Secondary craniofacial necrotizing fasciitis from a distant septic emboli: A case report

BACKGROUND

Craniofacial necrotizing fasciitis (CNF) is an uncommon but fatal infection that can spread rapidly through the subfascial planes in the head and neck region. Symptoms usually progress rapidly, and early management is necessary to optimize outcomes.

CASE SUMMARY

A 43-year-old man visited our hospital with left hemifacial swelling involving the buccal and submandibular areas. The patient had fever for approximately 10 d before visiting the hospital, but did not report any other systemic symptoms. Computed tomography scan demonstrated an abscess with gas formation. After surgical drainage of the facial abscess, the patient’s systemic condition worsened and progressed to septic shock. Further examination revealed pulmonary and renal abscesses. Renal percutaneous catheter drainage was performed at the renal abscess site, which caused improvement of symptoms. The patient showed no evidence of systemic complications during the 4-mo post-operative follow-up period.

CONCLUSION

As the patient did not improve with conventional CNF treatment and symptoms only resolved after controlling the infection, the final diagnosis was secondary CNF with septic emboli. Aggressive surgical decompression is important for CNF management. However, if symptoms worsen despite early diagnosis and management, such as pus drainage and surgical intervention, clinicians should consider the possibility of a secondary abscess from internal organs.

Do Spinopelvic Parameters Relate with Secondary Hip Spine Syndrome in Secondary Hip Arthritis?

Background

The prevalence of low back pain (LBP) with primary osteoarthritis (OA) hip undergoing total hip replacement (THA) has been studied. However, secondary OA hip affects younger individuals where changes in the sagittal spinal parameters (SSPs) could be reversible to reduce LBP. The study aims to document changes in clinical and radiological parameters following THA.

Methods

Thirty patients with secondary OA hip were included in the prospective analysis, excluding anyone with previous spine/hip surgery of known spinal diseases, including deformity, inflammatory or infective pathology. Visual analog scale for (VAS) hip and LBP, Oswestry disability index (ODI), and Harris core (HHS) along with SSPs were measured at baseline and three months and analyzed.

Results

 Mean age was 42.8 ± 8.9 years which 17 unilateral (U/L) and 13 bilateral (B/L) OA. Overall, no significant changes were seen in SSPs that included pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), pelvic incidence-lumbar lordosis (PI-LL) was seen except for an improvement in the sagittal vertical axis (SVA) [40.22 ± 36.67 to 24.06 ± 21.93, p < 0.001]. However, clinical variables such as VAS hip and LBP, ODI, and HHS improved post-hip THA. Similar findings were seen in sub-group analysis when U/L affected were compared to B/L affected.

Conclusion

The sagittal SSPs except SVA does not change significantly following THA in patients with secondary OA, though LBP improves clinically. Hence, we assume routine measurement of these parameters is not mandatory when planning for THA in these patients.

Comparison of the rapidity of SARS-CoV-2 immune responses between primary and booster vaccination for COVID-19

BACKGROUND/AIMS

The rapidity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific memory B or T cell response in vaccinated individuals is important for our understanding of immunopathogenesis of coronavirus disease 2019 (COVID-19). We therefore compared the timing of adequate immune responses between the first and booster doses of COVID-19 vaccines in infection-naïve healthcare workers.

METHODS

We enrolled healthcare workers who received two doses of either the BNT162b2 vaccine or the ChAdOx1 vaccine, all of whom received the BNT162b2 vaccine as the booster (the third) dose. Spike 1 (S1)-immunoglobulin G (IgG) antibodies and interferon gamma producing T cell responses were measured at 0, 7, 14, and 21 days after the first dose, and at 0 and between 2 to 7 days after the booster dose.

RESULTS

After the first-dose vaccination, the S1-IgG antibody responses were elicited within 14 days in the BNT162b2 group and within 21 days in the ChAdOx1 group. After the booster dose, the S1-IgG antibody responses were elicited within 5 days in both groups. The SARS-CoV-2-specific T cell responses appeared at 7 days after the first dose and at 4 days after the booster dose.

