It’s Not Always Cellulitis: An Unusual Presentation of Leukocytoclastic Vasculitis

Background: Leukocytoclastic vasculitis (LCV) is a histopathologic term for isolated cutaneous small vessel vasculitis (CSVV) without systemic involvement. LCV can be idiopathic or caused by medications, infections, vascular disorders or malignancies. The annual incidence of biopsy-proven leukocytoclastic vasculitis is approximately 45/million individuals. It presents as erythematous macules with palpable purpura bilaterally on dependent areas of the body. Unilateral and localized presentations are uncommon. Here, we present a rare case of isolated LCV on the abdomen. Case Presentation: A 65 year old woman with a history of vitiligo and Raynaud’s Syndrome, presented with a 12 day history of a tender abdominal rash associated with fevers at home, but no other systemic symptoms. The patient was started on multiple antibiotics in the outpatient setting without any improvement. The rash continued to expand and darken prompting her ED visit. On evaluation, vital signs were unremarkable. Abdominal inspection was significant for a large violaceous, palpable rash over the lower abdomen which was tender and warm to touch. Labs showed leukocytosis of 16K, sedimentation rate 104, ANA titer 1:80 but ANCA, antiphospholipid antibodies, HIV/Hepatitis serology, blood cultures, Ds-DNA, and RF were negative. Skin punch biopsy was performed from the right lower abdomen which was consistent with leukocytoclastic vasculitis and thrombotic vasculopathy with ischemic epidermal necrosis. Immunofluorescent studies were negative. Conclusions: Our case represents a rare presentation of LCV, localized in a non-dependent area. LCV should not be missed, as it can clinically mimic cellulitis, but would require a different management

Novel Green Micro-Synthesis of Graphene-Titanium Dioxide Nano- Composites with Photo-Electrochemical Properties

Background: Graphene-Titanium dioxide nano-composite forms a very promising material in the field of photo-electrochemical research. Methods: In this study, a novel environment-friendly synthesis method was developed to produce well-distributed anatase nano-titanium dioxide spherical particles on the surface of graphene sheets. This novel method has great advantages over previously developed methods of producing graphenetitanium dioxide nanocomposites (GTNCs). High calcination temperature 650°C was used in the preparation of nano titanium dioxide, and chemical exfoliation for graphene synthesis and GTNC was performed by our novel method of depositing titanium dioxide nanoparticles on graphene sheets using a Y-shaped micro-reactor under a controlled pumping rate with minimal use of chemicals. Results: The physiochemical and crystallographic properties of the GTNC were confirmed by TEM, XRD, FTIR and EDX measurements, confirming process repeatability. Spherical nano-titanium dioxide was produced in the anatase phase with very high crystallinity and small particle diameters ranging from 9 nm to 25 nm, also the as prepared graphene (RGO) exhibited minimal flake folding and a high carbon content of 81.28% with a low oxygen-to-carbon atomic ratio of 0.172 and GTNCs produced by our novel method had a superior loading content, a homogeneous distribution and a 96.6% higher content of titanium dioxide particles on the graphene sheets compared with GTNCs prepared with the one-pot method. Conclusion: For its photoelectrochemical properties, chronoamperometry showed that GTNC sample (2) had a higher peak current of 60 μA compared with that of GTNC sample (1), which indicates that the separation and transfer of electron-hole pairs are better in the case of GTNC sample (2) and according to the LSV results, the generation of photocurrent in the samples can be observed through multiple on-off cycles, which indicates that the electrodes are stable and that the photocurrent is quite reversible

