Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Priapism is rarely caused by essential thrombocytosis, a disorder characterised by increased number of megakaryocytes. We report a case of a 21-year-old man who presented with priapism and on investigation was found to have essential thrombocytosis as the cause.
A 63-year-old man presented with a pulsatile cutaneous horn on the nose and multiple angiomatous nodules on the gingiva and scalp, which appeared over 2 months. He had severe hypercalcaemia, lytic lesions in multiple bones and acute kidney injury. Excision biopsy from the gingival nodule showed a clear cell neoplasm. The bone marrow showed atypical cells with similar morphology. Imaging showed a 7 cmx7.5 cm mass at the upper pole of the left kidney with metastases to the bones, liver and lung. Immunohistochemistry was consistent with metastatic renal cell carcinoma. Renal cell carcinoma presenting as a cutaneous horn is extremely rare and to the best of our knowledge only one other case was found in the literature. There was visible regression in the size of the cutaneous horn and nodules following initiation of pazopanib therapy. However, he succumbed to his illness a month later.
Description
A 5-month-old male child was brought with the history of right-sided corneal opacity noticed for the past 2 months. The baby was immunised until now with an uneventful antenatal and peripartum history. Ocular examination showed normal sized cornea having a paracentral nebular opacity along the inferior and nasal aspect without any discharge or significant exposure keratopathy. The baby was able to fix at the light with each eye separately, the anterior chamber in both the eyes was of normal depth having a clear lens and retinal examination showed a well-defined posteriorly excavated area along the inferior portion of the optic disc in both the eyes. Sleeping intraocular pressures were 10 and 12 mm Hg in right eye and left eye, respectively. Posterior segment B-scan ultrasound showed a well-defined symmetric excavation along the inferior aspect of the optic disc in both the eyes with an axial length of 20 mm...
A 37-year-old woman presented with a 3-hour history of back pain, nausea and vomiting and an episode of syncope. A fluid collection in the lesser sac was detected on ultrasound and CT scan. Emergency laparoscopy and subsequent laparotomy were performed and a large blood clot was evacuated from the lesser sac. No identifiable source or predisposition to bleeding was found. She made a full recovery postoperatively. There are few reported cases of spontaneous intraperitoneal haemorrhage. In a third of cases, there is no identifiable source of bleeding. Unfortunately, patients present late with non-specific symptoms and a prompt diagnosis is difficult to make. The case reiterates the importance of awareness of lesser sac haematoma formation; an unusual clinical entity with a high morbidity and mortality rate. A high index of suspicion, radiological adjuncts and appropriate surgical intervention, especially in unstable patients, is essential for a good outcome.
We report successful transvenous treatment of direct carotid–cavernous fistula in a patient with Ehlers–Danlos syndrome type IV using a novel triple-overlay embolization (TAILOREd) technique without the need for arterial puncture, which is known to be highly risky in this patient group. The TAILOREd technique allowed for successful treatment using preoperative MR angiography as a three-dimensional overlay roadmap combined with cone beam CT and live fluoroscopy, precluding the need for an arterial puncture.
There has been an increase in the demand for esthetic dermatology treatments within the general population. The purpose of this study was to analyze, within the scope of general population, the relationship between people's perception of esthetic dermatology treatments and emotional well-being, as well as for differences in gender.
The Aesthetic Dermatology and Emotional Well-Being (DEBIE) Scale, [Journal of Cosmetic Dermatology vol. 13 (2014) 336-345] was applied to 770 Spanish people over 18 years old. The scale is structured according to six factors and classified into two dimensions: (1) Emotional Well-Being and (2) Perception of Aesthetic Dermatology. Cronbach alpha for the total scale was very high (0.90). Data analysis includes the following: (1) bivariate correlations with Pearson's coefficient; (2) gender differences through Student's t test, and (3) the effect size through R2 and Cohen's d.
A statistically significant relationship which is directly proportional has been identified between the degree of emotional well-being of people (self-esteem and assertiveness, optimism, and motivation) and the knowledge and attitude toward Aesthetic Dermatology. There are statistically significant differences according to gender: Women have a lower level of emotional well-being than men, as well as greater knowledge and more positive attitude toward Aesthetic Dermatology.
People who are familiar with Aesthetic Dermatology and have a better attitude toward it, are also more self-confident, more optimistic and more motivated; with emotional strength. Regarding gender, it is expected that women may seek more consultation and esthetic dermatology treatments than men do.