CONCLUSION

SARS-CoV-2-specific immune responses by memory B cells and T cells may be expected to appear around 4 to 5 days after the booster dose.

Individual- and school-level patterns of substance use and mental health symptoms in a population-based sample of secondary students: A multilevel latent profile analysis

BACKGROUND

While substance use and mental health symptoms commonly co-occur among adolescents, few population-level studies have examined profiles of co-occurrence to inform tailored prevention and early interventions.

METHODS

A multilevel latent profile analysis was conducted on a representative sample of 11,994 students in 68 secondary schools to: 1) identify distinct profiles of co-occurring substance use and mental health symptoms; 2) identify types of schools based on student profiles; and 3) explore school correlates of student profiles and school types, including school climate, belonging, and safety.

RESULTS

Five student profiles and three school types were identified. Among students, 57.6 % were in a low substance use and mental health profile, 22.5 % were in a high mental health but low substance use profile, 9.7 % were in a heavy drinking and cannabis use profile, 3.7 % were in a heavy drinking and smoking profile, and 6.5 % were in a high substance use and mental health profile. Positive school climate, belonging, and safety increased the odds of students being in the low profile, with belonging yielding larger effects among females. Among schools, 28 % had low, 57 % had moderate, and 15 % had high levels of student substance use and comorbid mental health symptoms. Rural schools were disproportionately represented in higher risk school types.

CONCLUSIONS

The identified student substance use and mental health symptom profiles can serve as targets for tailored prevention and early interventions. Results support examining school-based interventions targeting school climate, belonging, and safety with potential benefits to both substance use and mental health.

Alpha-chloralose poisoning in cats in three Nordic countries - the importance of secondary poisoning

BACKGROUND

Alpha-chloralose (AC) is a compound known to be toxic to various animal species and humans. In 2018 and 2019 an increase in suspected cases of AC poisoning in cats related to the use of AC as a rodenticide was reported to national veterinary and chemical authorities in Finland, Norway and Sweden by veterinarians working in clinical practices in respective country. The aims of this study were to prospectively investigate AC poisoning in cats, including possible secondary poisoning by consuming poisoned mice, and to study metabolism and excretion of AC in cats through analysis of feline urine.

METHODS

Data on signalment, history and clinical findings were prospectively collected in Finland, Norway and Sweden from July 2020 until March of 2021 using a questionnaire which the attending veterinarian completed and submitted together with a serum sample collected from suspected feline cases of AC-poisoning. The diagnosis was confirmed by quantification of AC in serum samples. Content of AC was studied in four feline urine samples, including screening for AC metabolites by UHPLC-HRMS/MS. Bait intake and amount of AC consumed by mice was observed in wild mice during an extermination of a rodent infestation.

RESULTS

In total, 59 of 70 collected questionnaires and accompanying serum samples were included, with 127 to 70 100 ng/mL AC detected in the serum. Several tentative AC-metabolites were detected in the analysed feline urine samples, including dechlorinated and oxidated AC, several sulfate conjugates, and one glucuronic acid conjugate of AC. The calculated amount of AC ingested by each mouse was 33 to 106 mg with a mean of 61 mg.

CONCLUSIONS

Clinical recognition of symptoms of AC poisoning in otherwise healthy cats roaming free outdoors and known to be rodent hunters strongly correlated with confirmation of the diagnosis through toxicological analyses of serum samples. The collected feline exposure data regarding AC show together with the calculation of the intake of bait and subsequent AC concentrations in mice that secondary poisoning from ingestion of mice is possible. The results of the screening for AC metabolites in feline urine confirm that cats excrete AC both unchanged and metabolized through dechlorination, oxidation, glucuronidation and sulfatation pathways.

Stereotactic radiosurgery and radiotherapy for resected brain metastases: current pattern of care in the Radiosurgery and Stereotactic Radiotherapy Working Group of the German Association for Radiation Oncology (DEGRO)

PURPOSE

Preoperative stereotactic radiosurgery (SRS) of brain metastases may achieve similar local control and better leptomeningeal control rates than postoperative fractionated stereotactic radiotherapy (FSRT) in patients treated with elective metastasectomy. To plan a multicentre trial of preoperative SRS compared with postoperative FSRT, a survey of experts was conducted to determine current practice.