Endoscopic Surveillance for Gastric Ulcers

Objective: Gastric ulcers (GUs) can be caused by a malignancy, and endoscopists are challenged with the question of how to rule out underlying malignancy. Although routine endoscopic surveillance is not advised, it is still overused. The purpose of this study was to explore the practice in our tertiary referral center during the last 3 years. Methods: We retrospectively reviewed all inpatient and outpatient esophagogastroduodenoscopies (EGDs) that were performed between November 2009 and November 2012 for GUs. Patients with GUs who normally would not undergo biopsy, such as patients who present with bleeding or had stigmata of high-risk bleeding, were excluded. Results: A total of 165 patients were diagnosed between November 2009 and November 2012 as having GUs on EGD. Fifty-two patients were excluded because they presented with bleeding or had GUs that had stigmata of high-risk bleeding. We reviewed the charts of 113 patients and endoscopic surveillance was recommended for 96 (85%). Of those 96 patients, 72 (64%) underwent repeat EGD. In those 72 patients, GU was still present in 9 patients and was completely healed or healing in 63 patients. Only 25 (22%) GUs were biopsied at initial EGD, 23 of which were benign and 2 were adenocarcinomas. No additional malignancy was found on surveillance EGD. Conclusions: EGD surveillance for GUs is a common practice, although the guidelines discourage such a practice. Our rate of endoscopic surveillance was significantly higher than reported previously (64% vs 25%). In our experience, such a high rate of surveillance did not reveal any additional gastric malignancy. Alternatively, the rate of biopsy of GUs at initial EGD is low (22%), which also reflects endoscopists' preference for endoscopic surveillance

Deeper Seated Than Skin Deep: Report of a Rare Case of Follicular Occlusion Tetrad and a Literature Review

Follicular occlusion tetrad (FOT) is a clinical syndrome consisting of hidradenitis suppurativa (HS), acne conglobata (AC), dissecting cellulitis of the scalp (DCS), and pilonidal cyst (PC). These entities typically occur independently, but occasionally present simultaneously comprising FOT. The four components share similar pathophysiology affecting the apocrine glands, follicular hyperkeratinization being the hallmark of each entity.Understanding shared similarities of each disease is paramount for the treatment approach as the relapsing and chronic nature of this syndrome can be burdening to patients. We present the case of a 22- year-old obese Hispanic man with a history of tobacco use who presented with worsening skin lesions. The patient developed extensive facial cystic acne 5 years before presentation, followed by left axillary hidradenitis suppurativa lesions two years before the presentation and right axillary involvement one year after. Skin manifestations then expanded to include the lower back, gluteal and perineal areas. The patient was diagnosed with FOT and despite conservative medical management, his lesions failed to improve. He ultimately underwent multiple staged excisional debridement surgeries and skin grafts. Our case underlines the presence of a syndromic association of cutaneous lesions that share a common pathogenesis and emphasizes that this entity requires a multidisciplinary approach. New biologic therapies continue to emerge and may potentially prevent the need for surgical intervention and the burden associated with it

Implementation of a Quality Improvement Project for Medical Reconciliation: Outcomes in a Primary Care Residency Clinic

Background: Medication reconciliation is the process of creating the most accurate list of medications a patient is taking and comparing it against the physician’s admission, and discharge orders. It is an effective intervention to prevent drug-related events which are the leading cause of medical errors. Medical reconciliation training promotes patient safety and is imperative for a better transition of care. Methods: We implemented a quality improvement project to promote awareness of medication reconciliation. We aimed to increase compliance of medication to 80% in 3 months and maintain it through March 2021. Our interventions consisted in reminders to prompt residents to perform medication reconciliation. As an independent reviewer, our clinic manager shared a monthly metric reports for the number of missed medication reconciliations. Results: Prior to our intervention, our percentage of medication reconciliation was 62% (August 2020). Following our intervention, the compliance increased to 82% in November 2020 and, in December, it peaked at 90%. At the end of our intervention, medication reconciliation plateaued at 85% (April 2021). Conclusions: Our quality improvement project increased resident and staff awareness of medication reconciliation. We maintained medication reconciliation above 80% from January 2021 to March 2021. In addition, we identified barriers in the process that were not recognized before including issues related with equipment, workflow and environment. Our intervention allowed for accountability because residents were monthly informed about their own performance. Our initiative allowed for development and self-improvement during training which, ultimately, might result in less medical errors

