Eye Masks and Earplugs to Improve Night Sleep Duration in Nulliparas: A Randomized Trial

Background Women experience significant sleep disruption throughout pregnancy. Lack of sleep during the last month of pregnancy is associated with longer labor, a higher rate of Cesarean births, gestational diabetes, hypertension, and preterm birth. Eye-mask and earplugs through sensory deprivation increase sleep duration and quality in patients in the intensive care environment but their impact at home or during pregnancy is not known. We sought to evaluate eye-mask and earplugs compared to sham/placebo headbands on night sleep duration in pregnancy. Materials and methods A randomized trial was performed in a university hospital in Malaysia. Nulliparas between 34 and 36 weeks of gestation with self-reported night sleep of fewer than six hours were randomized to the use of eye-mask and earplugs or "sham" headbands during night sleep (both introduced as sleep aids). Night sleep duration was measured through a wrist actigraphy monitor during non-intervention week one and intervention week two with the allocated sleep aid. Results Data from 56 participants were analyzed on an intention-to-treat basis. Mean night sleep duration increased in intervention week two compared to non-intervention week one in both trial arms, which were 279 ± 19 vs. 304 ± 19 minutes (mean increase of 25 minutes) p = <0.001 and 286 ± 21 vs. 302 ± 22 minutes (mean increase of 16 minutes) p = <0.001 for eye-masks-earplugs and headband respectively. However, the mean increase in night sleep duration across trial arms (p=0.13) was not significant. A higher proportion of participants in the eye-masks and earplugs arm had their night sleep duration increased by at least 30 minutes, 13/29 (45%) vs. 5/26 (19%), relative risk (RR) 2.3 (95% CI 1.0-5.6) p = 0.04, more likely to agree that they slept better 19/29 (66%) vs. 7/27 (26%), RR 2.2 (95% CI 1.1-4.6) p = 0.03, expressed higher satisfaction score with their sleep aid 7 (7.0-7.5) vs. 6 (5-7), p = 0.003 and had lower induction of labor rates 4/29 (14%) vs. 12/27 (44%), RR 0.3 (95%CI 0.1-0.8) p = 0.02. Conclusion Eye masks and earplugs use in nulliparas with short night sleep duration in late pregnancy, lengthen their night sleep duration over baseline. Sleep is reportedly better and maternal satisfaction is higher with eye masks and earplugs use.

Effect of Hospital Teaching Status on Outcomes of Patients With Acute Pancreatitis

Introduction Multiple studies have shown that outcomes of various diseases differ by the hospital teaching status. However, not much is known about the effects of hospital teaching status on outcomes of acute pancreatitis (AP). The aim of this study was to identify if there was an effect of hospital teaching status on the outcomes of AP. Methods The National Inpatient Sample (NIS) database was used to identify patients with a discharge diagnosis of AP from 2016 to 2019. Patients were classified according to whether they were admitted to teaching hospitals (TH) or non-teaching hospitals (NTH). Study outcomes were the length of stay (LOS), total hospitalization cost and charge, sepsis, shock, acute kidney injury, ICU admission, and mortality. Results A total of 1,689,334 patients were included in the study. Of these, 65.06% were in the TH group, while 34.94% were in the NTH group. Patients admitted to TH had a higher incidence of AKI (18.84% vs. 15.79%, p<0.001), shock (4.32% vs. 2.7%, p<0.001), sepsis (4.48% vs. 3.65%, p<0.001), and ICU admissions (4.78% vs. 2.90%, p<0.001) than NTH. Patients admitted to TH also had a higher length of stay (5.82 vs. 4.54 days, p<0.001) and higher hospitalization charges ($47,390 vs. $65,380, p<0.001). The mortality rate in TH was 2.25% compared to 1.5% in NTH (p<0.001). Conclusion Patients admitted to TH had higher mortality as compared to NTH. While the exact reason for this is unknown, it can be partially explained by a higher incidence of AKI, shock, and sepsis. Furthermore, ICU admissions were higher in TH, indicating higher resource utilization.