Publication date: Available online 18 August 2017
Source:Allergology International
Author(s): Masaru Tanaka, Jiro Nakayama
Gut microbial ecology and function are dynamic in infancy, but are stabilized in childhood. The 'new friends' have a great impact on the development of the digestive tract and host immune system. In the first year of life, especially, the gut microbiota dramatically changes through interactions with the developing immune system in the gut. The process of establishing the gut microbiota is affected by various environmental factors, with the potential to be a main determinant of life-long health. In this review, we summarize recent findings regarding gut microbiota establishment, including the importance of various factors related to the development of the immune system and allergic diseases later in life.
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Thyroid , Vol. 0, No. 0.
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In the 2017 American Academy of Dermatology Poster Abstract Supplement, a batch of abstracts was inadvertently omitted when the issue posted on May 31, 2017. The missing abstracts have been added to the issue and now appear on pages AB401-AB426.
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Psoriasis is associated with risk of cardiovascular (CV) disease (CVD) and a major adverse CV event (MACE). Whether psoriasis duration affects risk of vascular inflammation and MACEs has not been well characterized.
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A tracheoesophageal prosthesis (TEP) allows for speech after total laryngectomy. However, TEP placement is technically challenging, requiring a coordinated series of steps. Surgical simulators improve technical skills and reduce operative time. We hypothesize that a reusable 3-dimensional (3D)-printed TEP simulator will facilitate comprehension and rehearsal prior to actual procedures.
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To determine the reliability of thyroid FNAC as a single diagnostic modality in the case of nodular neoplastic lesions of the thyroid. Multiple databases were searched using the MESH terms thyroid*lesion*nodule*neoplasm*fine needle aspiration*histopathology*correlation. Meta analyses, RCTs, cohort or case control studies and case series were searched. 61 studies were examined to verify the search results after applying the inclusion and exclusion criteria. 422 studies were excluded after the first screening, leaving 61 full text articles. These were further analyzed for outcomes, and ultimately 9 studies were chosen for the final synthesis on the basis of clear recommendations given. FNAC as a single modality for the diagnosis of nodular neoplastic thyroid lesions is highly variable and therefore unreliable. The diagnostic yield may be improved if the Bethesda system of reporting is applied.
To determine the reliability of thyroid FNAC as a single diagnostic modality in the case of nodular neoplastic lesions of the thyroid. Multiple databases were searched using the MESH terms thyroid*lesion*nodule*neoplasm*fine needle aspiration*histopathology*correlation. Meta analyses, RCTs, cohort or case control studies and case series were searched. 61 studies were examined to verify the search results after applying the inclusion and exclusion criteria. 422 studies were excluded after the first screening, leaving 61 full text articles. These were further analyzed for outcomes, and ultimately 9 studies were chosen for the final synthesis on the basis of clear recommendations given. FNAC as a single modality for the diagnosis of nodular neoplastic thyroid lesions is highly variable and therefore unreliable. The diagnostic yield may be improved if the Bethesda system of reporting is applied.
In auditory rehabilitation, the most comfortable listening level (MCL) is important because the conversation partners of patients with hearing impairment are often individuals with normal hearing. Thus, normalizing MCL can help patients with hearing loss to reduce the communication handicap with individuals with normal hearing.
While active middle ear implants demonstrate comparable performance with conventional hearing aids (HA) with regard to functional hearing gain and speech intelligibility, little is known about the effect of middle ear implants on the MCL. Therefore, we evaluated the MCL of active middle-ear implants compared with that of conventional HA in patients with moderate and moderate-to-severe sensorineural hearing loss (SNHL).
We found that the Vibrant Soundbridge (VSB) active middle-ear implant had a pure-tone threshold similar to conventional HA. However, the MCL in VSB-aided conditions was significantly lower (by ~10 dB) than for HA-aided conditions. In addition, the significant improvement in MCL was attributable to robust amplifications at 1 kHz and 2 kHz compared with conventional HA.
VSB implantation nearly normalized MCL for patients with SNHL. In terms of normalizing MCL, VSB implantation is a good choice for hearing rehabilitation in patients with SNHL.
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A male patient, in his third decade, with pruritus and hearing loss is the typical clinical presentation of otomycosis in immunocompetent cases.
Summer is the season most frequently involved in otomycosis patients, high temperature and humidity are common environmental factors.
Microscopic direct exam has a 60% sensitivity for detecting fungal disease.
Immunocompetent patients are infected in the majority of cases by Aspergillus, being Aspergillus niger the most frequent species.
Culture remains the gold standard in the diagnosis of this disease.
