Clin. Pract., Volume 11, Issue 3 (September 2021) – 30 articles

A posterior flexion instability due to insufficiency of the posterior cruciate ligament (PCL) in cruciate retaining (CR) total knee arthroplasty (TKA) is an important but underdiagnosed problem. We hereby suggest a diagnostic algorithm, as demonstrated by a case report of a male patient suffering from anterior knee pain and instability after CR TKA. Clinical examination was followed by standard anterior–posterior and lateral radiographs. Stress radiographs in 30° and 90° posterior drawer position enabled a dynamic examination of the instability. SPECT/CT was used to determine the TKA component position in all planes and investigate bone tracer uptake (BTU) patterns. At revision surgery, an absent PCL after CR TKA was noted and a semi-constrained TKA was implanted. Full article

Dilated cardiomyopathy is a subset of cardiomyopathies defined by reduced ejection fraction of less than 45% and a dilated left ventricle. While dilated cardiomyopathy is common, its etiology is not always readily evident. Paraquat is used as an herbicide worldwide and is one of the main causes of fatal poisoning in underdeveloped countries in Asia, Central America, and the Pacific Islands. The most commonly affected organs are the lungs and kidneys. However, experimental research has shown that Paraquat can affect the heart indirectly through increased vascular permeability. In vivo animal studies have shown that paraquat poisoning causes myocardial contractile dysfunction by decreased fractional shortening and cardiac remodeling. We report the first case in published literature of a 52-year-old Hispanic man with dilated cardiomyopathy strongly associated with Paraquat exposure. It is important to obtain detailed medical history and proper diagnostic work-up including work, social, and family history, and echocardiography, baseline EKG, lab work, and ischemia cardiac testing as it can lead to improved diagnostic evaluation of possible etiologies of the commonly seen dilated cardiomyopathies and help identify less well-known etiologies as seen in our patient. Full article

In the United Arab Emirates (UAE), lung cancer (LC) was the third leading cause of deaths due to cancer in 2017. Around 80% of the patients in the UAE are diagnosed at a late stage, rendering the treatment less effective in improving survival outcomes. Lack of awareness of disease symptomatology, deficient screening initiatives, misdiagnosis, and delayed referral to the specialist are contributing factors for delayed diagnosis. Effective screening at a primary care setting can be crucial for early diagnosis, referral to specialists, and enhancing patient outcomes. It is important to establish screening and referral guidelines through which each suspected case can be identified and provided timely intervention. Although the international screening and referral pathway framework are comprehensive, several regional barriers need to be addressed before they can be adapted at the national level. A group of LC experts from the UAE deliberated on issues like delayed diagnosis of LC and strategic recommendations for overcoming the challenges. The discussion was based on the review of the published evidence, international and regional guidelines for screening and early diagnosis of LC. Herein, we present a guideline, endorsed by the esteemed panel of experts, for aiding early diagnosis and optimizing the management of LC in the UAE. Full article

Aims: To investigate the changes in vision-related quality of life after a loading dose of three consecutive intravitreal ranibizumab (IVR) injections in patients with unilateral diabetic macular edema (DME). Materials and Methods: Fifty-two eyes of 52 patients who received IVR injections in only one eye with DME were included in our study. The following characteristics of the patients were recorded: gender, education status, marital status, work status, presence of chronic disease. The changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) were evaluated at baseline (before treatment) and 1 month after the third intravitreal injection (after treatment). Patients were administered the Turkish form of the National Eye Institute 25-Item Visual Functions Questionnaire (NEI VFQ-25 TR). The quality of life scores assessed by the NEI VFQ-25 TR, the BCVA, intraocular pressure (IOP), and CMT measurements were compared at baseline (before treatment) and 1 month after the third intravitreal injection (after treatment). Results: We enrolled 52 patients (25 females, 27 males) in our study; mean age was 64.35 ± 9.26 years. After treatment, BCVA improved significantly (p = 0.001), and macular thickness decreased significantly (p < 0.001). All NEI VFQ-25 TR subscale scores were significantly higher after treatment (p < 0.05). However, no significant correlation was found between the change in BCVA and CMT and the change in NEI VFQ-25 TR subscale and composite scores. The increase in near activities scores was significantly higher in males (p = 0.020) and in the retired group (p = 0.022). There were no significant differences in the changes in NEI VFQ-25 TR subscale and composite scores in relation to educational status. Discussion: Significant improvements in BCVA, macular edema, and vision-related quality of life were found in DME patients who received IVR injections with a loading dose, as shown by the NEI VFQ-25 TR. Interestingly, a significant improvement in quality of life was observed even though the patients could see well with the fellow eye. In conclusion, the NEI VFQ-25 TR is a useful scale to evaluate the changes in visual function and psychosocial characteristics of DME patients after treatment. Full article