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

INTRODUCTION

Coronary artery disease (CAD) is a leading cause of death in developed countries. Non-invasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI.

METHODS

Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography.

RESULTS

A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male. Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study (67.99 (95% CI 60.49-75.49) vs. 77.56 months (95% CI 75.14-79.99); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1.15 (68.39 (95% CI 60.69-76.10) vs. 77.31 months (95% ICCI 74.68-79.76); p = 0.013).

CONCLUSION

In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest end-systolic volume ratio ≥ 1.15, during a follow-up period of five years.

Giving Rest to the Restless Leg: A Case Report of How Self-Education Prepending Web-Based Interventions Can Ameliorate Restless Leg Syndrome

Restless leg syndrome (RLS) is a neurological disorder characterized by an irresistible urge to move one's leg sporadically. The pathogenesis of RLS, also known as Willis Ekborn disease, is not fully understood; however, scientists note a complex interplay between multiple neuronal pathway-related genes with endogenous and exogenous factors. We report a case of a previously healthy 27-year-old man complaining of a continuous urge to move his right leg, notably at night. Laboratory evaluation proved negative for secondary causes of RLS; hence the condition was labeled as "primary idiopathic." The patient was started on appropriate pharmacotherapy and was advised to self-educate regarding his ailment. The patient began internet-based self-education and displayed excellent improvements on the International Restless Leg Syndrome Scale (IRLS). Mental exercises, such as self-education using web-based intervention and pharmacotherapy, could alleviate factors in patients with primary idiopathic RLS. Further research is needed to clarify self-education's role in managing RLS.

Perception of the Saudi Population on Abortion Decisions in Congenital Fetal Anomalies

Introduction Termination of pregnancy for fetal anomalies is well reported in the literature and accepted by the western and other non-Muslim communities, but Muslim communities' perception is poorly reported and rarely mentioned. This study aims to evaluate the perception of the Saudi community on abortion decisions as a management option in congenital fetal anomalies. Methods This is an observational, descriptive cross-sectional study, where participants of Saudi nationality, living in Jeddah, and consenting to participate in the research filled up a self-administrated, structured, close-ended, validated questionnaire. The level of agreement was measured on a Likert scale. Results A total of 574 participants were included in the study; 43.3% were female. The mean age of the participants was 30.3 years (SD = 10.6). Undergraduate students were 58.9%, single participants were 56.3%, and participants without children were 61.3%. The prevalence of abortion was 17.9%. The overall agreement on accepting abortion as an option was 61%. Gender (p<0.001), knowledge level (p=0.003), and religion (p=0.01) were the most important factors that influenced people's perception of abortion. Other factors like participants' age (p=0.09), level of education (p=0.48), marital status (p=0.16), having children (p=0.48), and gender of the fetus (p=0.2) were not significant factors in their decision to choose abortion. Conclusion Overall, Saudis were more inclined to accept abortion in case of a confirmed congenital anomaly, yet females were more accepting of the idea than males.

Congenital Pseudoarthrosis of the Tibia: A Narrative Review

Congenital pseudoarthrosis of the tibia, also known as CPT, is a rare bone disease mostly occurring in the pediatric age group of 10. The case generally represents anterolateral bowing of the tibia with refractures. This condition is quite rare and has very few cases per year. CPT is still a challenging concern in orthopedics. Bone reunion often requires repeated surgical measurements. With advancements, we have new treatment plans that include induced membrane techniques and bone marrow stromal cell grafts of various induced and morphogenetic protein, which still requires confirmation. Different treatment strategies based on surgical, mechanical, and biological concepts have been shown with varying success rates. Ilizarov technique and vascularised fibular grafts have vastly increased the effectiveness in treating CPT of the tibia. Constant and recurrent refracture, residual deformities, and difficulty obtaining bone union remain the challenges in managing CPT. Hence, phasing CPT as bowing the tibia in an anterolateral fashion is more appropriate because it's a heterogeneous entity with varying prognoses.