METHODS

A survey with 15 questions was distributed to the DEGRO Radiosurgery and Stereotactic Radiotherapy Working Group. Participants were asked under what circumstances they offered SRS, FSRT, partial and/or whole brain radiotherapy before or after resection of a brain metastasis, as well as the feasibility of preoperative stereotactic radiosurgery and neurosurgical resection within 6 days.

RESULTS

Of 25 participants from 24 centres, 22 completed 100% of the questions. 24 respondents were radiation oncologists and 1 was a neurosurgeon. All 24 centres have one or more dedicated radiosurgery platform and all offer postoperative FSRT. Preoperative SRS is offered by 4/24 (16.7%) centres, and 9/24 (37.5%) sometimes recommend single-fraction postoperative SRS. Partial brain irradiation is offered by 8/24 (33.3%) centres and 12/24 (50%) occasionally recommend whole-brain irradiation. Two centres are participating in clinical trials of preoperative SRS. SRS techniques and fractionation varied between centres.

CONCLUSION

All responding centres currently offer postoperative FSRT after brain metastasectomy. Approximately one third offer single-fraction postoperative SRS and four already perform preoperative SRS. With regard to potential co-investigators, 18 were identified for the PREOP‑2 multicentre trial, which will randomise between preoperative SRS and postoperative FSRT.

[Analysis of Clinicopathological Characteristics of 88 Cases with Secondary Neoplasms of the Thyroid Gland]

Objective

To analyze the clinicopathological characteristics of secondary neoplasms of the thyroid gland (SNTGs).

Methods

SNTG Patients who had pathology diagnosis of SNTGs between January 2010 and December 2019 at West China Hospital, Sichuan University were retrospectively enrolled. The SNTG cases were divided into two groups, a local invasion group and a distant metastasis group, and their clinical features were reviewed.

Results

The study involved 88 patients, with a female-to-male (F/M) ratio of 1/3 and an average age of 56 years. The local invasion group consisted of 72 patients (F/M, 1/8) who had the following types of tumors: 65 had squamous cell carcinomas (45 originated from larynx and 10 from laryngopharynx), 4 had adenoid cystic carcinomas, 1 had neuroendocrine carcinoma of esophagus, 1 had giant cell tumor, and 1 had type B3 thymoma. The distant metastasis group consisted of 16 patients (F/M, 7/1), all with previously confirmed history of malignancies of sites distant from the thyroid. Their primary tumor types were as follows, 6 had breast carcinomas, 5 had lung adenocarcinomas, 2 had nasopharyngeal non-keratinizing carcinomas, 1 had clear cell renal carcinoma, 1 had colon adenocarcinoma, and 1 had cervical squamous cell carcinoma.

Conclusions

Given that SNTGs are generally rare, the local invasion cases were predominantly squamous cell carcinomas that mainly originated from the larynx and the patients usually had no previous history of malignancy, while the distant metastasis cases often had a corresponding history of malignancies, consisting mainly of breast carcinoma and lung carcinoma.

Identification of risk factors that increase household transmission of COVID-19 in Afyonkarahisar, Turkey

INTRODUCTION

COVID-19 is the greatest pandemic of the 21st century. This cross-sectional study determined the factors that cause COVID-19 transmission in the household, increase in susceptibility of contacts, and increase in contagiousness of the primary case, and developed predictive calculations for determining secondary attack rate in the household.

METHODOLOGY

A total of 701 households with positive COVID-19 test cases, and 1813 adults living in these households, were studied from August 24-31, 2020 in Afyonkarahisar, Turkey. All the participants were interviewed by phone. The participants were divided into two groups: positives included those with positive Polymerase Chain Reaction (PCR) tests, negatives included those with a negative test and those who were without a PCR test. Descriptive statistics, Chi-square test, and multivariate logistic regression analysis were performed.

RESULTS

The secondary attack rate was 31.5%. Being male, having an education level > 8 years, living in the city, low number of people living in the household, having a severe illness, non-compliance with isolation requirement, and nonadherence to wearing masks increased contagiousness. The factors that increased the sensitivity of the household were determined as being female, having an education level of over 8 years, and being obese.