Background: To explore the prevalence of urinary tract infections (UTIs) among female patients in the Najran region of Saudi Arabia and determine their antimicrobial resistance pattern. Methods: This study was conducted on 136 urine samples collected from outpatient departments (OPDs) of the different government hospitals in the Najran region of Saudi Arabia. Over one year, the results of susceptibility testing reports of outpatient midstream urine samples from three government hospitals were prospectively evaluated. Results: Of 136 urine samples, only 123 (90.45%) were found to show significant growth for UTIs, from which 23 different uropathogens were identified. Escherichia coli (58.5%) was the most commonly isolated organism, followed by Klebsiella pneumoniae (8.1%). The isolated microorganism showed increased resistance patterns from 3.3% to 62.6%, with an overall resistance of 27.19%. Meropenem was the most effective antimicrobial, followed by amikacin and ertapenem (0.47%, 0.91%, and 1.5% resistance, respectively). At the same time, ampicillin and cephazolin were the least (62.6% and 59.5% resistance, respectively) effective. Overall, eleven (8.94%) uropathogens isolates were ESBLs, among which there were eight (6.5%) Escherichia coli, one (0.81%) Klebsiella pneumoniae, one (0.81%) Klebsiella oxytoca, and one (0.81%) Citrobacter amalonaticus. Conclusions: E. coli remains the most commonly isolated causative uropathogens, followed by Klebsiella species. The prevalence of pathogenic E. coli and Klebsiella species underscores the importance of developing cost-effective, precise, and rapid identification systems to minimize public exposure to uropathogens. Antibiotic susceptibility data revealed that most of the isolates were resistant to the majority of the antibiotics. The patients with UTIs in the Najran region of Saudi Arabia are at a high risk of antibiotic resistance, leading to significant problems in outpatient department (OPD) treatment outcomes and raising the alarm for the physician to change their empiric treatment. Full article

Background: Sensory motor impairment, the most common neuromuscular condition in stroke patients, often contributes to muscle weakness and imbalance. Objective: The purpose of this research was to investigate the effects of cognitive sensory-motor training (CSMT) on the muscle strength and balance ability in post-stroke patients. Methods: Thirty-five participants after stroke were randomly assigned to the CSMT (n = 17) or control group (n = 18). All participants received 30 min of training each time, five times per week, for six weeks. Lower extremity muscle strength of tibialis anterior (LEMTA) was evaluated using a digital muscular dynamometer. The Medical Research Council (MRC) scale was used to evaluate muscle strengths of the hip joint, knee joint, and ankle joint. For balance ability test, the center of pressure (COP) movement distance and limited of stability (LOS) were measured using BioRescue. Results: LEMTA, MRC scale, balance ability were significantly more improved in the CSMT group than in the control group (p < 0.05). Conclusions: Our findings indicate that CSMT is beneficial and effective for improving muscle strength of the lower extremity and balance ability of post-stroke patients. Full article

Background: Epithelioid trophoblastic tumor (ETT) is a rare and newly defined disease, which most commonly occurs in women of reproductive age and can be a sequela of any gestational event. ETT can be present in both intrauterine and extrauterine sites. Case report: A woman of reproductive age, without specific comorbidities and with a single pregnancy and natural childbirth eight years ago, was diagnosed initially with poorly differentiated pleomorphic leiomyosarcoma on the hemostatic uterine curettage. Conclusion: Our case highlights that ETT presents a diagnostic challenge due to its rarity and histologic resemblance to other pathologies. Misdiagnosis delays effective treatment and affects survival. To date, only 8 cases of ETT of the uterus without previous gestational event and normal human chorionic gonadotropin (β-HCG) levels in a 60-year literature survey have been reported. Full article

