Mycobacteriophages are viruses that infect mycobacterial hosts such as Mycobacterium smegmatis and Mycobacterium tuberculosis. All mycobacteriophages characterized to date are dsDNA tailed phages, and have either siphoviral or myoviral morphotypes. However, their genetic diversity is considerable, and although sixty-two genomes have been sequenced and comparatively analyzed, these likely represent only a small portion of the diversity of the mycobacteriophage population at large. Here we report the isolation, sequencing and comparative genomic analysis of 18 new mycobacteriophages isolated from geographically distinct locations within the United States. Although no clear correlation between location and genome type can be discerned, these genomes expand our knowledge of mycobacteriophage diversity and enhance our understanding of the roles of mobile elements in viral evolution. Expansion of the number of mycobacteriophages grouped within Cluster A provides insights into the basis of immune specificity in these temperate phages, and we also describe a novel example of apparent immunity theft. The isolation and genomic analysis of bacteriophages by freshman college students provides an example of an authentic research experience for novice scientists.

Objectives. Despite the increasing utilization of point-of-care critical care ultrasonography (CCUS), standards establishing competency for its use are lacking. The purpose of this study was to evaluate the effectiveness of a 2-day CCUS course implementation on ultrasound-naïve critical care medicine (CCM) fellows. Methods. Prospective evaluation of the impact of a two-day CCUS course on eight CCM fellows' attitudes, proficiency, and use of CCUS. Ultrasound competency on multiple organ systems was assessed including abdominal, pulmonary, vascular, and cardiac systems. Subjects served as self-controls and were assessed just prior to, within 1 week after, and 3 months after the course. Results. There was a significant improvement in CCM fellows' written test scores, image acquisition ability, and pathologic image interpretation 1 week after the course and it was retained 3 months after the course. Fellows also had self-reported increased confidence and usage of CCUS applications after the course. Conclusions. Implementation of a 2-day critical care ultrasound course covering general CCUS and basic critical care echocardiography using a combination of didactics, live models, and ultrasound simulators is effective in improving critical care fellows' proficiency and confidence with ultrasound use in both the short- and long-term settings.

Introduction: We report a rare case of Flood syndrome, which is a spontaneous rupture of an umbilical hernia.Case Presentation: A 42-year-old man with decompensated hepatitis C and alcoholic cirrhosis complicated by ascites and esophageal varices presented with 1 day of ascitic fluid drainage after rupture of a preexisting umbilical hernia associated with diffuse abdominal pain and tenderness. A pigtail drain was placed in the right upper abdominal quadrant to decrease fluid drainage from the abdominal wall defect, allowing it to heal naturally.Discussion: The spontaneous rupture of an umbilical hernia in our patient highlights a rare complication with high mortality rates and stresses the challenge of treatment that falls in the area between medical and surgical management.

Study aim To develop and apply a natural language processing algorithm for characterization of patients diagnosed with chronic pancreatitis in a diverse integrated U.S. healthcare system. Methods Retrospective cohort study including patients initially diagnosed with chronic pancreatitis (CP) within a regional integrated healthcare system between January 1, 2006 and December 31, 2015. Imaging reports from these patients were extracted from the electronic medical record system and split into training, validation and implementation datasets. A natural language processing (NLP) algorithm was first developed through the training dataset to identify specific features (atrophy, calcification, pseudocyst, cyst and main duct dilatation) from free-text radiology reports. The validation dataset was applied to validate the performance by comparing against the manual chart review. The developed algorithm was then applied to the implementation dataset. We classified patients with calcification(s) or �2 radiographic features as advanced CP. We compared etiology, comorbid conditions, treatment parameters as well as survival between advanced CP and others diagnosed during the study period. Results 6,346 patients were diagnosed with CP during the study period with 58,085 radiology studies performed. For individual features, NLP yielded sensitivity from 88.7% to 95.3%, specificity from 98.2% to 100.0%. A total of 3,672 patients met cohort inclusion criteria: 1,330 (36.2%) had evidence of advanced CP. Patients with advanced CP had increased frequency of smoking (57.8% vs. 43.0%), diabetes (47.6% vs. 35.9%) and underweight body mass index (6.6% vs. 3.6%), all p<0.001. Mortality from pancreatic cancer was higher in advanced CP (15.3/1,000 person-year vs. 2.8/1,000, p<0.001). Underweight BMI (HR 1.6,

Appendiceal inversion is an uncommon incidental finding on colonoscopy that can mimic pathologic processes such as colon polyps and neoplasms due to its mass-like appearance. Endoscopic removal of these lesions has been associated with a higher risk of peritonitis and bleeding. Awareness of appendiceal inversion may potentially decrease unwarranted interventions as well as its associated risks. Although there are many reported cases of iatrogenic appendiceal inversion due to the traditional inversion-ligation technique performed during open appendectomy, there are few reported cases of asymptomatic appendiceal inversion without a known history of iatrogenic inversion. Here, we present a case of an asymptomatic patient with appendiceal inversion and no prior history of appendectomy. Furthermore, we discuss management and characteristic imaging findings of appendiceal inversion that may help to distinguish it from similarly appearing pathologic conditions.

Meningioma represents the most frequently diagnosed primary brain tumor, accounting for over one-third of central nervous system neoplasms. The majority of tumors are categorized as benign. However, albeit rarely, meningiomas may metastasize to distant sites. We describe a 78-year-old man with a history of recurrent World Health Organization grade I meningioma managed who presented for evaluation of weakness and urinary retention. A computed tomography scan obtained in the emergency department revealed multiple scattered low-density liver lesions. Subsequent magnetic resonance imaging showed a 5.5-centimeter heterogeneous enhancing mass with 2 smaller enhancing lesions suspicious for a primary or secondary malignant neoplasm. Microscopic examination of a tissue sample obtained via liver biopsy demonstrated a metastatic spindle cell neoplasm with histologic features compatible with a diagnosis of World Health Organization grade I transitional meningioma. The patient was referred to hematology/oncology for systemic therapy.

