¿Neurologist's contribution to the diagnosis of sine materia respiratory insufficiency: case report¿

ABSTRACT: Right-to-left shunt (RLS) can be the reason of marked hypoxemia, this diagnosis of respiratory insufficiency is usually difficult to make by Respiratory Physicians as it develops in absence of an intrinsic lung disease. We report a case of RLS in a patient with a hepatopulmonary syndrome caused by chronic autoimmune cholangitis which was suspected clinically by physical examination and by standard CT imaging and MIP reconstruction of the pulmonary vascular bed. Repeated previous transthoracic echocardiography (TTE) studies didn't reveal the shunts. The final diagnosis was performed by a minimally invasive doppler transcranial examination with the use of agitated saline as contrast solution. Transcranial Colour-Coded Duplex Sonography (TCCS) with saline contrast medium injection is described to have an higher sensitivity compared with TTE and comparable with transesophageal echocardiography (TEE) in RLS diagnosis. The collaboration of Neurologists to this diagnosis of respiratory insufficiency is really important, as the examination is simple, well tolerated in comparison with the discomfort associated with transesophageal echocardiography, and of minimal invasivity in comparison with angiography which is the ultimate diagnostic procedure in this clinical scenario. TCCS with saline contrast medium injection, should be performed for the diagnosis of chronic hypoxemia for which causes are not detected with routine clinical examinations, in order to confirm RLS.     

Prostate carcinoma metastatic to the skin as an extrammamary Paget¿s disease

ABSTRACT: AimThe current paper describes a case of prostatic adenocarcinoma metastatic to the skin presenting as an extrammamary Paget's disease, a very rare and poorly characterised morphological entity. We report a case of prostatic carcinoma metastatic to skin showing a pattern of extramammary Paget's disease which has not been clearly illustrated in the literature Case presentation: A 63 year-old man with prostatic adenocarcinoma developed cutaneous metastases after 16 years. The inguinal metastases were sessile and 'keratotic.' The tumour displayed solid, glandular areas as well as a polypoid region suggestive of extramammary Paget's disease were identified.Discussion and conclusionsWe review the diagnostic criteria that have led to the correct histopathological diagnosis in this case. A differential diagnosis of the pagetoid spread in the skin and various forms of cutaneous metastases determined by a prostatic adenocarcinoma as well as the role of immunohistochemistry in establishing the prostatic origin are presented in the context of this case. Although, morphologically the cells presented in the skin deposits were not characteristic for adenocarcinoma of prostate, immunohistochemistry for PSA and PSAP suggested a prostatic origin.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1395450057455276.     

Non-Hodgkin¿s Lymphoma of the synovium discovered in total knee arthroplasty: a case report

ABSTRACT: BACKGROUND: Musculoskeletal involvement occurs in 25% of patients with non-Hodgkin's lymphoma (NHL). Primary lymphoma in the joint is rare. It can present as a bone lesion or as atypical soft tissue proliferation. NHL has an increased incidence in patients with autoimmune rheumatic diseases. CASE PRESENTATION: We present a case in which non-Hodgkin's lymphoma was found coincidentally in the synovium during knee joint replacement surgery in a 69-year old woman with rheumatoid arthritis. Pigmented, vitreous tissue was resected, which turned out to be a diffuse large B-cell lymphoma after histological examination. The coincidental intraoperative finding of intra-articular non-Hodgkin's lymphoma was reported twice before, presenting as synovial proliferation in elbow and shoulder surgery. In a few other cases non-Hodgkin's lymphoma presented most often in the knee, as a bone lesion or, when soft tissue was involved, as arthritis. CONCLUSION: Non-Hodgkin's lymphoma should be considered in patients with autoimmune rheumatic diseases. In case of persistent arthritis, non-respondent to anti-inflammatory drugs, a biopsy might be warranted. Moreover, when arthroscopy or arthrotomy is planned, any atypical tissue should be sent for histological analysis. Early diagnosis of NHL can contribute to improved outcome of its rapidly developing treatment options.     