Although there has been a drastic decline in the cases of Tuberculosis in the United States, the prevalence of infections caused by Mycobacterium avium Complex (MAC) has steadily increased in the past decades. Mycobacterium avium (M. avium) is one of the most abundant microorganisms in the MAC species. The mycobacterium genus is divided into two major groups: tuberculosis causing mycobacteria and non-tuberculous mycobacteria. MAC is most prominent among the non-tuberculous mycobacteria. MAC is an opportunistic pathogen that is present in soil, water, and droplets in the air. MAC infections can result in respiratory disease and can disseminate in affected patients. MAC infections are especially prevalent in patients with preexisting respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD). COPD is one of the most common lung conditions in the world with the primary cause being smoking in developed countries. COPD involves chronic inflammation of lung tissue resulting in increased susceptibility to infection. There is a lack of research regarding the pathophysiology that leads COPD patients to be susceptible to MAC infection. Our review paper therefore aims to investigate how the pathogenicity of MAC bacteria and immune decline seen in COPD patients leads to a greater susceptibility to MAC infection among COPD patients. Full article

The Central Sensitization Inventory (CSI) measurement properties in patients having nonspecific, noncancer pain are well-established. However, studies examining the reliability and validity of either the CSI or the Central Sensitization Inventory short-form version (CSI-9) in breast cancer survivors (BCS) are scarce. The purpose was to evaluate convergent validity and internal consistency of the CSI and CSI-9. Additionally, the relevance of a new cluster calculator using the CSI was explored. The cross-sectional multi-center study included 65 BCS and 37 healthy volunteers. Patients filled out multiple questionnaires assessing pain, number of painful areas, anxiety, depression and quality of life. The relevance of a cluster calculator was explored by known-group comparisons and boxplot description. All hypotheses were formulated before data analysis. The majority of hypotheses on the correlations between the CSI or CSI-9 and other health outcomes were confirmed (22 out of 27). The CSI and CSI-9 have excellent (α = 0.92) and good (α = 0.86) internal consistency, respectively. The CSI cluster calculator might be an interesting tool to use to have a patient’s overall condition snapshot. Generally, the study findings support the construct validity and internal consistency of the CSI, which underline the use of this self-reported instrument in BCS. The CSI-9 shows promising results, but should be further evaluated. Full article

Headache, a common prodromal symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can also be a manifestation of cerebral venous thrombosis (CVT), secondary to COVID-19. CVT management continues to evolve, with direct oral anticoagulants (DOACs) emerging as an alternative to warfarin. A 44-year-old Asian female, with no past medical history, presented to the emergency room (ER) with complaints of nonproductive cough and left-sided headache. She denied a history of COVID-19 vaccination, and SARS-CoV-2 testing (with reverse transcriptase-polymerase chain reaction) was positive. Non-contrast computed tomography (CT) of the head revealed left transverse sinus hyperdensity, consistent with dense vein sign, and magnetic resonance venography (MRV) confirmed the presence of thrombus. The initial treatment included subcutaneous enoxaparin with headache resolution, and she was discharged on apixaban. Five weeks later, a non-contrast head CT showed resolution of the dense vein sign and recanalisation of left transverse sinus was seen on MRV. This report has highlighted the need for increased awareness of coagulopathy and thrombotic events, including cerebral venous thrombosis, in patients infected with SARS-CoV-2. Unremitting headache, in context of SARS-CoV-2 infection, should be evaluated with appropriate neurovascular imaging. Controlled studies are required to compare the safety and efficacy of DOACs with warfarin for management of cerebral venous thrombosis. Full article

Background: Off-pump coronary artery bypass grafting (OPCAB) is believed to limit inflammatory reaction. Neutrophil to lymphocyte ratio (NLR) is one of the more common and easily accessible markers of inflammatory response. The aim of the study was to compare postoperative results of NLR with mid-term OPCAB results. Methods: In total, 224 patients (198 (88%) men and 26 (12%) women) with mean age 65 +/− 9 years who underwent OPCAB though median full sternotomy in our department in 2018 enrolled into the study. We scrupulously collected the postoperative mid-term results, including survival rate, clinical status and risk for major adverse events, and compared them with perioperative laboratory results. Results: A three-year follow-up was completed by 198 individuals (90% survival rate) with 12 (5%) showing major adverse cardiovascular (MACE) events risk. In the multivariable analysis, the laboratory parameters noticed on the 1st postoperative day were statistically significantly predictive of survival, including neutrophils (HR 1.59, 1.33–1.89 95%CI, p < 0.0001), platelets (HR 1.01, 1.01–1.01 95%CI, p = 0.0065), NLR (HR 1.47, 1.3–1.65 95%CI, p < 0.0001) and postoperative ejection fraction (HR 0.9, 0.87–0.95 95%CI, p < 0.0001). Conclusions: Postoperative NLR above 4.6, as an inflammatory reaction marker, is related to mid-term mortality in OPCAB patients. Full article