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Magnetic resonance imaging (MRI) is used to screen patients at risk for vestibular schwannoma (VS). These MRIs are costly and have an extremely low yield; only 3% of patients in the screening population has an actual VS. It might be worthwhile to develop a test to predict VS, and refer only a subset of all patients for MRI.
To examine the potential savings of such a hypothetical diagnostic test before MRI.
We built a decision analytical model of the diagnostic strategy of VS. Input was derived from literature and key opinion leaders. The current strategy was compared to hypothetical new strategies, assigning MRI to: (1) all patients with pathology, (2) all patients with important pathology and (3) only patients with VS. This resulted in potential cost savings for each strategy. We conducted a budget impact analysis to predict nationwide savings for the Netherlands and the United Kingdom (UK), and a probabilistic sensitivity analysis to address uncertainty.
Mean savings ranged from €256 (95%CI €250 - €262) or approximately US$284 (95%CI US$277 - US$291) per patient for strategy 1 to €293 (95%CI €290 - €296) or approximately US$325 (95%CI US$322 - US$328) per patient for strategy 3. Future diagnostic strategies can cost up to these amounts per patient and still be cost saving. Annually, for the Netherlands €2.8 to €3.2 million could be saved and €10.8 to €12.3 million for the UK.
The model shows that substantial savings could be generated if it is possible to further optimise the diagnosis of VS.
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Skip metastasis (SM) in Well Differentiated Thyroid Cancer (WDTC) patients are lateral neck lymph node metastasis that have skipped the central neck compartment. In these patients, prophylactic central neck dissection remains controversial.
We sought to identify clinicopathological factors associated with SM and determine the accuracy of central neck metastasis imaging in 68 patients at our institution over 16 years.
12 patients (17.6%) had SMs. Compared to the patients with occult central neck metastases, those with SM were more likely to have T1 tumors (p=0.005) and less likely to have extracapsular spread (p=0.032), thyroid capsule extension (p=0.003), soft tissue extension (p=0.006), and multifocal primary tumors (p=0.006).
In assessing the preoperative imaging, we compared central neck dissection pathology reports to the detection rates of CT and ultrasound. We found CT and ultrasound sensitivities of 31.8% and 45%, respectively and specificities of 80% and 85.7%, respectively.
WDTC patients with SM are more likely to have smaller, less aggressive primary tumors. However, the majority (82.4%) had central compartment disease and given the lack of sensitive preoperative imaging, we recommend prophylactic central neck dissections.
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We report the first successful treatment of noninfectious uveitis with ustekinumab in a patient with severe concomitant psoriasis and psoriatic arthritis who failed to respond to conventional immune suppressants and with contraindications to tumor necrosis factor alpha inhibitors.
Regorafenib is an oral multikinase inhibitor that has been demonstrated as clinically effective in patients with metastatic colorectal cancer in phase III studies. Although disease control was achieved in 40% ...
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Association Between Hypercoagulability and Severe Obstructive Sleep Apnea.
JAMA Otolaryngol Head Neck Surg. 2017 Aug 17;:
Authors: Hong SN, Yun HC, Yoo JH, Lee SH
Abstract
Importance: Obstructive sleep apnea (OSA) is related to the increased risk of cardiovascular disease. Although the pathogenesis of this association remains unclear, an alteration in coagulability is suspected as a link.
Objective: To investigate the association between the severity of OSA and blood coagulability.
Design, Setting, and Participants: A retrospective cohort study conducted at a tertiary care university hospital evaluated 146 patients with OSA from January 1, 2009, to July 31, 2015. The participants were divided into 4 groups according to the severity of OSA: control, mild, moderate, and severe.
Main Outcomes and Measures: Association between the severity of OSA and coagulation test results, including platelet count, bleeding time, prothrombin time (PT) in seconds and as international normalized ratio (INR), and activated partial thromboplastin time.
Results: Of the 146 patients, 135 (92.5%) were men; mean (SD) age was 34.8 (11.1) years. The control group included 41 (28.1%) patients; mild OSA, 32 (21.9%); moderate OSA, 30 (20.5%); and severe OSA, 43 (29.5%). Significant correlations were found between the apnea-hypopnea index and the PT seconds (Spearman r coefficient, -0.30; 95% CI, -0.44 to -0.14) and PT INR (Spearman r coefficient, -0.30; 95% CI, -0.44 to -0.14). There were significant differences between the OSA severity groups for PT seconds for the control group (mean, 11.26 [0.78] seconds) vs the moderate OSA group (10.74 [0.62] seconds; mean difference [MD], 0.52; 95% CI, 0.27 to 1.01) and the severe OSA group (10.67 [0.77] seconds; MD, 0.59; 95% CI, 0.14 to 1.03). Significant differences were also noted in PT INR between the control group (1.00 [0.07]) vs the moderate OSA group (0.95 [0.05]; MD, 0.04; 95% CI, 0.01 to 0.07) and the severe OSA group (0.94 [0.07]; MD, 0.05; 95% CI, 0.02 to 0.08). However, there was no significant difference between the control and mild OSA groups in PT seconds.
