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Autopsy findings led to the post-mortem diagnosis of Richter’s transformation of CLL. CONCLUSIONS Here, we describe a rare case of Hodgkin lymphoma RT from progressive CLL, with transformation occurring at approximately 12 years after initial diagnosis, despite treatment. Our case report underscores the diagnostic challenges and pitfalls associated with the granulomatous presentation masking RT transformation of CLL to Hodgkin lymphoma. The purpose of this report is to raise suspicion for the clinicopathological signs of Richter transformation in the presence of an atypical granulomatous presentation.BACKGROUND Dobutamine stress echocardiography (DSE) is commonly used for cardiovascular assessment before orthotopic liver transplantation (OLT). The coronary artery calcium score (CACS) is a useful screening tool for coronary artery disease (CAD). We aimed to compare the sensitivity and specificity of DSE and CACS for CAD in OLT candidates. MATERIAL AND METHODS A total of 265 of the 1589 patients who underwent OLT at our center between 2008 and 2019 had preoperative coronary angiography (CAG). Of these, 173 had DSE and 133 had a CT scan suitable for CACS calculation within 1 year of OLT. Patients with a nondiagnostic DSE were excluded (n=100). Two reviewers evaluated CACS on CT scans. The sensitivity/specificity of DSE and CACS for detection of angiographically significant CAD were calculated for patients with both tests (n=36). A separate analysis compared the sensitivity/specificity of a diagnostic DSE (n=73) and CACS (n=133) against CAG for all patients with either test. RESULTS Sensitivity and specificity were 57.1% and 89.7%, respectively, for DSE, compared with 71.4% and 62.1% for CACS at ≥100 Agatston score. For the analysis of all patients with either test, the sensitivity/specificity of DSE for detection of CAD and CACS were 30.8% and 85.0% and 80.0% and 62.8%, respectively. On ROC analysis, CACS was a satisfactory predictor of obstructive CAD (AUC, 0.76±0.06, 95% CI, 0.66-0.87; P less then 0.001). CONCLUSIONS CACS may be an important tool for cardiovascular assessment in patients undergoing OLT. DSE was nondiagnostic in a large percentage of OLT candidates, limiting its use in this population.

To investigate the correlation of volumetric measurements of intraretinal (IRF) and subretinal fluid (SRF) obtained by deep learning and central retinal subfield thickness (CSFT) based on optical coherence tomography (OCT) in retinal vein occlusion (RVO), diabetic macular edema (DME) and neovascular age-related macular degeneration (nAMD).

A previously validated deep learning-based approach was used for automated segmentation of IRF and SRF in spectral domain-OCT images. OCT volumes of 2.433 patients obtained from multicenter studies were analyzed. Fluid volumes were measured at baseline and under anti-vascular endothelial growth factor (VEGF) therapy in the central 1, 3, and 6 mm.

Patients with nAMD demonstrated generally the weakest association between CSFT and fluid volumes measurements in the central 1mm (0.107 to 0.569). In patients with DME, IRF correlated moderately with CSFT (0.668 to 0.797). In patients with RVO, IRF volumes showed a moderate correlation with CSFT (0.603 to 0.704).

The correlation of CSFT and fluid volumes depends on the underlying pathology. Although the amount of central IRF seems to partly drive CSFT in DME and RVO, it has only a limited impact on patients with nAMD. Our findings do not support the use of CSFT as primary or secondary outcome measure for quantification of exudative activity or treatment guidance.

The correlation of CSFT and fluid volumes depends on the underlying pathology. Although the amount of central IRF seems to partly drive CSFT in DME and RVO, it has only a limited impact on patients with nAMD. Our findings do not support the use of CSFT as primary or secondary outcome measure for quantification of exudative activity or treatment guidance.

To determine the prevalence and characteristics of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) in eyes with patchy atrophy due to pathologic myopia (PM).

Five hundred eyes of 253 patients with patchy atrophy were examined between 2014 and 2020 at the Advanced Clinical Center for Myopia. The main outcome measures included the prevalence and characteristics of active MFC/PIC lesions diagnosed by optical coherence tomography (OCT).

Fifty-five of the 500 eyes (11%) diagnosed with patchy atrophy had OCT features of active MFC/PIC lesions such as focal elevations of the RPE filled with medium hyperreflectivity material, curvilinear scars (Schlaegel lines), and/or areas of outer retinal atrophy. At the time when the MFC/PIC was diagnosed, the mean age was 57.3±12.0 years, and the mean axial length was 29.2±1.8 mm. Macular neovascularization (MNV) was found in 45 of eyes (81.8%) with MFC/PIC vs 151 eyes without such findings (33.9%; P <0.001). In 25 of the 55 eyes (45.5%), active MFC/PIC lesions were found before the development of the patchy atrophy. The Bruch’s membrane defects were co-located with these lesions.

Active MFC/PIC lesions were identified in a minority of eyes with PM, and a subset of these lesions were observed to progress to findings indistinguishable from myopic patchy atrophy. Evidence of MFC/PIC in eyes with PM appeared to be a risk factor for the development of MNV.