A 71-year-old man visited our hospital with dyspnea and left pleural effusion. Left pleural effusion was diagnosed as chylothorax by thoracentesis. He had no history of trauma or surgery, and there were no findings of malignant lymphoma or thrombosis. Furthermore, he was diagnosed with liver cirrhosis and hepatocellular carcinoma by computed tomography and hematological examinations, and the chylothorax was considered to be caused by liver cirrhosis. We report a review of the literature with this case since it is relatively rare for cirrhosis and hepatocellular carcinoma diagnosed from chylothorax. Full article

Background: The use of diverse therapies combined with a multidisciplinary approach and prevention initiatives for patients with chronic non-malignant pain (CNMP) can improve health and have a positive impact on psychotropic drug use and the self-management of pain. Purpose: This purpose of this study has been two-fold: to conduct a literature review with a view to selecting best evidence recommendations for CNMP and to prioritize self-care recommendations using a participatory methodology for the analysis and selection of interventions. Methods: A qualitative, descriptive, and documentary method based on participatory action research was used. Findings: Based on the study results, a multimodal psychosocial intervention program has been designed for CNMP that includes psychoeducational therapy, pharmacological therapy, physical exercise, and health assets. Discussion: The findings are consistent with previous studies underlining the need to invest in resources for the management of CNMP, including strategies for good differential diagnoses and pharmacological treatments combined with non-pharmacological treatments to confer greater well-being for people living with pain who want to participate in their own recovery. Full article

The importance of the psychological impact of diabetes is globally well-documented. Evidence suggests that there is a high level of psychosocial burden of diabetes in India. Moreover, there is a lack of relevant knowledge among the patients and caregivers regarding the psychological impact of diabetes and how to cope with it, as compared to the majority of other countries. “Happiness of the patient” is an essential component of diabetes management, which potentially affects the treatment outcome, treatment adherence, self-care, and lifelong management of diabetes. Although several validated tools and scales exist for measuring psychological outcomes both in patients and physicians, tools to assess “happiness in diabetes care” are still lacking. With this background, an expert group meeting was held in India in September 2019, involving nine expert diabetologists and endocrinologists across the country to discuss the concept of “glycemic happiness”. This article summarizes the expert opinion on the factors affecting psychological outcomes in diabetes, introduces the concept of glycemic happiness, describes available scales and tools to measure general happiness, and delineates the five sets of questionnaires developed with questions that may help correlate with “glycemic happiness”. The questionnaires are based on a five-point Likert method. The experts also discussed and decided upon the study design for a proposed observational survey to assess glycemic happiness of persons with type 2 diabetes mellitus (T2DM) based on the developed five sets of questionnaires. Given the huge burden of diabetes in India, the introduction of the concept of glycemic happiness will help in the optimization of diabetes care in the country. Full article

Background: In patients with prostatic and breast cancer the application of peridural anesthesia (PDA) showed a beneficial effect on prognosis. This was explained by reduced requirements for general anesthetics and perioperative opioids as well as a lower perioperative stress level. The impact of PDA in patients with more aggressive types of cancer has not been completely elucidated. Here, we analyzed the prognostic influence of PDA on overall survival after surgery as primary in patients that underwent radical resection of pancreatic adenocarcinoma. Methods: Records of 98 consecutive patients were reviewed. In 70 of these cases PDA was applied. Patient characteristics such as demographics, TNM stage, and operative data were retrospectively collected from medical records and analyzed. Survival data were analyzed by Cox’s proportional hazard regression model. Results: Overall, no significant prognostic influence of PDA on recurrence or overall survival (p = 0.762, Hazard Ratio [HR] 0.884, 95% confidence interval [CI] 0.398–1.961) was found. However, there was a trend towards a longer overall survival (p = 0.069, HR 0.394, 95% CI 0.144–1.078) associated with PDA in a subgroup of patients with better differentiation of pancreatic adenocarcinoma. Conclusion: The observation of longer survival associated with PDA in our subgroup of patients with better-differentiated pancreatic carcinomas is in line with previous reports on various other less aggressive tumor entities. Our results indicate that PDA might improve the oncological outcome of patients with pancreatic adenocarcinoma. Full article

