reconstruction targeted by CDU appears to be high and the procedure provides a wide scope of applications and margin of safety. It is evident that the risk of venous congestion is 11 times greater in the lower extremities than the truncus, a finding that needs further attention in future studies.Level of Evidence: Level IV, risk/prognostic study.

Clear cell sarcoma-A review.

Clear cell sarcoma (CCS) previously known as malignant melanoma (MM) of the soft tissue, although, similar in morphology to MM, contemporary histopathologic and cytogenetic techniques have made this diagnosis obsolete, as it is now possible to distinguish between CCS and MM. CCS is often diagnosed in young adults with median age of 25 years. Overall mortality is generally poor, and the 5-year survival is between 40 and 60%. Hence, early diagnosis and radical surgery are key in the treatment of this extremely rare malignancy of the soft tissue comprising only about 1% of all sarcomas. This article present an overview of this rare malignancy.

Prurigo Nodularis after Radiotherapy: An Isoradiotopic Response?

Prurigo nodularis is a rare and chronic skin disorder with multiple, pruritic, and firm nodules. The exact pathophysiology is still unknown. Skin disorders appearing at sites of radiation can be defined as isoradiotopic. A 35-year-old male had developed a skin lesion in the left submandibular area on a base of irradiated skin which was initially suspected as a skin malignancy. The patient had a history of undifferentiated nasopharyngeal cancer with lymph node involvement which was treated by radiochemotherapy thirteen years previously. Histological examination confirmed that it was a case of prurigo nodularis which subsequently evolved at distant sites. This presentation may suggest a case of an isoradiotopic response.

Breastfeeding difficulty after polyacrylamide hydrogel (PAAG) mediated breast augmentation.

INTRODUCTION: Breast augmentation using polyacrylamide hydrogel (PAAG) has been routinely used in the past as a minimal invasive procedure. However, several patients undergoing this procedure have started to report complications. We report a case of breast augmentation using PAAG leading to a delayed infection and breastfeeding complication. CLINICAL CASE: A 36-year-old Danish female who was treated with PAAG fifteen years earlier, presented with difficulty in breastfeeding and fistulation. Clinical evaluation revealed structural deformity of the right breast and a 5×5mm skin defect. Mammography showed diffuse microcalcification density grade 4. Ultrasound and MRI displayed inhomogeneous gelatinous material in both breasts diffused into the pectoralis major muscle. Initial management involved aspiration of the material. The patient developed infection and was subjected to modified radical debridement removing the PAAG. The patient healed without any further complications. DISCUSSION: The prevalence of PAAG mediated breast augmentation related complications are increasing. The most prominent complication being late infections, breast hardening and subsequent breastfeeding difficulties. In this case, the difficulty in breastfeeding was induced by the PAAG within the breast tissue. The inhomogeneous gelatinous material was surgically removed leading to complete remission. CONCLUSION: Long-term complications, among others breast feeding difficulty, in women treated with PAAG are increasing and need appropriate management strategy. PAAG mediated breast augmentation may cause irreversible damage to the breast in healthy women necessitating complex debridement.

[Turban tumour with intracranial invasion].

This is a case report of a 76-year-old woman, who had Brooke-Spiegler syndrome (BSS) and presented with multiple confluent tumours of the scalp. An MRI showed an intracranial invasion. Multiple excisions were made due to recurrence of the intracranial tumour, and reconstruction was achieved with free flaps and skin grafts. BSS is caused by a mutation in CYLD, a tumour suppressor gene located on chromosome 16q12-q13. Surgical excision is often not a curative treatment, and the recurrence rate is 35%. Quality of life is significantly affected with regards to cosmetic appearance, painful tumours and multiple surgical treatments.

Trans-vaginal mesh surgery for management of recurrent pelvic organ prolapse following abdominal sacrocolpopexy.

OBJECTIVE: To evaluate the outcome of transvaginal mesh surgery as a management of recurrent pelvic organ prolapse, in patients previously treated with sacrocolpopexy. CASE REPORT: A series of three patients who developed recurrent pelvic organ prolapse more than 9 years after sacrocolpopexy. A 50-year-old and two 77-year-old patients who presented with recurrent pelvic organ prolapse at 9, 15 and 17 years, respectively after the primary abdominal sacrocolpopexy were managed by transvaginal mesh surgery. CONCLUSION: Management of recurrent pelvic organ prolapse using transvaginal mesh would be an option for patients treated previously by sacrocolpopexy.

Ureterovaginal fistula: A complication of a vaginal foreign body.

