Clinical competencies consisting of skills, knowledge, and communication techniques should be acquired by all medical graduates to optimize healthcare quality. However, transitioning from observation to hands-on learning in clinical competencies poses a challenge to medical students. The aim of this study is to evaluate the impact of a novel interactive multimedia eBook curriculum in clinical competency training. Ninety-six medical students were recruited. Students in the control group (n = 46) were taught clinical competencies via conventional teaching, while students in the experimental group (n = 50) were taught with conventional teaching plus interactive multimedia eBooks. The outcomes of clinical competencies were evaluated using Objective Structured Clinical Examination (OSCE) scores, and feedback on their interactive eBook experiences was obtained. In the experimental group, the average National OSCE scores were not only higher than the control group (214.8 vs. 206.5, p < 0.001), but also showed a quicker improvement when comparing between three consecutive mock OSCEs (p < 0.001). In response to open-ended questions, participants emphasized the importance of eBooks in improving their abilities and self-confidence when dealing with ‘difficult’ patients. Implementing interactive multimedia eBooks could prompt a more rapid improvement in clinical skill performance to provide safer healthcare, indicating the potential of our innovative module in enhancing clinical competencies.

Hemophilic arthropathy causes the damage of synovium, cartilage, and subchondral bone. The present study evaluated the safety and the effect of extracorporeal shockwave therapy (ESWT), a safe treatment widely used in musculoskeletal conditions in patients with hemophilic arthropathy. Between 1 August 2019 and 31 July 2020, seven hemophilia A patients were enrolled and treated with medium-energy ESWT on the knee joint in the first two months after prophylactic coagulation factor administration. At the beginning of the study and at 1-, 2-, 3-, and 6-month follow-ups, the Hemophilia Joint Health Score (HJHS), visual analog scale score (VAS), and Hemophilia Early Arthropathy Detection with Ultrasound score (HEAD-US) were evaluated for therapeutic effectiveness and safety, while serum bone morphogenetic protein 2 (BMP-2) and von Willebrand factor (vWF) levels were analyzed for assessing chondroprotection and bone healing. Magnetic resonance imaging (MRI) of the knee was performed at the beginning of the study and the 6-month follow-ups. As a result, a non-significant decrease in VAS scores (p = 0.151) but not HJHS after treatment was noticed. At the 3-month follow-up, there was a non-significant increase in BMP2 levels (p = 0.171) but not vWF. Ultrasonography showed no disease activity score elevation in five patients and no further disease damage in all patients. Repeated MRI examinations in three patients showed no structural progression during the 6-month follow-up. As to adverse events, redness, local heat, and mild swelling were noted in five patients without breakthrough bleeding. We concluded that medium-energy ESWT might be safe for hemophilic arthropathy once prophylactic coagulation factors are administered.