CONCLUSIONS

The secondary attack rate (SAR) was higher in Turkey than in other countries and there was limited compliance with quarantine and isolation measures. Household transmission can be reduced by interventions such as masks, isolation, and quarantine. The transmission of COVID-19 in households can be reduced if preventive measures are taken in the early stages of infection.

The Disaggregated Effects of Visual Performance Feedback on Teachers' Use of Behavior Specific-Praise and Reprimands

Behavior-specific praise (BSP) is one of the simplest classroom management strategies to implement and considered an evidence-based practice. Unfortunately, teachers underuse BSP and deliver more reprimands to students in their classrooms. Secondary students receive the highest rates of reprimands and exclusionary discipline (i.e., office discipline referral [ODR], suspension, expulsion) with students of color receiving disproportionate rates compared to their White peers. Performance feedback is a commonly used strategy to change teacher practices however, little is known about the impact of performance feedback on the equitable delivery of BSP and reprimands to students by race and sex. The purpose of this multiple baseline design study was to examine the effects of a visual performance feedback (VPF) intervention with secondary teachers on their equitable delivery of BSP and reprimands and the collateral impacts on student outcomes. In the first phase of intervention, teachers received VPF on their total BSP and reprimands. In the second phase, teachers received disaggregated VPF on their rates of BSP and reprimands delivered to students by race and sex. Results indicate a functional relation between VPF and total BSP and an overall reduction in total reprimands. Mixed results were found between VPF and the equitable delivery of BSP and reprimands rates delivered to students by race and sex. Student outcomes indicated an increase in average class-wide academic engagement and no impact on ODRs as no teacher delivered a single ODR. Key findings, limitations, and future research are discussed.

Metastatic Neoplasms Involving the Stomach

OBJECTIVES

Metastatic neoplasms involving the stomach are rare and diagnostically challenging if clinical history of malignancy is absent or unavailable. This study was designed to identify the tumors that most frequently metastasize to the stomach and the morphologic features that can provide clues to investigate the possibility of metastasis and predict the primary sites.

METHODS

All patients with metastatic neoplasms involving the stomach were included in the study. The H&E- and immunohistochemical-stained slides were reviewed, and all clinical, endoscopic, and radiologic information was recorded.

RESULTS

One hundred fifty patients, including 84 (56%) women and 66 (44%) men (mean age, 64 years), were identified. Gastric metastases were the initial presentation in 15% cases. Epithelial tumors (73.3%) comprised the largest group, followed by melanoma (20.6%), sarcomas (4%), germ cell tumors (1.3%), and hematolymphoid neoplasms (0.7%). Lobular breast carcinoma was the most common neoplasm overall in women, while in men, it was melanoma. Solid/diffuse growth pattern (75%) was more common compared with glandular morphology. The solid/diffuse category included lobular breast carcinoma (21.3%), melanoma (20.6%), and renal cell carcinoma (10.6%), while the glandular category was dominated by gynecologic serous carcinomas (7.3%) with papillary/micropapillary architecture.

CONCLUSIONS

Metastatic neoplasms should be considered in the differential diagnosis of gastric neoplasms, particularly those with a diffuse/solid growth pattern. Glandular neoplasms are difficult to differentiate from gastric primaries except for Müllerian neoplasms, which frequently show a papillary/micropapillary architecture.

Efficacy of Physiotherapy Interventions for The Management of Adults With Cervicogenic Headache: A Systematic Review and Meta-Analyses of Randomized Controlled Trials

OBJECTIVE

To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache.

LITERATURE SURVEY

Bibliographic searches were conducted up to September 2021 for randomized controlled trials, assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, PEDro, PubMed, Sage Journals and Wiley Online Library.

METHODS

Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the GRADE approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses.