The lack of long-term maintenance of the weight loss achieved during weight-management programs is the major cause of failure in obesity treatments. The identification of factors related to this outcome has clinical implications. Therefore, we aimed to assess the relationship between sarcopenic obesity (SO) and the weight-loss percentage (WL%). The WL% was measured at the six-month follow-up and after more than 12 months, in 46 adult participants with obesity, during an individualized weight-management program where participants were categorized as having or not having SO at the baseline. At the six-month follow-up, participants with SO did not display a significant difference in terms of WL%, when compared to those without SO (−10.49 ± 5.75% vs. −12.73 ± 4.30%; p = 0.148). However, after a longer term (i.e., >12 months), the WL% appeared to be significantly lower in the former (SO vs. non-SO) (−7.34 ± 6.29% vs. −11.43 ± 4.31%; p = 0.024). In fact, partial correlation analysis revealed a relationship between SO at the baseline and a lower WL% after more than 12 months (ρ = −0.425, p = 0.009), after controlling for age, sex, and body mass index (BMI). Participants with SO appeared to face more difficulties in maintaining the achieved WL over a longer term (>12 months follow-up) by comparison with their counterparts (i.e., non-SO). Should this finding be replicated in larger-sample studies, new strategies should be adopted for these patients in order to improve this clinical outcome, especially during the weight-maintenance phase. Full article

A 63-year-old male patient with a history of hypertension, diabetes mellitus type 2, prostate cancer and class two obesity was admitted for encephalopathy. During his hospital stay he developed narrow complex tachycardia and it was difficult to definitively diagnose the underlying arrhythmia. Observation of the cool down phenomenon on telemetry strip allowed us to make the diagnosis of atrial tachycardia and elegantly rule out other causes. We report this interesting case of narrow complex tachycardia. Full article

Since smoking accounts for around 30% of all cancer deaths, public health campaigns often focus on smoking cessation as a means of primary prevention. However, smoking after cancer diagnosis is also associated with a higher symptom burden and lower survival rate. As data regarding smoking cessation vary dramatically between different populations, we aimed to analyze smoking prevalence in cancer patients, smoking cessation after cancer diagnosis, and the factors associated with smoking cessation in the setting of a developing country. We performed a cross-sectional survey on 695 patients in two clinical hospital centers. After cancer diagnosis, 15.6% of cancer patients stopped smoking. Male gender, younger age, and smoking-related cancer were the main factors associated with greater smoking cessation (p < 0.05). A total of 96% of breast cancer patients continued to smoke after cancer diagnosis and, compared to lung and colorectal cancer patients, exhibited a lower reduction in the number of cigarettes smoked (p = 0.023). An alarming rate of smoking prevalence was recorded in younger patients (45.6% at the time of cancer diagnosis) suggesting a future rise in smoking-related cancers and complications. These results should guide anti-smoking public health campaigns in transitional countries with a critical focus on younger and breast cancer patients. Full article

In children, spontaneous mediastinitis is a rare, severe and commonly misdiagnosed disease. Although standard of care treatment frequently involves surgery, we report a case of mediastinitis in a five-year-old child, successfully treated with 4 weeks of intravenous antibiotics. Ultrasound imaging was used to monitor patient response to conservative treatment while reducing radiation exposure. Full article

The thyroid gland plays a significant role in the metabolism and proliferation of blood cells; hematological disorders are frequently observed in patients with thyroid disorders, and the most frequent problem is anemia. The main objective of this research work is to evaluate the prevalence and types of thyroid dysfunction and their association with anemia in different gender stratified by age in the Asir region of Saudi Arabia. Four years of data from July 2016 to July 2020 for 9992 study subjects were collected. Statistical analysis was performed based on thyroid disorder and anemia stratified by gender and age subgroup. The mean age of the study subject was 43.4 ± 15.8 years, and females constituted 61.7% of cases. Thyroid dysfunction was observed in 49.76% (4973), and subclinical hypothyroidism was the most prevalent type (3922/9992), followed by primary hypothyroidism (530/9992). Females have a significantly higher overall prevalence of thyroid dysfunction than males (p < 0.05). Anemia was detected in 1344 females and 465 males with a thyroid disorder, and also, the prevalence was significantly higher (p < 0.05), compared to the normal thyroid group. Thyroid disorders are a common problem in our population, more prevalent in females than males, with the peak age of above 30 years, and are associated with an increased prevalence of anemia. Full article