A 51-year-old woman with a past medical history of type II diabetes mellitus and dyslipidemia presented to the Dermatology Department with pain, swelling, and crusting of the lips. This was accompanied by anal pain, odynophagia, and weight loss of 20 kg since the onset of symptoms. Previous evaluations by Head and Neck Surgery, Allergy, and Infectious Diseases Departments included lip biopsy, viral and bacterial cultures, and treatment with topical antifungals, an oral antiviral, topical and oral antibiotics, and topical steroids. The biopsy and culture studies did not reveal the etiology of her condition, and the treatments did not improve her symptoms.One year after onset of her mucosal lesions, the patient developed an abdominal eruption consisting of several tense vesicles and bullae on an erythematous base (Figure 1). She also had lip edema and crusting, oral erosions and ulcerations, and an anal fissure. Histologic examination revealed suprabasal acantholysis (Figure 2), the histologic hallmark of Pemphigus vulgaris (PV) that is essential for diagnosis.1 Furthermore, direct immunofluorescence showed intercellular staining with immunoglobulin G (IgG) and complement test C3, which was also consistent with PV.After biopsy, the patient was empirically started on methylprednisolone, 48 mg daily. After confirmation of her diagnosis, the patient was also started on mycophenolate mofetil, 500 mg twice daily. The methylprednisolone was later switched to prednisone, 80 mg daily, because of gastrointestinal intolerance. Owing to minimal response after 2 months of therapy, the patient received 2 rituximab infusions of 1000 mg, 2 weeks apart. There was noticeable improvement within 2 weeks of her first dose of rituximab. DISCUSSIONPV is an autoimmune disease with the average age of onset between 40 and 60 years of age. It is characterized by involvement of the oral mucosa, such as painful oral erosions that often precede painful, cutaneous flaccid vesicles and bullae.2 Involvement of the oral mucosa is usually accompanied by severe pain that can lead to weight loss and malnutrition. Although it is a rare disease, with incidence rates between 0.1 and 0.5 per 100,000 people per year, PV has the potential for lifethreatening complications, and treatment is always indicated at the time of disease onset.3 PV can be further subdivided into mucosal dominant type, presenting with mucosal lesions and minimal skin involvement; and mucocutaneous type, which presents with skin blisters and erosions along with mucous membrane lesions. IgG antibodies against desmoglein (Dsg) 1 and Dsg 3, cadherin-type cell-to-cell adhesion molecules in desmosomes, are believed to play a role in inducing vesicle and bullae formation in PV. 4 The dysfunction in Dsg 1 and Dsg 3 results in the loss of cell-to-cell adhesion in skin membranes and mucous membranes, respectively. ABSTRACTWe report a case of a 51-year-old woman with a history of type II diabetes mellitus and dyslipidemia presenting with pain, swelling, and crusting of the lips. One year aft...

Objectives: The objective of this study is to compare the rates of secondary intervention following uterine artery embolization (UAE) versus myomectomy for the treatment of symptomatic uterine fibroids. Material and Methods: This is a multicenter retrospective cohort study. Eight hundred and sixty-three patients are included in this analysis, 451 patients who underwent UAE and 412 patients who underwent myomectomy between January 1, 2008, and December 31, 2012. The UAE group was significantly older than the myomectomy group with a median age of 46 versus 38 (P < 0.0001). Patient data were collected from electronic medical records between the time of their initial procedure and December 31, 2017. The primary endpoint was secondary intervention rate. Secondary endpoints included time to secondary intervention, post-procedural complications, differences in mean hemoglobin levels following the procedures, symptomatic improvement, and subsequent pregnancy outcomes. All statistical analyses were two sided and performed using SAS EG 7.13 (Cary, NC). Results: The median follow-up for the UAE and myomectomy groups was 7 and 7.3 years, respectively. Overall, the rates of secondary intervention were not statistically significant between the UAE and myomectomy groups, 8.9% and 11.2%, respectively (P = 0.26). However, stratified analysis in women aged 30–39 years old demonstrated an increased rate of secondary intervention in the UAE arm with a hazards ratio of 3.76 (P = 0.0099). In patients ≥40 years old, there was no significant difference in secondary intervention rate. Both groups demonstrated a significant increase in mean hemoglobin at 1 year following initial procedure with a mean difference (SD) of 1.8 (2.1) in the UAE group and 1.8 (2.5) in the myomectomy group (P < 0.0001 for both groups). The myomectomy group had a higher rate of post-procedural blood transfusion than the UAE group, 2.9% versus 0.9%, respectively (P = 0.028). Both groups had comparable rates of post-procedural pelvic infection and rehospitalization. Patients with pre-procedural menorrhagia who received UAE reported a higher rate of symptomatic improvement when compared to the myomectomy group, 75.4% versus 49.5% (P < 0.0001). Both groups reported similar rates of improvement in bulk symptoms, 46.1% and 43.2%, respectively (P = 1.0). Conclusion: Overall, UAE and myomectomy have comparable rates of secondary intervention during a median 7-year follow-up period. However, in women between 30 and 39 years of age, UAE resulted in higher rates of secondary intervention. UAE may be more effective in controlling patients’ menorrhagia and has lower rates of post-procedural blood transfusions.