SYNTHESIS

Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (MD: -0.93 episodes/week; 95%CI: -1.40 to -0.46; 2 RCTs; n=265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95%CI: -1.55 to -0.91; 3 RCTs; n=126) and intensity (MD: -1.63/10; 95%CI: -2.15 to -1.10; 4 RCTs; n=208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD VAS 0-10: -0.12; 95%CI: -0.49 to 0.26; 2 RCTs; n=265) nor frequency (MD: -0.32 episodes/week; 95%CI: -0.91 to 0.28; 2 RCTs; n=265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduces headache intensity compared to no treatment (MD: -1.51/10; 95%CI: -2.52 to -0.50; n=100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95%CI: -2.1 to -0.20; n=180).

CONCLUSIONS

Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high quality evidence is needed and future results may change the current conclusions. This article is protected by copyright. All rights reserved.

Risk of Secondary Non-hematologic Malignancies after Allogeneic Stem Cell Transplantation: A Nationwide Case-Control Cohort Study

This study investigated the incidence of secondary non-hematologic malignancies in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT) and explored its risk compared with the general population. A population-based case cohorts with adult patients who received allo-SCT between January 2002 and December 2018 and a control cohort with matched general population were extracted from the Korean National Health Insurance Service database. Each case and control cohort included 5177 patients. With a median follow-up of 2374 days for the case cohort and 2269 days for the control cohort, the 10-year cumulative incidence rate of non-hematologic malignancy was significantly higher in the case cohort compared with the control cohort (4.23% vs. 2.3%, hazard ratio (HR) 1.73, 95% confidence interval (CI) 1.32-2.25, p<0.001). The sub-class analysis according to cancer-site revealed significantly higher risks of 10-year cumulative incidence for cancers of head, neck, and esophagus (HR 3.19, 95% CI 1.34-7.59, p=0.003); cancers involving upper gastrointestinal tract (HR 3.74, 95% CI 1.58-8.85, p<0.001), colorectal cancer (HR 2.02, 95% CI 1.04-3.91, p=0.029), thyroid cancer (HR 2.09, 95% CI 1.1-3.97, p=0.012), gynecological cancer (HR 2.69, 95% CI 1.04-6.96, p=0.048) in the case cohort compared with the control cohort. No significant differences were detected for cancers involving lung, mediastinum, and heart, breast cancer in female, cancers of the hepatobiliary and pancreatic system, and cancers associated with urological system. These findings suggest the need for enhanced screening for non-hematologic malignancies in allo-SCT recipients compared with the general population. This article is protected by copyright. All rights reserved.

Primary versus secondary closure of tracheocutaneous fistula in pediatric patients

OBJECTIVE

Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure.

METHODS

Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups.

RESULTS

A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010.

CONCLUSION

Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.

Clinical characteristics and outcomes of 100 adult patients with pure red cell aplasia

Adult pure red cell aplasia (PRCA) is a rare syndrome characterized by a severe normocytic anemia, reticulocytopenia, and absence of erythroblasts from bone marrow. The standard treatment has not yet been established for PRCA, although cyclosporine (CsA), corticosteroids (CS) showed a response in PRCA. We retrospectively analyzed the clinical data of 60 primary and 40 secondary adult patients with acquired PRCA. The proportion of secondary PRCA is relatively high and commonly associated with large granular lymphocyte leukemia (LGLL) (28 cases, 70.0%). The remission-induced regimens included CS, CsA, or other agents, and the response rate was 66.7%, 71.4%, and 50%, respectively (P = 0.336). When treating with CsA, the response rate of LGLL-associated PRCA was lower than primary PRCA (42.1% vs 85.7%, P = 0.001). Logistic regression analysis showed that ORR was inversely related to LGLL-associated PRCA. LGLL-associated PRCA had poor therapeutic efficacy to CsA.