Anthracycline-based regimens with or without anti-human epidermal growth factor receptor (HER) 2 agents such as trastuzumab are effective in breast cancer treatment. Nevertheless, heart failure (HF) has become a significant side effect of these regimens. This study aimed to investigate the incidence and factors associated with HF in breast cancer patients treated with anthracyclines with or without trastuzumab. A retrospective cohort study was performed in patients with breast cancer who were treated with anthracyclines with or without trastuzumab between 1 January 2014 and 31 December 2018. The primary outcome was the incidence of HF. The secondary outcome was the risk factors associated with HF by using the univariable and multivariable cox-proportional hazard model. A total of 475 breast cancer patients were enrolled with a median follow-up time of 2.88 years (interquartile range (IQR), 1.59–3.93). The incidence of HF was 3.2%, corresponding to an incidence rate of 11.1 per 1000 person-years. The increased risk of HF was seen in patients receiving a combination of anthracycline and trastuzumab therapy, patients treated with radiotherapy or palliative-intent chemotherapy, and baseline left ventricular ejection fraction <65%, respectively. There were no statistically significant differences in other risk factors for HF, such as age, cardiovascular comorbidities, and cumulative doxorubicin dose. In conclusion, the incidence of HF was consistently high in patients receiving combination anthracyclines trastuzumab regimens. A reduced baseline left ventricular ejection fraction, radiotherapy, and palliative-intent chemotherapy were associated with an increased risk of HF. Intensive cardiac monitoring in breast cancer patients with an increased risk of HF should be advised to prevent undesired cardiac outcomes. Full article

Background: The process to obtain valid informed consent in healthcare reflects many aspects. Healthcare professionals that take care of the patient must provide him all the necessary information and verify his understanding, considering individual characteristics. Nurses are one of the main participants in this process. Objective: This study assesses nurses’ perceptions of their role in the informed consent process. Material and Methods: An observational study involving 300 nurses operating in 13 wards of the Padua Hospital, through the submitting of a questionnaire in the period November–December 2018. Results: The final sample is made up of 206 nurses—27 males (13.11%) and 179 females (86.89%). Work experience, on average 15 years, is significant in determining the answers to questions about opinions and experiences. Age is significant in determining how often nurses provide information to the patient’s family members about the actions to be taken after discharge. The ward was decisive in the responses related to information provided to patients on the nursing care level and the actions to be taken after discharge, and the definition of the nurse’s duties. Conclusions: The data collected show the need for interventions to reduce the causes of difficult that the nurse has in informing patients. Full article

Dihydropyrimidine dehydrogenase (DPD) is the major enzyme in the catabolism of 5-Fluorouracil (5-FU) and its prodrug capecitabine. We report cases from our institute with colorectal cancer who experienced severe toxicities to standard dose 5-FU based chemotherapy. DPYD gene sequencing revealed rare different polymorphisms that prompted dose adjustments of administered 5-FU and capecitabine. To our knowledge, this is the first case series looking at DPYD polymorphisms in the Saudi Arabian population. Full article

Although rare, acute myelogenous leukemia (AML) can include extramedullary manifestations, sometimes presenting as a solid tumor called a myeloid sarcoma. Myeloid sarcoma can be the cause of the initial presenting complaint before AML diagnosis, or may be detected as a sign of disease-relapse after treatment. Here, we report a case in which the initial presentation included abdominal discomfort and signs of kidney failure. Further investigation revealed signs of unilateral hydronephrosis. Due to a diagnostic delay, the patient was diagnosed with AML with extramedullary manifestation only after the development of full-blown leukemia. Biopsy of the compressive tumor confirmed an extramedullary myeloid sarcoma, and [¹⁸F]-FDG-PET/CT proved useful for patient diagnosis and follow-up. This case report illustrates the importance of thorough examination and diagnosis, as a serious underlying disease with a rare cause can debut with an unusual presentation. Full article

A 41-year-old woman with no significant past medical history presented to the hospital with complaints of nausea, vomiting, and generalized weakness over two weeks. The patient did not seek medical attention as she assumed that her symptoms willwould resolve. Following her initial denial of drug abuse and her abnormal urine drug screening, we discussed the findings with the patient. She later admitted to using both amphetamines and marijuana. This led us to take a detailed social history that revealed an unexpected event. Full article

