Course Of Clinical Management Research Articles

O-189 Letrozole-resistant PCOS: prevalence, further options and course of fertility treatment

Abstract Study question What is the prevalence of letrozole-resistance in infertile women with polycystic ovary syndrome (PCOS) and what is the course of clinical management for such women? Summary answer Even after 10 mg/day dose of letrozole, 2.7% women did not ovulate. Clomiphene citrate (CC) should be tried first in these women, followed by gonadotrophins What is known already Letrozole is the preferred drug for ovulation induction (OI) in infertility associated with PCOS because it results in better pregnancy and live birth rates than CC. Women not responding to conventional dose of letrozole, may require alternate regimens like two-step, higher and extended dose. But some women may remain refractory even to the maximum dose of letrozole. While CC-resistance and its management are well established, clinical management of women with PCOS resistant to the maximum dose of letrozole remains largely undocumented. Study design, size, duration A prospective observational study was conducted in a Fertility Centre between April 2018 and March 2023 after obtaining Institutional Ethics Committee approval and informed written consent from all the participants. Out of total 1851 women with PCOS and infertility, 1522 were included in the study, of which 50 were found to be resistant to letrozole. Participants/materials, setting, methods Infertile women with PCOS (defined by Rotterdam criteria), age 21-35 years, with patent fallopian tubes and normal semen reports of partner, who received no previous OI were recruited. Women who failed to ovulate (confirmed with transvaginal ultrasound) after 3 consecutive cycles of incremental (5, 7.5 and 10 mg/day) doses of letrozole were switched to CC. In case of CC-resistance, options of laparoscopic ovarian drilling (LOD) or gonadotrophins were offered. Clinical and pregnancy-associated parameters were assessed. Main results and the role of chance Out of 50 letrozole-resistant women, 19 (38%) ovulated after subsequent OI with CC, of which seven (36.8%) conceived and two (28.8%) had twin pregnancy. Out of 31 CC-resistant women, seven were lost to follow up. The singlet woman who opted for LOD did not have subsequent spontaneous ovulation and therefore, required gonadotrophins later on. All 24 women who received gonadotrophins ovulated. Most of them developed one (11, 45.83%) or two (12, 50%) follicles. However, one woman developed 10 follicles leading to ovarian hyperstimulation syndrome, for which the OI cycle was converted to in-vitro fertilization (IVF). With gonadotrophins, nine (37.5%) women conceived and one (11.1%) had triplet pregnancy that miscarried in the first trimester. The remaining 16 women who failed to conceive were offered three cycles of intrauterine insemination followed by IVF. The mean time to pregnancy from the start of treatment was 10.81 (±7.71) months. The live birth rate was similar (P = 0.0416) between gonadotrophins (6, 27.2%) and CC (5, 22.7%), Between CC-resistant and CC-responsive women, all clinical, biochemical and biophysical parameters were similar except the mean levels of luteinizing hormone, which were significantly higher in CC-resistant group (16.3 ±5.3 versus 13.2 ±4.7 mU/ml, P = 0.036). Limitations, reasons for caution The study was conducted in a single center and the results may be difficult to extrapolate on women belonging to other ethnicities. The sample size was small. Wider implications of the findings Some women with PCOS may not respond even to the maximum dose (10 mg/day) of letrozole. Correct identification of letrozole-resistance and choosing the subsequent appropriate methods of OI are of paramount importance in timely management of infertility in these couples. Trial registration number NA