Impacts of secondary aerosol formation and long range transport on severe haze during the winter of 2017 in the Seoul metropolitan area

Severe haze episodes occur frequently in the Seoul Metropolitan Area (SMA) and throughout East Asian countries, especially during the winter and early spring. We investigated the sources and chemistry of particulate matter (PM) during three winter haze episodes in Seoul that occurred between January 1st and February 10th in 2017 using a high resolution time-of-flight aerosol mass spectrometer (HR-ToF-AMS) and positive matrix factorization (PMF) analysis. The average concentration of sub-micrometer aerosol (PM₁ = NR-PM₁ + black carbon (BC)) was 32.6 μg/m³, which was composed of 42% organics, 27% nitrate, 11% sulfate, 13% ammonium and 4% BC by mass. Six distinct sources of organic aerosol (OA) were identified: vehicle emitted hydrocarbon-like OA (HOA), cooking OA (COA), biomass burning OA (BBOA), and 3 different types of secondary OA (SOA) with varying degrees of oxidation and temporal trends. The nitrate mass fraction increased during the three haze episodes, with nitrate accounting for 27-33% of PM₁ mass. Enhanced nitrate concentrations and higher nitrate oxidation ratios (NOR), despite lower enhancement in relative humidity (RH) than the low PM loading period, suggest that regional transport of nitrate contributed to the nitrate mass during the haze periods. Lower HOA and COA concentrations during the high PM loading periods further confirm that local emissions or stagnant meteorological conditions were not the main reason for the severe haze. Residence time analysis (RTA), concentration field analysis (CFA), and column-CFA results from FLEXPART also showed that the measurement period was accompanied by atmospheric transport of nitrate, sulfate, and ammonium from eastern China. Nevertheless, we found that NO₂, a precursor of nitrate, was predominantly from local emissions. These findings suggest that nitrate in Seoul is not only locally formed, but also transported from upwind areas.

The evolving classifications and epidemiological challenges surrounding chronic migraine and medication overuse headache: a review

Changes in diagnostic criteria, for example, the various International Classification of Headache Disorders criteria, would lead to changes in the outcomes of epidemiological studies. International Classification of Headache Disorders-1 was based mainly on expert opinion, yet most of the diagnostic criteria were reliable and valid, but it did not include chronic migraine. In its second version, the classification introduced chronic migraine, but this diagnosis resembled more a high-frequency migraine rather than the actual migraine transformation process. It also introduced medication overuse headache, but it necessitated analgesic withdrawal and subsequent headache improvement to be diagnosed as such. Hence patients having medication overuse headache could only be diagnosed in retrospect, which was an awkward situation. Such restrictive criteria for chronic migraine and medication overuse headache omitted a high proportion of patients. International Classification of Headache Disorders-3 allows a diagnosis of medication overuse headache due to combination analgesics if taken for at least 10 days per month for more than three months. Hence the prevalence rate of medication overuse headache and chronic migraine can increase compared to the previous version of the headache classification. Different criteria have been used across studies to identify chronic migraine and medication overuse headache, and therefore the information acquired from previous studies using earlier criteria becomes uncertain. Hence much epidemiological research would need to be interpreted cautiously or repeated with the most updated criteria, since the subjects in studies that apply the latest criteria may be phenotypically different from those in older studies.

Updates in the Diagnostic Approach of Headache

PURPOSE OF REVIEW

In this review, we summarize updates in the diagnostic approach of headaches with the aim of facilitating the distinction between primary and secondary etiology in headaches.

RECENT FINDINGS

In the USA, headache is the fifth most common complaint in the emergency department, but only a minority will have a secondary etiology. Initial suspicion and diagnostic workup of secondary headache relies on a patient's medical history due to a scarcity of validated biomarkers. A special interest group under the International Headache Society recently synthesized information on red flags (information that indicates a secondary etiology) and green flags (information that indicates a primary etiology). A systematic diagnostic approach using red flags and green flags can help reduce unnecessary testing and shift attention to patient care. Going forward, further validation of these concepts is needed to properly introduce them for clinical use.