Small-cell lung cancer (SCLC) is an aggressive subtype of lung cancer characterized by a rapid initial response and early development of resistance to systemic therapy and radiation. The management of SCLC significantly changed for the first time in decades with the introduction of immune checkpoint inhibitors. Pembrolizumab, a humanized IgG4 isotype antibody, targets the programmed cell death protein 1 (PD-1) pathway to restore anti-tumor immunity. Prospective trials of pembrolizumab in patients with previously treated SCLC showed significant durability of responses. These results led to the U.S. Food and Drug Administration (FDA) granting pembrolizumab accelerated approval as second- or third-line monotherapy for patients with extensive-stage (ES) SCLC. In a recent clinical trial that included patients with previously untreated ES-SCLC, pembrolizumab in combination with platinum/etoposide met its progression-free survival endpoint, but overall survival (OS) did not cross the threshold for superiority. With the therapeutic landscape for SCLC rapidly evolving, we review prior experience and future directions of pembrolizumab in ES-SCLC. Full article

Diseases of the breast in adolescent women are usually benign, and their treatment is simple using appropriate medical strategy and rarely surgical therapy. The whole team’s real challenge is when the girl presents malignant breast cancer symptoms such as a non-movable tumor, nipple discharge, nipple retraction, retraction of the skin, inflammatory infiltration of the breast, or ulceration. Presented here is a case of a 15-years-old girl with the features of a malignant neoplasm of the breast. There was an observed non-movable tumor, retraction of the nipple, inflammatory infiltration, and pain. The performed ultrasound and magnetic resonance imaging suggested a malignant lesion measuring 84 mm × 66 mm × 50 mm. After many diagnostic difficulties, the lesion evacuated spontaneously, and the abscess was diagnosed. In conclusion, not all features of a malignant breast tumor in adult women are typical for adolescent females. In young girls, breast diseases are usually benign, and appropriate diagnostics and therapy allow for an effective cure. Atypical breast lesions require the extraordinary cooperation of a multidisciplinary team. Full article

Left ventricular assist device implantation is a challenging procedure in the presence of a giant thrombosed aneurysm, and no standard surgical techniques are currently recommended in this setting. In this case, we report the successful implantation of a left ventricular assist device (HeartMate III) in a patient with a massive thrombosed apical aneurysm. The patient presented with extended antero-apical necrosis as a result of a delay in hospital admission for acute coronary syndrome due to the patient’s concerns about the COVID-19 pandemic outbreak. Full article

Radiotherapy plays an important role in the treatment of localized primary malignancies involving the chest wall or intrathoracic malignancies. Secondary effects of radiotherapy on the lung result in radiation-induced lung disease. The phases of lung injury from radiation range from acute pneumonitis to chronic pulmonary fibrosis. Radiation pneumonitis is a clinical diagnosis based on the history of radiation, imaging findings, and the presence of classic symptoms after exclusion of infection, pulmonary embolism, heart failure, drug-induced pneumonitis, and progression of the primary tumor. Computed tomography (CT) is the preferred imaging modality as it provides a better picture of parenchymal changes. Lung biopsy is rarely required for the diagnosis. Treatment is necessary only for symptomatic patients. Mild symptoms can be treated with inhaled steroids while subacute to moderate symptoms with impaired lung function require oral corticosteroids. Patients who do not tolerate or are refractory to steroids can be considered for treatment with immunosuppressive agents such as azathioprine and cyclosporine. Improvements in radiation technique, as well as early diagnosis and appropriate treatment with high-dose steroids, will lead to lower rates of pneumonitis and an overall good prognosis. Full article

We report a 38-year-old female patient affected with anti-citrullinated protein antibody (ACPA)-positive rheumatoid arthritis (RA) who developed mild hemolytic anemia (Hb = 10.5 vs. >12 gr/dL), indolent oral ulceration, ANA (1:1280, homogeneous pattern), and anti-dsDNA antibody positivity following 8 months of therapy with an adalimumab biosimilar (GP2017). Rhupus syndrome was diagnosed. Replacing GP2017 with infliximab, anemia, oral ulcer, and anti-dsDNA antibodies quickly disappeared, while low-titers (1:80) ANA are still present after more than a year. The possibility that the patient suffered from rhupus rather than drug-induced lupus erythematosus associated to anti-ACPA positivity RA was discussed. To date, after a 14-month follow-up, no manifestations of LE have reappeared. To the best of our knowledge, this is the first report of adalimumab-induced rhupus. Full article