Pars Plana Vitrectomy With Internal Limiting Membrane Peeling for the Treatment of Cystoid Macular Edema in a Patient With Syphilitic Uveitis and HIV Infection

We report a case of cystoid macular edema (CME) secondary to syphilitic uveitis that was successfully treated with pars plana vitrectomy with internal limiting membrane peeling. A 37-year-old male with a history of HIV developed a CME secondary to syphilitic panuveitis. His uveitis resolved following treatment with intravenous penicillin, yet his CME persisted and was refractory to four posterior sub-tenon triamcinolone acetonide injections. A pars plana vitrectomy with internal limiting membrane peeling was performed, resulting in lasting resolution of the CME and the improvement of his visual acuity at the two-month follow-up visit. Pars plana vitrectomy with internal limiting membrane peeling may be a viable alternative for the treatment of CME in patients with syphilitic uveitis. In particular, it may serve as a viable alternative for the treatment of CME in patients with a history of infectious uveitis or other comorbidities, such as HIV infection.

KIT (CD117) Positive Huge Primary Malignant Extra Gastrointestinal Stromal Tumors (EGISTs) Arising From Jejunal Mesentery: A Rare Case Report

Tumors arising outside gastrointestinal systems are known as extra gastrointestinal stromal tumors (EGISTs). Outside gastrointestinal sites include the mesentery, omentum, peritoneum, pancreas, and liver. Our case highlights a rare occurrence of an EGIST in jejunal mesentery in a 45-year-old male with an asymptomatic large abdominal growth and weight loss. A contrast-enhanced multi-dimensional computed tomography scan showed a large heterogeneous mass in the left hypochondrium. lumbar, and paraumbilical regions. Later, the patient underwent surgical resection of the tumor along with the involved jejunal segment and small tumor masses in the mesentery. Histopathological examination reported a malignant EGIST of mesentery and invasion into the jejunum, further confirmed by immunohistochemistry (IHC) markers like CD117 and smooth muscle actin with a high proliferative index (Ki67). One should be aware that these are different from other malignancies arising from the mesentery. Their cell of origin is different and needs a specific type of treatment. The clinical history, radiological findings, histopathology, and IHC help in diagnosing especially when they are arising from unusual areas like jejunal mesentery. Surgical intervention and chemotherapy are mainstay treatments.

Valvular Heart Disease Presenting as Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Phenomenon: A Diagnostic and Management Paradigm

Sympathetic crashing acute pulmonary edema (SCAPE) is an acute decompensated heart failure due to sympathetic overflow. SCAPE is usually triggered by acute insults with an underlying substrate such as long-standing hypertension, chronic heart failure, and valvular heart disease. We present a case of SCAPE in a 91-year-old female due to underlying multivalvular heart disease. Because of severe acute presentation, SCAPE should be identified early, and management should be urgently done to decrease the need for invasive ventilation and prolonged hospitalization.

Ewing Sarcoma of the Lung: Imaging of a Rare Tumor

Primary pulmonary Ewing sarcoma is an extremely rare tumor of neuroectodermal tissue. In this article, we report on the case of a 45-year-old female who presented in the emergency department with shortness of breath and night fever. Radiologic findings suggested a massive pulmonary mass and a metastatic liver lesion. The diagnosis of Ewing sarcoma was established through a percutaneous biopsy of the lung mass and liver lesion. We highlight the importance of considering a broad differential diagnosis for a large pulmonary mass in order to lead to a prompt diagnosis and treatment.

Black Pleural Effusion as a Complication of Acute Pancreatitis

Transient and reactive pleural effusion is a known consequence of acute pancreatitis. Usually, the pleural effusion is unilateral, transudate, straw-colored, and self-resolving. We report a rare case of massive left-sided black pleural effusion as a complication of acute pancreatitis with the background of chronic pancreatitis being secondary to alcohol abuse. The pleural effusion resulted in hypoxic respiratory failure. However, the patient had significant improvement after drainage of the pleural effusion and the appropriate management of sepsis with broad-spectrum antibiotics. The patient had a significant improvement and recovery with conservative management without the need for endoscopic therapy or surgical intervention.