Primary Versus Secondary Anaplastic Thyroid Carcinoma: Perspectives from Multi-institutional and Population-Level Data

Primary (or de novo) anaplastic thyroid carcinoma (ATC) is ATC without pre-existing history of differentiated thyroid carcinoma (DTC) and no co-existing DTC foci at the time of diagnosis. Secondary ATC is diagnosed if the patient had a history of DTC or co-existing DTC components at time of diagnosis. This study aimed to investigate the incidence, clinical presentations, outcomes, and genetic backgrounds of primary versus secondary ATCs. We searched for ATCs in our institutional databases and the Surveillance, Epidemiology, and End Result (SEER) database. We also performed a systematic review and meta-analysis to analyze the genetic alterations of primary and secondary ATCs. From our multi-institutional database, 22 primary and 23 secondary ATCs were retrieved. We also identified 620 and 24 primary and secondary ATCs in the SEER database, respectively. Compared to primary ATCs, secondary ATCs were not statistically different in terms of demographic, clinical manifestations, and patient survival. The only clinical discrepancy between the two groups was a significantly larger tumor diameter of the primary ATCs. The prevalence of TERT promoter, PIK3CA, and TP53 mutations was comparable between the two subtypes. In comparison to primary ATCs, however, BRAF mutations were more prevalent (OR = 4.70; 95% CI = 2.84-7.78) whereas RAS mutations were less frequent (OR = 0.43; 95% CI = 0.21-0.85) in secondary tumors. In summary, our results indicated that de novo and secondary ATCs might share many potential developmental steps, but there are other factors that suggest distinct developmental pathways.

Malignant Cartilage-Forming Tumors

Chondrosarcomas are heterogeneous matrix-producing cartilaginous neoplasms with variable clinical behavior. Subtypes include conventional (75%), dedifferentiated (10%), clear cell (2%), mesenchymal (2%), and periosteal chondrosarcoma (<1%). Tumor location and primary vs secondary also play a role. In conventional chondrosarcoma, histologic grading (I, II, and III) remains the gold standard for predicting recurrence and metastases. Due to the locally aggressive but overall nonmetastatic behavior, grade I chondrosarcomas (primary and secondary) of long and short tubular bones have been reclassified as atypical cartilaginous tumor. In this review, the pathologic features of malignant cartilage tumors are discussed with updates on recent genetic findings.

Turning Off the Tap: A Typology for Homelessness Prevention

As states move beyond simply managing their homelessness crises to looking for ways to reduce and ultimately end homelessness, broad-scale efforts to prevent homelessness are lacking. Experiences of homelessness are often harmful, traumatic, and costly, making a compelling case for why homelessness prevention should be prioritized. In recent years, countries such as Australia, Finland, and Wales have shifted their focus to prevention, but there remains a conceptual and systematic gap in our collective knowledge about what precisely homelessness prevention is, what policies, programs, and interventions are captured in a homelessness prevention strategy, and how to build a framework for orienting our response to homelessness towards prevention. This article begins to fill that gap by providing a definition and typology of homelessness prevention (THP). Our definition offers a schema to clarify the nature of homelessness prevention and to develop a collective response between various policies and practices that can and should be framed as homelessness prevention. Building off of the public health model of prevention and pre-existing homelessness prevention classification systems, our THP complements the definition by specifying the pragmatic nature of prevention initiatives and the range of sectors, stakeholders, and levels of government required to respond to the causes of homelessness. Our typology is made up of five interrelated elements: structural, systems, early intervention, evictions prevention, and housing stabilization. Each of these elements contains actionable strategies that cut across primary, secondary, and tertiary prevention to ensure that people at various levels of risk have access to the tools and resources necessary to find and maintain safe, appropriate, and suitable housing. Together the definition and THP are useful tools to envision a new way forward in how we respond to homelessness.

Malaria-associated secondary hemophagocytic lymphohistiocytosis: A case report

BACKGROUND

Malaria-associated secondary hemophagocytic lymphohistiocytosis (HLH) is rare. Moreover, the literature on malaria-associated HLH is sparse, and there are no similar cases reported in China.

CASE SUMMARY

We report the case of a 29-year-old woman with unexplained intermittent fever who was admitted to our hospital due to an unclear diagnosis. The patient concealed her history of travel to Nigeria before onset. We made a diagnosis of malaria-associated secondary HLH. The treatment strategy for this patient included treatment of the inciting factor (artemether for 9 d followed by artemisinin for 5 d), the use of immunosuppressants (steroids, intravenous immunoglobulin) and supportive care. The patient was discharged in normal physical condition after 25 d of intensive care. No relapses were documented on follow-up at six months and 1 year.