Conclusions and Relevance: These results suggest that patients with moderate to severe OSA have elevated blood coagulability markers compared with healthy individuals, which may contribute to the occurrence of cardiovascular complications.
PMID: 28817760 [PubMed - as supplied by publisher]
JAMA Otolaryngology-Head & Neck Surgery.
JAMA Otolaryngol Head Neck Surg. 2017 Aug 01;143(8):748
Authors:
PMID: 28817758 [PubMed - in process]
Highlights.
JAMA Otolaryngol Head Neck Surg. 2017 Aug 01;143(8):747
Authors:
PMID: 28817757 [PubMed - in process]
Incorrect Middle Initial in Byline.
JAMA Otolaryngol Head Neck Surg. 2017 Aug 01;143(8):849
Authors:
PMID: 28817756 [PubMed - in process]
The "Surgeon on Service" Model for Timely, Economically Viable Inpatient Care of Tracheostomy Patients in Academic Pediatric Otolaryngology.
JAMA Otolaryngol Head Neck Surg. 2017 Aug 17;:
Authors: Lavin JM, Schroeder JW, Thompson DM
Abstract
Importance: The traditional practice model for pediatric otolaryngologists at high-volume academic centers is to simultaneously balance outpatient care responsibilities with those of the inpatient service, emergency department, and ambulatory care clinics. This model leads to challenges with care coordination, timeliness of nonemergency operative care, and consistent participation in care and consultation at the attending surgeon level. The "surgeon on service" (SOS) model-where faculty members rotate to manage the inpatient service in lieu of outpatient responsibilities-has been described as one method to address this conundrum. The operational and economic feasibility of the SOS model has been demonstrated; however, its impact on care coordination, time from consultation to surgical care, and length of stay (LOS) have not been evaluated.
Objective: To determine the impact of the SOS model on the quality principles of timeliness and efficiency of tracheostomy tube placement and to determine if the SOS model is fiscally feasible in an academic pediatric otolaryngology practice.
Design, Setting, and Participants: Medical record review of patients undergoing tracheostomy in a pediatric academic medical center and survey of their treating physician trainees, comparing the 6-month SOS pilot phase (postimplementation, January-June 2016) with the 6-month preimplementation period (January-June 2015).
Intervention: Implementation of the SOS model.
Main Outcomes and Measures: Time to tracheostomy, frequency of successful coordination of tracheostomy with gastrostomy tube placement, total LOS, productivity measured in work relative value units, and responses to trainee surveys.
Results: Of the 41 patients included in the study (24 boys and 17 girls; mean age, 3 years; range, 3 months to 17 years), 15 were treated before SOS implementation, and 26 after. Also included were 21 trainees. Before SOS implementation, median time to tracheostomy was 7 days (range, 2-20 days); after SOS implementation, it was 4 days (range, 1-10 days) (difference between the medians, before to after, -3 days; 95% CI, -5 to 0 days). There was no significant difference in overall LOS or ability to coordinate tracheostomy with gastrostomy tube placement. Preimplementation trainee surveys cited dissatisfaction with the communication channels to the primary team when the consulting surgeon was not immediately available to perform tracheostomy. No challenges were reported after implementation. Productivity was comparable to that in the outpatient setting.
Conclusions and Relevance: In this study, the presence of a rotating inpatient pediatric otolaryngologist was a productive approach to patient care associated with more timely performance of tracheostomy. Other benefits were an improved balance of service with education to trainees and a better perception of communication with consulting services.
PMID: 28817750 [PubMed - as supplied by publisher]
The detection of melanoma poses a substantial challenge, particularly for primary care providers (PCPs) who may have limited training in discriminating between suspicious and benign melanocytic lesions. The noninvasive optical transfer diagnosis (OTD) method was designed to be used by PCPs in their decision-making process.
The aim of this clinical study was to assess the potential of the OTD method by developing, training, and validating an OTD indication algorithm for automated discrimination between benign melanocytic lesions and malignant lesions, based on a set of 712 lesions.