Peripheral Neuropathy in Beta-Thalassemia: Corneal Confocal Microscopy-Based Study

Background Peripheral neuropathy is a controversial but serious complication of beta-thalassemia (β-Th). Although few studies have reported no relationship between neuropathy and thalassemia, many have linked it with increasing age, iron overload, and iron chelator toxicity. This study aims to investigate the presence of neuropathy in β-Th using corneal nerve fibers. Methodology A cross-sectional study was conducted using corneal confocal microscopy on individuals with intermediate and major β-Th who were compared to healthy individuals. The main outcome variables were corneal main nerve and branch nerve densities which were calculated using Image J software. The comparison between groups was done using the independent-samples F-test and Bonferroni post-hoc analysis. Results There was reduced corneal main nerve and branch nerve density in β-Th intermediate and major patients compared to the control group, and the results were statistically significant (p-value <0.05). However, a significant correlation was not observed between serum ferritin levels and corneal nerve parameters. Conclusions The reduction in corneal nerve parameters in β-Th patients compared to healthy controls can be an indication of peripheral neuropathy in β-Th. Further work is needed to confirm these findings.

The Development of Psychiatric Illness and Chemoprophylaxis of Botulinum Toxin in Migraine: A Narrative Review

A migraine is not just a headache. It is an extremely prevalent neurological condition marked by periodic episodes of unilateral headache, with more than 10 million cases yearly. Migraine often begins at the age of puberty. It substantially impacts the brain and, consequently, psychiatric behavior linked with frequent migraine attacks that may be moderate to severe in intensity. A crucial aspect of migraine variability is comorbidity with other neurological diseases, vascular diseases, and mental illnesses. Psychiatric disorders related to migraine include anxiety disorders, panic disorder, bipolar disorder, depression, etc. It is also estimated that people suffering from migraine are about five times more likely to develop depression than others without migraine. The stimulus for migraine is stress, lack of sleep, skipped meal or fasting, visual stimulation due to high intensity of light, auditory stimulus due to noise, and olfactory stimulus due to a pungent smell. A majority of patients suffer from migraine attacks triggered by noise, some due to visual stimulation, and a few due to perfumes or other odors that trigger their migraine. Diagnosis of this is primarily dependent on history taking and clinical evaluation. Migraine can be classified depending on whether an aura is present or absent. It can further be divided based on the frequency of headaches into episodic migraine or chronic migraine, which may be determined by the duration of the headache. The development of migraine is influenced by both genetics and the environment. It has a detrimental effect on children's quality of life. A comprehensive analysis of psychiatric illnesses in migraine contributes to early diagnosis and proper treatment of the disease. Also, having a healthy lifestyle (including exercise, a balanced diet, and enough sleep) seems to prevent and improve the condition. Headache in migraine is resistant to medical treatment but responds well to botulinum toxin. This review primarily focuses on the psychiatric issues like depression and anxiety that often accompany migraine. The article also highlights the effects of botulinum toxin on migraine.

RUSHing to the Diagnosis: Aortic Abdominal Aneurysm Detected Using the Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol in the Wards