CONCLUSION

Early diagnosis of the primary disease along with timely intervention and a multidisciplinary approach can help patients achieve a satisfactory outcome.

Perspective: Early diagnosis and treatment of postoperative recurrent cerebrospinal fluid fistulas/ dural tears to avoid adhesive arachnoiditis

Background:

Intraoperative traumatic cerebrospinal fluid (CSF) fistulas/dural tears (DT) occur in up to 8.7–9.5% of primary lumbar surgical procedures. Further, they recur secondarily in between 8.1% and 17% of cases. It is critical to diagnose and treat these recurrent lumbar DT early (i.e. within 3–4 weeks of the index surgery) to avoid the evolution of adhesive arachnoiditis (AA), and its’ permanent neurological sequelae.

Methods:

Postoperative lumbar CSF fistulas/DT should be diagnosed on postoperative MR scans, and confirmed on Myelo-CT studies if needed. They should be definitively treated/occluded early on (e.g. within 3–4 postoperative weeks) to avoid the evolution of AA which can be readily diagnosed on MR studies, and corroborated, if warranted, on Myelo-CT examinations. The most prominent MR/Myelo-CT findings include; nerve roots aggregated in the central thecal sac, nerve roots peripherally scarred/adherent to the surrrounding meningeal wall (“empty thecal sac sign”), soft tissue masses in the subarachnoid space, and/or multiple loculated/scarred compartments.

Results:

Percutaneous interventional procedures (i.e. epidural blood patches, injection of fibrin glue (FG)/fibrin sealants (FS)) are rarely effective for treating postoperative recurrent lumbar CSF fistulas. Rather, direct surgical occlusion is frequently warranted including the use of; an operating microscope, adequate surgical exposure, 7-0 Gore-Tex sutures, muscle/dural patch grafts or suture anchors, followed by the application of microfibrillar collagen, and fibrin sealant/glue.

Conclusion:

Lumbar AA most commonly results from the early failure to diagnose and treat recurrent postoperative CSF fistulas. Since the clinical course of lumbar AA is typically one of progressive neurological deterioration, avoiding its’ initial onset is key.

Primary Roux-en-Y Gastric Bypass Results in Greater Weight Loss at 15-Year Follow-Up Compared with Secondary Roux-en-Y Gastric Bypass After Failure of Gastric Band or Mason McLean Vertical Gastroplasty

PURPOSE

The aim of the study is to compare the outcomes of patients treated with secondary Roux-en-Y gastric bypass (RYGB) after adjustable gastric banding (AGB) or vertical banded gastroplasty (VBG) with those of patients having primary RYGB.

MATERIALS AND METHODS

Patients undergoing secondary RYGB after AGB or VBG between 1997 and 2004 with a minimal follow-up of 15 years were matched using a propensity score (according to gender, age, BMI, duration of follow-up) with comparable patients who underwent primary RYGB.

RESULTS

The mean follow-up was 16.50 years in the secondary RYGB group (N = 32) versus 16.33 years in the primary RYGB group (N = 32). Early postoperative complications rate was 6.25% in the secondary RYGBs versus 9.38% in the primary RYGBs (P = 1). Late postoperative complications and additional surgical procedures were 56.25% and 37.5% in the secondary and primary RYGB group, respectively (P = 0.21). Long-term (at 16-20 years) %TWL and %EWL were significantly lower (P < 0.01 and P = 0.013, respectively) after secondary RYGB (%TWL = 7.56%; %EWL = 17.15%) than after primary RYGB (%TWL = 24.51%; %EWL = 55.61%). Remission of obesity-related comorbidities was comparable (P > 0.05). Gastroesophageal reflux was more frequent after secondary RGYB-43.75% versus 25%, P < 0.05. Quality of life-Morehead-Ardelt II score (0.02 in secondary RYGB versus 0.69 in primary RYGB, P = 0.13), general self-assessment of health status and weight satisfaction were comparable.

CONCLUSION

Secondary RYGB after AGB or VBG is less efficient at weight loss, GERD remission and energy expenditure at 15 years after conversion. However, it is as effective for improvement/resolution of obesity-related comorbidities and is associated with similar QoL scores.