Diagnostic and economic evaluation of new biomarkersfor Alzheimer¿s disease: the research protocol of a prospective cohort study

ABSTRACT: BACKGROUND: New research criteria for the diagnosis of Alzheimer's disease (AD) have recently been developed to enable an early diagnosis of AD pathophysiologyby relying on emerging biomarkers. To enable efficient allocation of health care resources, evidence is needed to support decision makers on the adoption of emerging biomarkers in clinical practice. The research goals are to 1) assess the diagnostic test accuracy of current clinical diagnostic work-up and emerging biomarkers in MRI, PET and CSF, 2) perform a cost-consequence analysis and 3) assess long-term cost-effectiveness by an economic model.Methods/designIn a cohort design 223 consecutive patients suspected of having a primary neurodegenerative disease are approached in four academic memory clinics and followed for two years. Clinical data and data on quality of life, costs and emerging biomarkers are gathered.Diagnostic test accuracy is determined by relating the clinical practice and new research criteria diagnoses to the reference diagnosis. The clinical practice diagnosis at baseline is reflected by a consensus procedure among experts using clinical information only (no biomarkers). The diagnosis based on the new research criteria is reflected by decision rules that combine clinical and biomarker information. The reference diagnosis is determined by a consensus procedure among experts based on clinical information on the course of symptoms over a two-year time period.A decision analytic model is built combining available evidence from different resources among which (accuracy) results from the study, literature and expert opinion to assess long-term cost-effectiveness of the emerging biomarkers. DISCUSSION: Several other multi-centre trials study the relative value of new biomarkers for early evaluation of AD and related disorders. The uniqueness of this study is the assessment of resource utilization and quality of life to enable an economic evaluation. The study results are generalizable to a population of patients who are referred to a memory clinic due to their memory problems.Trial registrationNCT01450891.     

Performance of ¿VIKIA Malaria Ag Pf/Pan¿ (IMACCESS®), a new malaria rapid diagnostic test for detection of symptomatic malaria infections

ABSTRACT: BACKGROUND: Recently, IMACCESS[REGISTERED SIGN] developed a new malaria test (VIKIA Malaria Ag Pf/Pan[TRADE MARK SIGN]), based on the detection of falciparum malaria (HRP-2) and non-falciparum malaria (aldolase). METHODS: The performance of this new malaria rapid diagnostic test (RDT) was assessed using 1,000 febrile patients seeking malaria treatment in four health centres in Cambodia from August to December 2011. The results of the VIKIA Malaria Ag Pf/Pan were compared with those obtained by microscopy, the CareStart Malaria[TRADE MARK SIGN] RDT (AccessBio[REGISTERED SIGN]) which is currently used in Cambodia, and real-time PCR (as "gold standard"). RESULTS: The best performances of the VIKIA Malaria Ag Pf/Pan[TRADE MARK SIGN] test for detection of both Plasmodium falciparum and non-P. falciparum were with 20--30 min reading times (sensitivity of 93.4% for P. falciparum and 82.8% for non-P. falciparum and specificity of 98.6% for P. falciparum and 98.9% for non-P. falciparum) and were similar to those for the CareStart Malaria[TRADE MARK SIGN] test. CONCLUSIONS: This new RDT performs similarly well as other commercially available tests (especially the CareStart Malaria[TRADE MARK SIGN] test, used as comparator), and conforms to the World Health Organization's recommendations for RDT performance. It is a good alternative tool for the diagnosis of malaria in endemic areas.     