The rapid ultrasound for shock and hypotension (RUSH) protocol is a useful tool used in the emergency department (ED) when addressing the severity and etiology of shock. It was designed to be performed in under two minutes with evaluation of the pump (heart), tank (inferior vena cava, thoracic and abdominal compartments) and the pipes (large arteries and veins). However, its application or one similar should extend beyond the ED and into the hospital floor. Here we present an 80-year-old gentleman with a history of atrial fibrillation (A-Fib) on anticoagulation who arrived at the ED due to an episode of pre-syncope just prior to arrival. Initial EKG is concerning for A-Fib with rapid ventricular response (RVR) with a rate in the 130s. After fluid resuscitation patient improved and he was admitted to the telemetry floor for further cardiac workup and cardiology consultation. While waiting for a room in the ED, patient became hypotensive, diaphoretic and pale. After complaining of lower abdominal pain, the ED physician performed a RUSH which showed an abdominal aorta of 8 cm concerning for dissection. Diagnosis was confirmed with CT angiography of the abdomen and he was taken to the OR with successful repair of the abdominal aortic aneurysm (AAA). Patient made meaningful recovery and was discharged to in-patient rehab. The patient described in this vignette was delayed in the ED due to lack of beds on the floor. This allowed for quick ultrasound work-up by the ED physician which led to immediate recognition of the AAA and immediate response by the vascular surgery team. Should this patient have been on the hospital floor, it is unclear if such prompt steps would have occurred prior to patient's further hemodynamic demise.

Evaluation of Osteopathic Principles in Cadaveric Specimens Using Radiological Assessment

BACKGROUND

Osteopathic manipulative treatment (OMT) of the spine requires the physician to first be able to diagnose with palpation of the spinous processes, transverse processes, and facets, test for movement of the anatomy, and evaluate changes in tissue texture at each level. Physicians should then apply these changes to Fryette's Principles to effectively understand the corresponding somatic dysfunction and provide treatment. Continuing education in osteopathic principles and practices is important throughout an osteopathic physician's training.

AIM

Diagnosis and treatment require an understanding of the complex neuroanatomy and physiology of patients. We sought to evaluate the diagnostic capabilities of osteopathic physicians. This was done by evaluating the accuracy of diagnosis of somatic dysfunction on a cadaver specimen and verifying via fluoroscopy and blunt dissection.

MATERIALS & METHODS

Fresh refrigerated cadavers were palpated for lesions in the thoracic spine by residents and attendings, and diagnoses of somatic dysfunction were made. Anterior-posterior X-rays were taken with a C-arm. These levels were then exposed by blunt dissection, and somatic dysfunctions were visualized and recorded. Comparative analyses were conducted to evaluate the accuracy of diagnosis.  Results: The accuracy of diagnoses was correct in those who had OMT skills reassessed throughout training and continuing medical education. Osteopathic physicians who routinely kept up with their training were better able to make diagnoses of somatic dysfunction.

CONCLUSION

Continuing osteopathic medical education with an emphasis on the maintenance of palpatory skills is important. Those physicians with the greatest accuracy of somatic dysfunction diagnosis were physicians who routinely underwent reassessment and continuing medical education of osteopathic skills.

Recurrent Metastatic Renal Cell Carcinoma Diagnosed With Endoscopic Ultrasound-Guided Fine Needle Aspiration 18 Years After Initial Surgery

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an alternative approach to sample kidney lesions that is less commonly used compared to percutaneous CT or ultrasound guidance. In this case, we present a 70-year-old female who was diagnosed with metastatic renal cell carcinoma (RCC) 18 years post-nephrectomy with EUS-FNA in conjunction with immunohistochemistry. This case report supports the use of EUS-FNA in conjunction with immunohistochemistry as a robust technique that can safely and effectively diagnose recurrent renal cell carcinoma.

Fortuitous Discovery of Nutcracker Syndrome During Acute Appendicitis: A Case Report

Nutcracker syndrome (NCS) belongs to a group of rare vascular disorders. It refers to compression of the left renal vein (LRV) generally between the abdominal aorta (AA) and the superior mesenteric artery (SMA). It is one of the most unknown causes of chronic abdominal pain. Herein, we present the case of a young patient who came to the emergency department for acute abdominal pain. Patient's history revealed an uncharacterized chronic epigastric pain evolving for 13 years. The imaging showed acute appendicitis and NCS; the latter finding was the principal explanation for the patient's chronic pain. We hope that the concise and synthetized structure of this case report will help physicians acquire the necessary reflexes to notice and diagnose this already underdiagnosed syndrome.