Large submucous uterine fibroid mass

Background: Uterine fibroids or leiomyomas, are common benign tumors originating from the smooth muscle cells of the uterus. While typically asymptomatic, large submucous fibroids can cause significant clinical manifestations, including abnormal uterine bleeding, pelvic pain, and reproductive issues. Radiological imaging, such as ultrasound, played a crucial role in the accurate diagnosis and characterization of these fibroids, guiding appropriate clinical management decisions. Methods: We present a case report of a 28-year-old female with complaints of heavy menstrual bleeding and pelvic discomfort. Clinical evaluation prompted the utilization of radiological imaging techniques to assess the uterine anatomy. Ultrasound was employed to visualize and characterize the large submucous uterine fibroid mass. Imaging findings were correlated with clinical symptoms to formulate an appropriate treatment plan. Results: ultrasound revealed a large submucous uterine fibroid mass measuring 105.7mm x 75.6mm x 79.6mm in its dimensions. The fibroid was heterogeneous in its echo texture and it is located in the submucosal layer of the uterus. Doppler imaging demonstrated some areas of flow within the fibroid mass. The correlation of imaging findings with clinical symptoms aided in determining the extent of fibroid-related symptoms and guiding further management decisions. Conclusion: This case report underscores the significance of radiological imaging, particularly ultrasound in diagnosing and characterizing large submucous uterine fibroid masses. Accurate radiological assessment is crucial for determining the appropriate course of clinical management, which may include medical therapy, minimally invasive procedures, or surgical intervention. The collaborative approach between gynecologists and radiologists is pivotal in optimizing patient care for individuals with symptomatic uterine fibroids.

Mapping Immune-Tumor Bidirectional Dialogue Using Ultrasensitive Nanosensors for Accurate Diagnosis of Lung Cancer.

Lung cancer is one of the most common cancers with high mortality worldwide despite the development of molecularly targeted therapies and immunotherapies. A significant challenge in managing lung cancer is the accurate diagnosis of cancerous lesions owing to the lack of sensitive and specific biomarkers. The current procedure necessitates an invasive tissue biopsy for diagnosis and molecular subtyping, which presents patients with risk, morbidity, anxiety, and high false-positive rates. The high-risk diagnostic approach has highlighted the need to search for a reliable, low-risk noninvasive diagnostic approach to capture lung cancer heterogeneity precisely. The immune interaction profile of lung cancer is driven by immune cells' distinctive, precise interactions with the tumor microenvironment. Here, we hypothesize that immune cells, particularly T cells, can be used for accurate lung cancer diagnosis by exploiting the distinctive immune-tumor interaction by detecting the immune-diagnostic signature. We have developed an ultrasensitive T-sense nanosensor to probe these specific diagnostic signatures using the physical synthesis process of multiphoton ionization. Our research employed predictive in vitro models of lung cancers, cancer-associated T cells (PCAT, MCAT) and CSC-associated T cells (PCSCAT, MCSCAT), from primary and metastatic lung cancer patients to reveal the immune-diagnostic signature and uncover the molecular, functional, and phenotypic separation between patient-derived T cells (PDT) and healthy samples. We demonstrated this by adopting a machine learning model trained with SERS data obtained using cocultured T cells with preclinical models (CAT, CSCAT) of primary (H69AR) and metastatic lung cancer (H1915). Interrogating these distinct signatures with PDT captured the complexity and diversity of the tumor-associated T cell signature across the patient population, exposing the clinical feasibility of immune diagnosis in an independent cohort of patient samples. Thus, our predictive approach using T cells from the patient peripheral blood showed a highly accurate diagnosis with a specificity and sensitivity of 94.1% and 100%, respectively, for primary lung cancer and 97.9% and 94.4% for metastatic lung cancer. Our results prove that the immune-diagnostic signature developed in this study could be used as a clinical technology for cancer diagnosis and determine the course of clinical management with T cells.

A Novel MSH6 Gene Variant in a Lynch Syndrome Patient with Lipomas

Colorectal cancer is one of the most frequently occurring cancers today, with a large percentage of cases having a hereditary basis. Lynch syndrome is the most common cause of hereditary colorectal cancer. The genetic defect characteristics of this syndrome involve mutations in mismatch repair (MMR) genes, which result in microsatellite instability. Early detection of the mutation can help evaluate the cancer risk and, consequently, a proper course of clinical management for the person harboring the mutation. Herein, we describe the first report of a c.1458dup (p.Glu487*) new mutation in a 53-year-old colorectal cancer patient with diagnosed Lynch syndrome. Additionally, the existence of lipomas in this patient and his family could be related to this syndrome. Further investigation may provide a possible visual clue that can indicate a need for genetic screening.