OBJECTIVE: To know the diagnostic tools and proper management of ureterovaginal fistula following neglected vaginal foreign body in order to achieve optimal outcome. CASE REPORT: A case of ureterovaginal fistula associated with a neglected vaginal foreign body. The patient was complaining of a foul-smelling vaginal discharge and lower abdominal pain. On vaginal examination, a hard and large foreign body was found. Examination under anesthesia was performed, and an aerosol cap was removed from her vagina. The patient developed urinary incontinence after removal of the foreign body. Subsequent work-up demonstrated the presence of a right ureterovaginal fistula. The patient underwent an abdominal ureteroneocystostomy. At one year follow up, the patient had fully recovered. CONCLUSION: Ureterovaginal fistula following neglected vaginal foreign body is a serious condition. Early diagnosis, treatment of infection and proper surgical management can improve the outcome and decrease complications.

Idiopathic scrotal calcinosis - A case report.

INTRODUCTION: Idiopathic scrotal calcinosis is a rare benign condition which presents with asymptomatic multiple nodules on the scrotal skin. PRESENTATION OF CASE: Our patient, a 64-year-old Indian male with Fitzpatrick skin type 4, presented with multiple nodules, which were completely surgically excised with no complications. Histological examination reveals extensive intradermal deposition of calcium surrounded by histiocytes and without cystic structure. DISCUSSION: Numerous theories about the pathogenesis have been proposed and the evidence presented suggests this is a continuum. CONCLUSION: The nature of idiopathic scrotal calcinosis is still unknown and it is up to debate whether the term "idiopathic" is appropriate for the condition.

Five-Year Outcome of MiniArc Single-Incision Sling Used in the Treatment of Primary Urodynamic Stress Incontinence.

STUDY OBJECTIVE: To evaluate the effectiveness and safety of the MiniArc single-incision sling in the treatment of urodynamic stress incontinence (USI) through 5 years. DESIGN: Retrospective observational study (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: Eighty-five patients with USI without needing concurrent procedures who underwent anti-incontinence surgery using the MiniArc SIMS from February 2010 to December 2011. INTERVENTIONS: Anti-incontinence surgery. MEASUREMENTS AND MAIN RESULTS: Objective cure was defined as no demonstrable leakage of urine on the cough stress test and 1-hour pad test weight <2 g. Subjective cure was based on negative response to Urinary Distress Inventory question 3, no leakage on coughing, sneezing, or laughing. Most patients were postmenopausal, overweight, and multiparous. Postoperative USI significantly improved (p < .001) through 3 years, and the 1-hour pad test showed significant improvement through 5 years (p < .001). Although 13 patients had recurrence of USI, no repeat surgery was done. The cumulative cure rates may show a declining trend of cure, yet subjective cure was 80.0% and objective cure 84.7%, with age as a significant risk factor for sling failure. CONCLUSION: MiniArc maintains its effectiveness and safety in treatment of USI through 5 years with high objective and subjective cure rates and low incidence of complications.

The Effects of Glial Cell Line-Derived Neurotrophic Factor after Spinal Cord Injury.

Spinal cord injury (SCI) is a devastating condition affecting 270,000 people in the United States. The use of growth factors is a potential treatment for reducing secondary damage, promoting axon growth, and restoring some of the lost function post-SCI. Glial cell line-derived neurotrophic factor (GDNF) is an important growth factor, because it can affect both neurons and support cells. Here, we give an in-depth review of the previously published literature where GDNF was used to treat SCI. The effects of GDNF have been shown to decrease lesion size, improve allodynia, and regenerate axons in the central nervous system and peripheral nervous system. GDNF is necessary for early development, and lack of GDNF can lead to abnormal development of the autonomic nervous system or death. Exogenous administration of GDNF either before or immediately after SCI is most effective. Even though GDNF can be directly administered, genetically modified cells are often used as a delivery vehicle. Several different types of genetically modified cells have been used with varying success. Although GDNF is effective when used alone, it has been shown to be more effective when used in combination with other neurotrophic factors. Overall, GDNF significantly improved functional recovery, increased the number of sprouting neurons, reduced lesion size at the injury site, and had minimal adverse effects.

A complicated urethrovaginal fistula following an inappropriate urethral diverticulum management.

OBJECTIVE: Urethral diverticulum is uncommon, therefore appropriate evaluation, preoperative planning and counseling must be done in order to make correct diagnosis and prevent complications. MATERIALS AND METHODS: A case of anterior vaginal wall mass was treated elsewhere by a gynecologist as periurethral cyst abscess; incision and drainage were done but a symptom of pus discharge was observed after 2 weeks. Therefore, exploration, cyst wall excision and primary closure were done though histopathological examination surprisingly confirmed the presence of urethral tissue suggestive of diverticulum. RESULTS: Subsequently, she developed persistent urinary leakage along with urethrovaginal fistula for which they again performed pervaginal multilayer closure. Patient was later referred to us with recurrent urethrovaginal fistula. We performed posterior urethral fistulectomy with anterior vaginal wall flap and multilayer closure. Three years follow up reveals complete recovery. CONCLUSION: Even urethral diverticulum is a rare condition, should be kept in mind as early diagnosis and management.