Improvement of Hip Pain After Total Hip Arthroplasty With Dry Needling as an Adjunct to Conventional Physiotherapy: A Case Series

While total hip arthroplasty (THA) is one of the most common and successful orthopedic surgeries, some patients may experience persistent, recurrent, or new hip pain despite successful THA. Dry needling (DN) is a common treatment for musculoskeletal pain, yet little data has been published on the use of DN on hip pain after THA. This series highlights two patients with prior THA and current hip pain that improved with DN used alongside conventional physiotherapy exercises. Patient 1, a 70-year-old male four years post left THA, presented to a physical therapist with a three-year history of left hip pain. Patient 2, a 65-year-old female 10 years post right THA, presented with a one-month history of right hip pain after a fall. Both patients were reported to have a stable prosthesis without clinical or radiological evidence of loosening or other major complications. Examination of both patients revealed decreased hip range of motion, decreased hip strength, and lateral hip trigger points suggestive of a muscular origin of pain. The physical therapist treated both patients with DN alongside strengthening and stretching exercises, yielding significant improvements in pain severity, function, and range of motion. These cases illustrate the successful use of DN alongside conventional physiotherapy to alleviate hip pain in patients with previous THA. Further research is needed to examine the efficacy and safety of DN for hip pain in individuals with prior THA.

Primary Intraosseous Malignant Peripheral Nerve Sheath Tumor of the Humerus: Report of a Rare Case

Malignant peripheral nerve sheath tumors (MPNSTs) usually arise in the soft tissues. Intraosseous MPNSTs are rare. They may arise de novo but are typically associated with neurofibromatosis type 1 (NF1) and radiation therapy. Our patient is a 58-year-old female patient that presented with right shoulder pain. An MRI showed a shoulder mass, and percutaneous bone biopsy demonstrated morphology suggestive of an MPNST; besides, on immunohistochemistry, SOX10 was positive, and H3K27me3 expression was entirely lost. The patient underwent total resection of the right proximal humerus and endoprosthetic shoulder reconstruction, followed by radiation therapy and chemotherapy. Only a few cases in the mandible, spine, maxilla, ulna, metacarpal, tarsal, and one in the humerus have been published. In this paper, we contribute with an additional case of primary intraosseous MPNST in the humerus and a brief literature review.

Poison With a Purpose: A Case Report on Arsenic Cardiotoxicity and Obesity

Acute promyelocytic leukemia (APL) is a form of leukemia in which there is an arrest of the maturation of the myeloid lineage at the promyelocyte stage. Although there is high early mortality due to coagulopathy, APL is now a curable disease with the use of arsenic trioxide (ATO) and all-trans-retinoic acid (ATRA). Arsenic is weight-based for the treatment of APL, and many toxicities are dose-dependent, although there are no guidelines regarding dosing adjustments for obese patients. We present a case of a 34-year-old male with obesity and APL who developed arsenic-induced QTc prolongation and symptomatic sinus tachycardia while receiving treatment. Further research is needed to guide appropriate dosing for obese patients to determine if ideal body weight dosing is able to provide similar cure rates with fewer adverse events.

Mismatch Negativity Responses to Different Auditory Attributes in Normally Developing Infants and Children

Introduction Mismatch negativity (MMN) is a change-specific component of the event-related potentials that is elicited by an irregularity in repetitive auditory stimulation. As it is developmentally stable and can be measured in the absence of the participant's attention, it can be a valuable method for assessing auditory discrimination in infants and young children. The classic MMN paradigm involves tone frequency as the mismatching attribute. Multi-feature MMN paradigms which involve different auditory attributes can assess discrimination abilities in a wider group of disorders. The study aimed to report standardised MMN values obtained with MMN paradigms including several auditory attributes to extend the clinical applicability of the test in infants and young children. Methods MMN responses were recorded in 42 normal infants and young children (2 months to 5 years) with multi-feature MMN paradigms. MMN variables in different trials were compared by one-way ANOVA. Pearson's correlation coefficient and independent sample t-test were performed for finding an association with the age and gender of the participants respectively. P<0.05 was considered as statistically significant. Results MMN amplitude exhibited statistically significant differences in different MMN paradigms (p<0.05). An increase in the degree of standard and deviant differences and double deviant responses also resulted in larger MMN. MMN latency variation in the trials was not statistically significant. The age and gender of the participants did not influence the MMN variables with statistical significance. Conclusion MMN paradigms with different auditory attributes report significant amplitude variations. Multi-feature MMN paradigms can optimize the clinical applicability of the test and can determine the profile of different auditory discrimination abilities.

