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INTRODUCTION:Paroxysmal nocturnal hemoglobinuria has an incidence of 1.3 case per 1 million, but the incidence is significantly increased in patients with aplastic anemia. We present a patient with a history of aplastic anemia who presents with findings concerning for Budd-Chiari.CASE DESCRIPTION/METHODS:A 44 year old man with a history of aplastic anemia presented with dyspnea and abdominal distention that started over the course of several days. At time of presentation, he appeared uncomfortable, but was hemodynamically stable. Due to initial concern for PE, CT chest was obtained and negative for pulmonary process. CT did note liver changes concerning for cirrhosis, however patient denied history of liver disease or risk factors associated with cirrhosis. Work up for causes of cirrhosis was initiated, and lab studies were unrevealing. SAAG score of 2.1 indicating portal hypertension as a cause of ascites. Due patient's fairly rapid onset of symptoms and otherwise unremarkable work up, CT liver protocol was performed with concern for Budd-Chiari. Imaging was suggestive of cirrhosis, and could not rule out Budd-Chiari, however no evidence of thrombosis was identified. Portal venous duplex suggested patent portal system without thrombosis. Given high level of suspicion for Budd-Chiari, hepatic venography was obtained, and significant for partial or complete thrombosis of all hepatic veins. In the setting of a patient with aplastic anemia and Budd-Chiari, work up for PNH was initiated and consistent with PNH. With diagnosis of cirrhosis due to Budd-Chiari, patient was referred to transplant clinic. With new diagnosis of PNH, he was started on Eculizumab with Hematology follow up.DISCUSSION:If there is concern for Budd-Chiari, diagnosis is generally with doppler ultrasonography. If US unremarkable, CT or MRI can be performed. If noninvasive diagnostic tools are nondiagnostic, hepatic venography can be performed given there is strong clinical suspicion. In PNH, thrombosis is the leading cause of death, though rare as a presenting symptom. Thromboses typically occur in unusual locations, and approximately two-thirds of thrombosis occur in intra-abdominal locations. The incidence of PNH is significantly increased in patients with aplastic anemia. In a patient with high concern for Budd-Chiari and unremarkable noninvasive testing, hepatic venography is a helpful diagnostic tool. In a patient with significant thrombosis such as this with a history of aplastic anemia, it is important to consider PNH.

Background The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care. Methods We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program. Results The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program. Conclusions This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

A preadolescent female presented to the emergency department with an acute asthma exacerbation. Chest radiograph and computed tomography scan showed extensive pneumomediastinum with a small pneumopericardium without a distinct source for this air leak. The patient was admitted for noninvasive monitoring, analgesia, and high concentration oxygen. Serial chest radiographs showed marked improvement following high concentration oxygen, and she was discharged on hospital day 3. Spontaneous pneumomediastinum and pneumopericardium are rare complications of asthma that can often be managed conservatively but should be considered on the differential for this patient population, and may be a complication of COVID-19.

We report on a solution-growth based method to synthesise single crystals of Y\\(_2\\)Co\\(_3\\) and on its structural and magnetic properties. We find that Y\\(_2\\)Co\\(_3\\) crystallizes in the La2Ni3-type orthorhombic structure with space group Cmce (No. 64), with Co forming distorted kagome lattices. Y\\(_2\\)Co\\(_3\\) orders antiferromagnetically below \\(T_N\\) = 252 K. Magnetization measurements reveal that the moments are primarily aligned along the b axis with evidence for some canting. Band-structure calculations indicate that ferromagnetic and antiferromagnetic orders are nearly degenerate, at odds with experimental results. Magnetization measurements under pressure up to 1 GPa reveal that the N/'eel temperature decreases with the slope of -1.69 K/GPa. We observe a field-induced spin-flop transition in the magnetization measurements at 1.5 K and 21 T with magnetic field along the b direction. The magnetization is not saturated up to 35 T, indicating that the antiferromagnetic ordering in Y\\(_2\\)Co\\(_3\\) is quite robust, which is surprising for such a Co-rich intermetallic.