A Proposed Expert System for Diagnosis of Migraine

Migraine is a complex neurological disorder characterized by recurrent moderate to severe headaches, accompanied by additional symptoms such as nausea, sensitivity to light and sound, and visual disturbances. Accurate and timely diagnosis of migraines is crucial for effective management and treatment. However, the diverse range of symptoms and overlapping characteristics with other headache disorders pose challenges in the diagnostic process. In this research, we propose the development of an expert system for migraine diagnosis using artificial intelligence and the CLIPS (C Language Integrated Production System) framework. The expert system utilizes a rule-based inference engine to analyze patient-reported symptoms and provide reliable diagnoses or probability scores indicating the likelihood of migraine. The knowledge base of the expert system is designed based on expert knowledge obtained from medical professionals specializing in migraines. The collected knowledge is translated into a structured format suitable for the CLIPS inference engine, incorporating rules and facts to represent the diagnostic criteria and associated symptoms. The system prompts users to provide relevant information about their symptoms, medical history, and potential triggers. It applies the defined rules and facts to evaluate the likelihood of migraine and generate accurate diagnoses or probability scores. Preliminary evaluation results demonstrate the potential of the expert system as a valuable tool for diagnosing migraines. A dataset of anonymized patient records with confirmed migraine cases was used to test the system. The diagnoses generated by the expert system were compared against the known diagnoses, and a high level of accuracy was observed, with 90% of cases correctly diagnosed as migraines. These results highlight the effectiveness and reliability of the system in assisting medical professionals in the diagnosis of migraines. The proposed expert system offers several advantages for migraine diagnosis. It leverages the collective knowledge and expertise of experienced migraine specialists, providing a standardized and consistent approach to diagnosis. The system can handle large amounts of patient data and effectively analyse complex relationships between symptoms, risk factors, and diagnostic criteria. Furthermore, it offers real-time feedback and recommendations, supporting medical professionals in their clinical decision-making process. Future work involves refining the expert system based on feedback from medical experts, expanding the knowledge base to encompass a wider range of symptoms and risk factors, and conducting further evaluations to enhance its accuracy and applicability in clinical settings. The development of an expert system for migraine diagnosis has the potential to improve the diagnostic process, leading to more effective management and treatment strategies for individuals suffering from migraines

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Evaluation of serum interleukin-1 beta as an inflammatory marker in COPD patients

Background: COPD is a chronic disease of the lungs characterized by increased obstruction to airflow that does not change markedly over periods of several months. Low-grade systemic inflammation is considered a hallmark of COPD that potentially links COPD to increased rate of systemic manifestations of the disease. Evaluation of systemic inflammation in COPD particularly when the disease is severe and during exacerbation can be measured either as increased circulating cytokines, chemokines and acute phase proteins, or as abnormalities in the circulating cells and markers. One of these inflammatory mediators is IL-1B which demonstrated recent reports in significantly high levels of IL-1β in serum of the COPD patients as compared to the healthy controls. Aim of the study: To assess the level of serum IL-1B in chronic obstructive pulmonary disease patients during acute exacerbation and in stable conditions and also, to determine if the changes in its level correlated with changes in the ventilatory functions. Methods: 80 cases were included in this study: 60 COPD patients and 20 healthy subjects as a control. There were 48 males and 12 females in COPD groups and 17 males and 3 females in the control group. Their age ranged from 41 to 79 years with a mean age of 59 years. The subjects were classified into 3 groups. Group I includes (30) patients with acute exacerbation of COPD. Group II includes (30) patients with stable controlled COPD. Group III includes (20) healthy persons as a control. Results: There was a highly statistically significant difference in serum IL-1B (pg/ml) between studied groups, which indicates that IL-1B plays a role in systemic inflammatory process. There was a highly statistically significant difference in serum IL-1B concentration (pg/ml) and severity of COPD cases. Conclusions: IL-1β correlated with clinical aspects of disease severity, suggesting that IL-1β may play a critical role in COPD