A Novel Tongue-Based Tumor With an RREB1-MRTFB Fusion: Variant Rhabdomyosarcoma or Aggressive Variant of Ectomesenchymal Chondromyxoid Tumor

The presence of a FOXO1 fusion in a tumor is one of the most important prognostic factors in rhabdomyosarcoma. Most histologically defined alveolar rhabdomyosarcomas bear a FOXO1 fusion. We discuss a case that was initially thought to be a rhabdomyosarcoma but was later discovered to have an RREB1-MRTFB fusion. This fusion has never been reported in rhabdomyosarcoma but typically characterizes ectomesenchymal chondromyxoid tumor (ECT), a neoplasm with typically rather benign behavior. In this article, the authors discussed whether this patient's aggressive presentation represents a variation of ECT or an unusual case of rhabdomyosarcoma.

N-butyl 2-Cyanoacrylate (NBCA) in Nephron Sparing Superselective Embolization of Iatrogenic Renovascular Injuries: A Single Centre Experience

Purpose To evaluate the safety and efficacy of N-butyl-2-cyano-acrylate (NBCA) for endovascular management of iatrogenic renal-vascular injuries and effects on renal function. Material & Methods Fifteen patients with diagnosed or suspected iatrogenic renal vascular injuries, following percutaneous procedures formed the study group. All the patients were having retroperitoneal hemorrhage or hematuria, with hemodynamic instability at the time of presentation. Pseudoaneurysms, active extravasation of contrast, and the arteriovenous fistula were identified as the cause of bleeding on digital subtraction angiography. Patients underwent trans arterial super-selective embolization. Renal function was monitored using serum creatinine, estimated glomerular filtration rate (eGFR), and mean blood pressure of all the patients at immediate post-procedure and two months intervals. Results Technical and clinical success was achieved in all the cases using NBCA alone. Patients improved hemodynamically. None of the patients required repeat embolization. No derangement in renal function was observed immediately after the procedure and at interval follow-up. Conclusion NBCA can be used as a safe embolizing agent to provide a quick and effective cure for iatrogenic renovascular injuries. Renal parenchymal loss can be minimized by super selective technique.

Native Knee Septic Arthritis Due to Cutibacterium acnes: A Case Report

Commensal skin anaerobes have been described as causative agents of prosthetic joint infections. Infection of native joints by these agents are, however, less common. We present the case of a 34-year-old male with recurrent joint effusion following closed trauma to the knee, four years ago, refractory to corticosteroid injections and several arthrocenteses. A synovial biopsy revealed Cutibacterium acnes infection leading to antibiotic therapy with clindamycin, and the patient was referred to orthopaedic and submitted to arthroscopic lavage. Atypical cartilage lesions, resembling the "growth of bacterial colonies", were found in the tibial plateaus with repeated isolation of C. acnes. Inpatient treatment with penicillin and vancomycin was conducted, followed by an oral course of amoxicillin, with no further registered recurrences. In this case, the authors describe a rare cause of native knee septic arthritis while highlighting the importance of repeated microbiology studies and adequate collection technique and sample handling, in order to better ascertain whether the isolated agent represents a contaminated sample or a true infection.

Unusual Findings in Down's Syndrome: Hand Agenesis and Hypospadias

A baby with Down syndrome presented initial findings at the first-trimester ultrasound of increased nuchal thickness and unilateral hand agenesis. During follow-up, other elements were found mainly hypospadias. This report emphasizes through prenatal and postnatal imaging the phenotypic variability of Down syndrome babies.