The authors performed in vivo OTD capture and subsequent analysis of 712 pigmented lesions. Of the lesions, 415 were clinically and dermoscopically benign, and 297 were dermoscopically suspicious or equivocal. After image capture, all suspicious or equivocal lesions were biopsied and examined histopathologically.
Of the 297 suspicious or equivocal lesions, histopathologic findings revealed 80 to be malignant (64 melanomas, 13 basal cell carcinomas, and 3 squamous cell carcinomas). OTD misdiagnosed 1 of the 80 malignant lesions as benign (sensitivity, 99%). The OTD specificity was 93% for the dermoscopically benign lesions, 73% for all lesions included in the study, and 36% for the clinically suspicious, but histopathologically benign lesions.
High sensitivity and specificity, as provided by OTD in this preliminary study, would help PCPs reduce the number of referrals for dermatology consultation, excision, or biopsy. Further studies are planned for screening patients in a primary care setting, with comparisons of OTD results to biopsy or dermoscopy results.
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Linked Comment: Eriksson et al. Br J Dermatol 2017; 177:513–521
Linked Comment: Asgari et al. Br J Dermatol 2017; 177:428–435
Linked Comment: Simonsen et al. Br J Dermatol 2017; 177:395–405
Linked Comment: Khoury et al. Br J Dermatol 2017; 177:436–444
Linked Comment: Zimmer et al. Br J Dermatol 2017; 177:445–455
Aside from Helicobacter pylori, another cause for the development or worsening of gastrointestinal ulcers is scrub typhus, an acute febrile disease caused by Orientia tsutsugamushi. We aimed to compare the endoscopic characteristics of peptic ulcers caused by these infectious agents.
This retrospective case-control study involved patients who underwent upper gastrointestinal endoscopy at Chosun University Hospital in Korea. We compared endoscopic features and demographic characteristics between patients with H. pylori infection and those with O. tsutsugamushi infection.
A total of 141 patients with peptic ulcer were included in the study. Compared to patients with O. tsutsugamushi infection (n = 62; age, 63.8 ± 12.1 years; male sex, 42%), those with H. pylori infection (n = 79; age, 53.0 ± 14.8 years; male sex, 81%) were younger and more likely to be male (P < .001 for both). Patients with O. tsutsugamushi infection were more likely to have multiple lesions (40/62, 64.5% vs 37/79, 46.8%; P = .042) and irregular-shaped lesions (27/62, 43.6% vs 20/79, 25.3%; P = .031). Patients with H. pylori infection had higher incidence of hemorrhagic ulcers (26/79, 32.9% vs 8/62, 12.9%; P = .007), and lesions occurred most often in the duodenum (43.0%), followed by the antrum (36.7%), body (34.2%), and angle (12.7%) of the stomach. In patients with O. tsutsugamushi infection, lesions occurred most often in the antrum (70.97%), followed by the duodenum (35.5%), body (22.6%), and angle (14.5%) of the stomach. In both groups, gastric ulcer lesions occurred most often in the antrum, followed by the body and angle of the stomach (36.7% vs 70.97%, 34.2% vs 22.6%, and 12.7% vs 14.5% for gastric ulcers associated with H. pylori and O. tsutsugamushi infection, respectively). Patients with O. tsutsugamushi infection had significantly higher incidence of ulcers on the antrum (70.97% vs 36.7%, P < .001) and the greater curvature (45.2% vs 24.0%, P = .012). Finally, 35.5% of patients with gastric ulcer caused by scrub typhus also had duodenal ulcer.
This is the first study to compare endoscopic features of peptic ulcers caused by H. pylori and O. tsutsugamushi. Peptic ulcers in patients with H. pylori infection occurred predominantly in the antrum/body/lesser curvature and presented with single, round/oval lesions, while ulcers in patients with scrub typhus occurred predominantly in the antrum/greater curvature and presented with multiple, irregular lesions. Scrub typhus should be considered as a cause of duodenal ulcer in scrub typhus-endemic areas.
Allergy immunotherapy (AIT) is the only disease-modifying therapy for the treatment of allergic diseases. Although its efficacy and utility are well-established, the potential for serious adverse events, cumbersome and lengthy treatment protocols, and variability of natural allergen preparations have limited its widespread application. Recent advances in recombinant technology have opened new avenues for the development of AIT vaccines. The purpose of this review is to highlight recent evidence on the use of novel recombinant vaccines and review the mechanisms, efficacy, safety, and limitations of AIT. Emerging evidence suggests that recombinant vaccines may provide a viable treatment alternative that improves on the limitations of natural extract therapy while maintaining efficacy.