Active MFC/PIC lesions were identified in a minority of eyes with PM, and a subset of these lesions were observed to progress to findings indistinguishable from myopic patchy atrophy. Evidence of MFC/PIC in eyes with PM appeared to be a risk factor for the development of MNV.

Gastroesophageal reflux has been associated with idiopathic pulmonary fibrosis (IPF). Mean nocturnal baseline impedance (MNBI) is a marker of esophageal mucosal integrity, whereas postreflux swallow-induced peristaltic wave (PSPW) index reflects esophageal chemical clearance. Both metrics offer novel ways to assess reflux burden on multichannel intraluminal impedance-pH testing (MII-pH), but their role in extraesophageal reflux remains unclear. We aimed to evaluate the relationship between these novel metrics and lung function decline in patients with IPF.

Adults with IPF undergoing prelung transplant MII-pH were enrolled. All patients completed pulmonary function testing (PFT) at the time of MII-pH and at the 1-year follow-up. MNBI was calculated by averaging baseline impedance at three 10-minute intervals (1 AM/2 AM/3 AM). PSPW index was the proportion of all reflux episodes, followed by a peristaltic swallow within 30 seconds. Univariate (Student t-test/Pearson correlation) and multivariable (general lore severe lung function decline over 1 year in patients with IPF. These impedance metrics may have prognostic value and support a role for reflux in IPF pathogenesis.

The new Joint Commission requirements on perinatal safety present a unique opportunity for the simulation community to actively engage with labor and delivery units nationwide. Considerations for implementation using “real-life” experience with the programmatic development of an in situ team-based simulation training program in obstetric emergencies are discussed. We urge simulationists to explore opportunities to promote culture change on a large scale to move the needle of maternal morbidity and mortality.

The new Joint Commission requirements on perinatal safety present a unique opportunity for the simulation community to actively engage with labor and delivery units nationwide. Considerations for implementation using “real-life” experience with the programmatic development of an in situ team-based simulation training program in obstetric emergencies are discussed. We urge simulationists to explore opportunities to promote culture change on a large scale to move the needle of maternal morbidity and mortality.

Frontline health care workers who perform potentially aerosol-generating procedures, such as endotracheal intubations, in patients with coronavirus disease 2019 may be at an increased risk of exposure to severe acute respiratory syndrome coronavirus 2. To continue to care for patients with coronavirus disease 2019, minimizing exposure is paramount. Using simulation, we devised a testing method to evaluate devices that may mitigate the spread of aerosol and droplet-sized particles.

In this prospective single-center study, participants intubated a manikin 3 times using standard personal protective equipment, once with no barrier device, once with an acrylic box, and once with a modified horizontal drape. The micrometer-sized particle count, generated by a nebulization model, was recorded before and after each intubation. The first-pass intubation rate and time to intubation were recorded. Each operator completed a postsimulation survey about their experience using the barrier devices.

Thirty airway proceduralists completed the simulation and survey. There was no significant difference in particle counts (aerosols or droplets) or first-pass intubation, but the horizontal drape was found to significantly increase intubation time (P = 0.01). Most participants preferred the drape over the acrylic box or no barrier device.

The acrylic box and plastic drape did not mitigate particle spread. However, our testing method can be used to test barrier designs using negative pressure or other mitigation strategies for particle spread.

The acrylic box and plastic drape did not mitigate particle spread. However, our testing method can be used to test barrier designs using negative pressure or other mitigation strategies for particle spread.

Initial healthcare delivery after warfront injury is unpredictably challenging for military forces. As preparatory training, healthcare providers use simulation to improve their performance in stressful critical situations. This study investigated whether a digital CA held by the team leader improved performance in simulated combat casualty care.

This randomized controlled trial was performed during a combat casualty training course for military physicians and nurses in France. Each pair of care providers completed 2 scenarios randomized to be undertaken either with or without a digital CA. The primary end point was the technical performance evaluated from a video recording by 2 independent raters using a pre-established score grid (up to 100%) according to military protocols. The secondary end point was the nontechnical performance (TEAM scale, maximum 54 points).

Thirty-six pairs of participants were included. Use of the digital CA improved both technical (74% vs 53%, P < 0.001) and nontechnical (42 vs 32, P < 0.001) performance.

The digital CA improved technical and nontechnical performance during training of medical care for military combat casualties. Use of a dedicated digital CA might improve care in a combat environment.

This study is a randomized controlled trial.

This study is a randomized controlled trial.

Trauma teams are ad hoc, multidisciplinary teams that perform complex patient care and medical decision making under dynamic conditions. The ability to measure and thus understand trauma team processes is still limited. Agent-based simulation modeling (ABSM) can be used to investigate complex relationships and performance within a trauma team. However, the foundational work to support such efforts is lacking. The goal of this work is to develop a comprehensive process model for the primary survey in trauma that can support ABSM.

A process model for the primary survey of patients with blunt traumatic injuries was developed using Advanced Trauma Life Support guidelines and peer-reviewed publications. selleckchem This model was then validated using video recordings of 25 trauma resuscitations in a level 1 trauma center. The assessment and treatment pathway followed in each video were mapped against the defined pathway in the process model. Deviations were noted when resuscitations performance did not follow the defined pathway.