1. Introduction Langerhans cell histiocytosis (LCH) is a disorder characterized by abnormal proliferation of histiocytes, commonly involving the bone, skin, lungs, liver, spleen and lymph nodes. LCH is rare at birth and may easily be confused with other cutaneous lesions, thereby posing a diagnostic challenge for pediatricians. Herein, we present a patient with congenital LCH involving the skin and lungs who presented with multiple hemorrhagic vesicles with a large vascular mass at birth, closely resembling multiple infantile hemangiomas. 2. Patient history This 2600-g male infant was born vaginally at 34+ weeks of gestation to a gravida 2 para 2 31-year-old Taiwanese mother after an uneventful pregnancy. Multiple hemorrhagic papules 0.5–1 cm in diameter were present at birth, mostly on his palms and soles and sparsely distributed over his face and trunk, in addition to a large, vascularized raised mass measuring 4.5 × 3 × 1.5 cm on his right flank. Dyspnea with retractions were noted by the fourth hour of life, and a chest x-ray on admission showed bilateral reticular infiltrates. Non-invasive positive pressure ventilation was given for 15 days followed by 22 days of supplemental oxygen. Due to the vascularized appearance of the cutaneous lesions, a presumptive diagnosis of multiple infantile hemangiomas was made, and a short course of oral propranolol (2 mg/kg/day) was prescribed. Empirical oxacillin and gentamycin were given until the results of a complete septic workup including blood and urine cultures, TORCH, varicella and VDRL titers, and aerobic and anaerobic cultures were found to be negative. Immunohistochemical staining of both a skin biopsy and tissue from the right flank mass were positive for CD1a antigen and S-100 protein, consistent with the diagnosis of Langerhans cell histiocytosis (LCH). A computed tomography scan of his chest showed bilateral ground-glass changes in the lower lung parenchyma with diffuse nodules and mild cystic changes. Sequential workup showed no involvement of the brain, liver, bone, bone marrow or spleen. He received chemotherapy for a total of 52 weeks according to the Taiwan Pediatric Oncology Group-2003 Langerhans cell histiocytosis – high risk protocol (TPOG-2003 LCH-HR). Complete resolution of the cutaneous lesions and almost full resolution of the lung lesions were noted 7 months after initiation of chemotherapy. No recurrent or new lesions were recorded at 18 months of age (Fig. 1 (d)). Fig. 1 (a) Multiple hemorrhagic papules on the hands and feet. (b) Large hemangioma-like mass on the patient's right flank. Computed tomography scan of the chest: (c) at initial diagnosis: diffusely distributed nodules and ground-glass changes consistent with LCH lung involvement, and (d) seven months after starting chemotherapy: marked improvement with very mild residual ground glass changes in the lungs. Biopsy of the flank mass: (e) H&E staining showing grooved nuclei, (f) positive S100 stain, and (g) positive CD1a staining consistent with LCH. View Large Image Figure Viewer Download Hi-res image Download (PPT) 3. Discussion Congenital LCH is a rare cause of multiple hemorrhagic lesions at birth. Skin lesions in neonates are often described as being brownish to reddish papulonodular lesions or a large single lesion, and less commonly, hemorrhagic bullae or vesicles. Our case is unique in its presentation with multiple hemorrhagic lesions coupled with a large highly vascularized mass which closely resembled multifocal infantile hemangiomas, which most commonly present as a single rapidly growing lesion within the first 6 months of life. Multiple or fully formed lesions at birth should elicit a broader differential diagnosis including malignant and non-malignant causes such as metastatic neuroblastoma, rhabdomyosarcoma or vascular malformations.¹ Frieden I.J. Rogers M. Garzon M.C. Conditions masquerading as infantile haemangioma: Part 1. Australas J Dermatol. 2009; 50 (quiz 98): 77-97 Crossref PubMed Scopus (45) Google Scholar Our case serves as a reminder that vascularity itself does not exclusively occur in infantile hemangioma. To the best of our knowledge, only two cases of congenital LCH with small hemorrhagic lesions coupled with a large soft tissue mass mimicking multifocal hemangiomas have been reported. Both of these patients had congenital self-healing reticulohistiocytosis (CSHR) with only skin involvement. The first was a Taiwanese female newborn who presented with hemorrhagic lesions ranging from 0.5 to 4 cm in size,² Huang C.Y. Chao S.C. Ho S.F. Lee J.Y. Congenital self-healing reticulohistiocytosis mimicking diffuse neonatal hemangiomatosis. Dermatology. 2004; 208 : 138-141 Crossref PubMed Scopus (15) Google Scholar and the other was a Thai newborn with hemorrhagic lesions, the largest of which was an 8-cm mass on her right sole.³ Timpatanapong P. Rochanawutanon M. Siripoonya P. Nitidandhaprabhas P. Congenital self-healing reticulohistiocytosis: report of a patient with a strikingly large tumor mass. Pediatr Dermatol. 1989; 6 : 28-32 Crossref PubMed Scopus (16) Google Scholar In contrast, our patient presented with multi-systemic disease manifestations including skin lesions and respiratory distress at birth. Most reports of congenital LCH diagnosed at birth have isolated cutaneous disease that regresses spontaneously, a condition referred to as CSHR.⁴ Larsen L. Merin M.R. Konia T. Armstrong A.W. Congenital self-healing reticulohistiocytosis: concern for a poor prognosis. Dermatol Online J. 2012; 18 : 2 PubMed Google Scholar However, there have been several case reports of disseminated LCH at birth, one of whom died.⁵ Lee C.H. Lau T.K. To K.F. Lam H.S. Chan A.W. Ng P.C. Congenital systemic Langerhans cell histiocytosis presenting as hydrops fetalis. Acta Paediatr. 2005; 94 : 1843-1847 Crossref PubMed Scopus (11) Google Scholar ^{,  6} Goñi-Orayen C. Ruiz-Cano R. Pérez-Martínez A. Escario-Travesedo E. Atienzar-Tobarra M. Martínez-Gutiérrez A. A fatal case of congenital disseminated Langerhans cell histiocytosis. J Perinat Med. 1999; 27 : 228-230 Crossref PubMed Scopus (7) Google Scholar Given that patients with CSHR and those with disseminated LCH have virtually indistinguishable cutaneous manifestations, workup of high-risk organs including the lungs, liver, spleen, lymph nodes and hematological involvement should be performed in all patients with congenital LCH. In conclusion, we present a case of neonatal LCH presenting with multiple hemorrhagic lesions and a large vascularized mass at birth mimicking multiple infantile hemangiomas. Our case illustrates the importance of an early skin biopsy in patients with multiple fully formed vascular lesions at birth. Early diagnosis and treatment of congenital LCH with pulmonary involvement in our patient led to resolution of the lesions and no recurrence at 18 months of age. Conflicts of interest The authors have no conflict of interests.

Background/Objectives: Relapsed B-cell acute lymphoblastic leukemia (B-ALL) remains an unresolved matter of concern regarding adverse outcomes. This case study aimed to evaluate the effectiveness of blinatumomab, with or without door lymphocyte infusion (DLI), in treating measurable residual disease (MRD)-positive B-ALL. Methods: All patients who received blinatumomab salvage therapy were included in this study. Eleven patients were included in the study. All patients were evaluated for MRD-negativity. Results: Before starting blinatumomab therapy, seven patients tested positive for MRD, three tested negative, and one had refractory disease. Hematopoietic cell transplantation (HCT) was reserved for five patients with persistent MRD. Six patients became MRD-negative and subsequent HCT was not performed. Only two patients relapsed; one patient died of relapse, and the other one received carfilzomib-based therapy and was MRD-negative thereafter. Nine patients were MRD-negative at a median follow-up of 28 months (15–52 months). Two of three MRD-positive post-transplant patients remained in complete molecular remission after preemptive DLI at the last follow-up date. In the first salvage, blinatumomab may achieve complete remission and bridging to HCT in pediatric patients with end-of-induction MRD-positive B-cell precursor ALL. Conclusions: The decision on how to treat post-transplant relapse continues to affect survival outcomes. Blinatumomab combined with DLI may extend the armamentarium of release options for high-risk pediatric patients. This approach is encouraging for high-risk ALL patients who are MRD-positive post-transplantation.