Allergy immunotherapy (AIT) is the only disease-modifying therapy for the treatment of allergic diseases. Although its efficacy and utility are well-established, the potential for serious adverse events, cumbersome and lengthy treatment protocols, and variability of natural allergen preparations have limited its widespread application. Recent advances in recombinant technology have opened new avenues for the development of AIT vaccines. The purpose of this review is to highlight recent evidence on the use of novel recombinant vaccines and review the mechanisms, efficacy, safety, and limitations of AIT. Emerging evidence suggests that recombinant vaccines may provide a viable treatment alternative that improves on the limitations of natural extract therapy while maintaining efficacy.
Die Psychoonkologie wird heute als konzeptionell wichtiger Bestandteil der medizinischen Versorgung in allen Bereichen wie der Primärversorgung im Akutkrankenhaus, der ambulanten oder stationären Rehabilitation sowie der ambulanten Versorgung angesehen. Trotz einiger Fortschritte in der psychoonkologischen Versorgung in Deutschland sind noch zahlreiche Lücken insbesondere im ambulanten Bereich sowie Verbesserungsbedarf in allen Versorgungsbereichen festzustellen. Daher sind die Themen der psychoonkologischen Versorgungsforschung sehr vielfältig. Dieser Übersichtsbeitrag konzentriert sich auf die in der S3-Leitlinie genannten zentralen Aufgabengebiete der Psychoonkologie und benennt die sich daraus ableitenden Bereiche psychoonkologischer Versorgungforschung.
Die Aufgabenbereiche der Versorgungsforschung im Bereich Psychoonkologie werden anhand von 4 Themen zusammengefasst: (1) Belastungsscreening und Psychodiagnostik, (2) psychoonkologische Interventionen, (3) Inanspruchnahme psychoonkologischer Versorgung und Versorgungsbarrieren sowie (4) Qualitätssicherung. Der jeweilige Kenntnistand wird auf der Basis einer selektiven Literaturrecherche dargestellt und zukünftige Aufgaben werden kurz skizziert.
Die psychoonkologische Versorgungsforschung kann mit dazu beitragen, Lücken in der psychosozialen Versorgung aufzudecken und Lösungen für eine verbesserte Patientenversorgung aufzuzeigen.
Leiomyoma is a benign neoplasm originating from smooth muscle cells and is most commonly seen in the uterus, followed by the small bowel and oesophagus. We report a rare case of a 41-year-old male patient with a spermatic cord leiomyoma that presented as an inguinal canal mass mimicking an irreducible inguinal hernia without scrotal involvement. This report highlights the rare presentation and workup of an inguinal mass, importance of intraoperative decision making based on operative findings and the significance of postoperative pathology findings.
Vitamin B12 deficiency is a recognised pathology in several populations, with a particular prevalence in an older adult population. We present two cases whereby vitamin B12 deficiency is the causative factor in marked pancytopaenia. Oval macrocytosis and hypersegmented neutrophils were noted on both peripheral blood samples, which are a characteristic finding in macrocytic anaemia due to B12 deficiency. Distinct underlying pathologies were identified in both cases; food-cobalamin malabsorption and pernicious anaemia. Parenteral vitamin B12 supplementation resulted in a marked reticulocytosis and rapid improvement of haematological indices in both cases. We present this series to serve as a reminder that B12 deficiency can present as life-threatening pancytopaenia.It has has multiple underlying pathologies,defined risk populations and has characteristic blood film findings which can guide investigations, diagnosis and treatment.
A 69-year-old man with a history of hypercholesterolaemia presented to the emergency department with atypical chest pain. Physical examination was normal and ECG showed no evidence of ischaemic changes. Laboratory studies were notable for a D-dimer level of 1842 ng/mL (reference value <500 ng/mL) and the troponin I level was normal.
Chest X-ray was normal. Chest CT angiography ruled out a pulmonary embolism but showed a giant and extensive aneurysm of the right coronary artery (RCA) up to 45 mm in diameter with a partly thrombosed lumen and evidence of right ventricle compression on four-chamber view (figures 1 and 2). The volume of the aorta and the RCA appeared similar (figure 3). Doppler echocardiography did not demonstrate right or left heart haemodynamic abnormalities.
Figure 1
Coronary CT angiography in four-chamber view, evidence of external diameter with arrow and coronary lumen with head arrow.
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