Socioeconomic inequality and obesity prevalence trends in luxembourg, 1995¿2007

ABSTRACT: BACKGROUND: Overweight and obesity are becoming increasingly critical problems in most developed countries. Approximately 20% of adults in most European countries are obese. This study examines the prevalence of overweight and obesity in Luxembourg and their association with different demographic, socioeconomic (SES), and behavioural factors. METHODS: The data used in this study were taken from 2 surveys on household income and living conditions conducted in 1995 and 2007. The target population was household residents aged 16 years and older, and body mass index (BMI) data were self-reported. Average BMI, overweight, and obesity prevalence rates were calculated according to each demographic (gender, nationality, marital status), SES (educational level, profession, and place of residence), and behavioural (physical activity and diet) factors. A multivariate logistic regression analysis was conducted to measure the relationship between obesity and demographic, SES, and behavioural factors. All analyses were conducted according to gender, and data used were weighted. RESULTS: Between 1995 and 2007, the average BMI remained nearly constant among men and women in the entire study population. Obesity prevalence increased by 24.5% through the study period (14.3% in 1995 to 17.8% in 2007). Obesity prevalence increased by 18.5% for men (15.1% in 1995 to 17.9% in 2007) and by 30% for women (13.6% in 1995 to 17.7% in 2007). Between 1995 and 2007, obesity increased sharply by 48.2% (from 11% to 16.3%) in Portuguese men, 76.7% (from 13.3% to 23.5%) in Portuguese women, 79.7% (from 17.2% to 30.9%) in widowed men, and 84.3% (from 12.1% to 22.3%) in divorced women. Multivariate logistic regression analysis showed that the relationship between the educational level and obesity was not statistically significant for men, but was significant for women. CONCLUSIONS: The prevalence of overweight and obesity is high in Luxembourg and has changed slightly in recent years. SES inequalities in obesity exist and are most compelling among women. The fight against obesity should focus on education, with emphasis on the socially disadvantaged segment of the population.     

Sleep problems in Parkinson¿s disease: a community-based study in Norway

ABSTRACT: BACKGROUND: The purpose of this study was to examine the prevalence of sleep problems in a community-based sample of patients with Parkinson's disease (PD) in Norway, and their associated factors. METHODS: 176 consecutive PD outpatients (41% females) were included in a study of non-motor symptoms, including sleep problems. All participants responded to the Parkinson's Disease Sleep Scale (PDSS), where an overall score below 82 or a score below 5 on a sub-item indicate possible sleep problem. Factors associated with sleep were also investigated, with special emphasis on severity of PD, fatigue, mental health and restless legs syndrome (RLS). RESULTS: The mean age was 68.5 years (range 35--90); the mean Hoehn and Yahr stage was 2.11 (SD 0.86), and the mean UPDRS part III was 22.3 (SD 11.7). Sleep problems were common among PD patients. While only 17% of the sample had an overall score below 82 on the PDSS, 70% of the patients had a score below 5 on one item. There was no significant association between PD severity and any of the sleep items in the PDSS; whereas fatigue, mental health problems, and RLS were associated with PDSS score. CONCLUSIONS: The current findings call for increased awareness of sleep problems in PD patients, especially focusing on the association with mental health problems, fatigue and RLS.     

¿Existe mayor riesgo de diabetes gestacional en pacientes con disfunción tiroidea autoinmune?

ObjectiveSome recent studies have related autoimmune thyroid dysfunction and gestational diabetes (GD). The common factor for both conditions could be the existence of pro-inflammatory homeostasis. The study objective was therefore to assess whether the presence of antithyroid antibodies is related to the occurrence of GD.Material and methodsFifty-six pregnant women with serum TSH levels ≥ 2.5 mU/mL during the first trimester were retrospectively studied. Antithyroid antibodies were measured, and an O'Sullivan test was performed. GD was diagnosed based on the criteria of the Spanish Group on Diabetes and Pregnancy.ResultsPositive antithyroid antibodies were found in 21 (37.50%) women. GD was diagnosed in 15 patients, 6 of whom (10.71%) had positive antibodies, while 9 (16.07%) had negative antibodies. Data were analyzed using exact logistic regression by LogXact-8 Cytel; no statistically significant differences were found between GD patients with positive and negative autoimmunity (OR = 1.15 [95%CI = 0.28-4.51]; P = 1.00).ConclusionsThe presence of thyroid autoimmunity in women with TSH above the recommended values at the beginning of pregnancy is not associated to development of GD. However, GD prevalence was higher in these patients as compared to the Spanish general population, suggesting the need for closer monitoring in pregnant women with TSH levels ≥ 2.5 mU/mL.     

El paciente anciano en Urgencias. ¿Es el mejor escenario para la toma de decisiones complejas?

Clinical evaluation of elderly patients must include a comprehensive geriatric assessment. This is vital when deciding if a patient with a demonstrated critical disease should receive an active treatment, defined as the set of measures to treat an acute disease.The clinical outcomes are presented of four elderly patients who were admitted from the Emergency Department and whose severe acute diseases were treated with Comfort Measures Only. During their admission in the Geriatrics Acute Unit, and due to a reported clinical improvement, an active treatment was provided. All patients were discharge from the hospital after a favourable clinical course.