Adenocarcinoma Mucinoso de Apéndice Cecal, informe de caso

Cecal appendix adenocarcinoma occurs in approximately 0.1% to 0.2% of all appendectomies. One subtype, mucinous adenocarcinoma, represents 0.08% of all neoplasms. Diagnosis is usually incidental and surgery is the best treatment option. We describe the case of a 55-year-old male patient, evaluated for severe pain in the right iliac fossa, who was found to have an appendiceal mass during open appendectomy. A fragmented appendix measuring 7 x 1.8 x 0.8cm, with mucoid content in its lumen; as well as mucin pools in more than 50% of the sample and signet ring cells in light microscopy, revealed the pathological diagnosis of mucinous adenocarcinoma. Therefore, the pathological analysis of surgical pieces is transcendental, since there are infrequent diagnoses that can change the prognosis and course of clinical management of a patient.

Impact of Molecular Tumor Board on the Clinical Management of Patients With Cancer.

PURPOSEMultidisciplinary molecular tumor boards (MTBs) help in interpreting complex genomic data generated by molecular tumor profiling and improve patients' access to targeted therapies. The purpose of this study was to assess the impact of our institution's MTB on the clinical management of patients with cancer.METHODSThis study was conducted at a tertiary cancer center in India. Cases to be discussed in the MTB were identified by molecular pathologists, scientists, or oncologists. On the basis of the clinical data and molecular test reports, a course of clinical management was recommended and made available to the treating oncologist. We determined the proportion of patients who were recommended a change in the clinical management. We also assessed compliance of the treating oncologists with MTB recommendations.RESULTSThere were 339 discussions for 328 unique patients. The median age of the cohort was 54 years (range 17-87), and the majority of the patients were men (65.1%). Of 339 cases, 133 (39.2%) were recommended continuation of ongoing therapy while the remaining 206 (60.7%) were recommended a change in clinical management. Compliance with MTB recommendations for a change in clinical management was 58.5% (79 of 138 evaluable cases). Compliance and implementation for MTB's recommendation to start a new therapy in 104 evaluable cases were 60.5% and 44.2%, respectively. A total of 248 biopsies had at least one actionable mutation. A total of 646 mutations were identified in the cohort, with EGFR being the most frequently altered gene.CONCLUSIONMTBs help in interpreting results of molecular tests, understanding the significance of molecular abnormalities, and assessing the benefits of available targeted therapies and clinical trials in the management of patients with targetable genetic alterations.

Deep sequencing reveals the spectrum of BCR-ABL1 mutations upon front-line therapy resistance in chronic myeloid leukemia: An Eastern-Indian cohort study

The course of clinical management in chronic myeloid leukemia (CML) often faces a road-block in the form of front-line (imatinib) therapy resistance. Subsequently, several hotspot mutations were clinically validated in the kinase domain (KD) of BCR-ABL1, in deterring imatinib sensitivity and further, made targeted by next-generation tyrosine-kinase-inhibitor (TKI) drugs. Identifying KD mutations, occurring even at low frequencies, became pertinent here. Globally, cohorts from different origins were tested and the mutational spectra were mapped to categorize clinical management as well as related pathological features of CML. Moreover, targeted deep sequencing could reveal the mutational landscape more efficiently than the less sensitive Sanger sequencing method. However, no such efforts were reported from Eastern Indian cohorts of imatinib-resistant CML-sufferers. This study assessed a prospective study cohort of imatinib-resistant CML cases from Eastern India. Following dissecting the molecular and clinical parameters, the mutational spectrum was comparatively examined using conventional Sanger and next-generation deep sequencing method. This cohort showed a prevalence of e14a2-p210 variant of BCR-ABL1 and acquired resistance against imatinib, while the disease was mostly confined in its chronic phase. Together with a few common hotspot mutations identified in this cohort, deep sequencing revealed cases with a candidate mutation, otherwise undetermined by Sanger method. Also, cases with a second low frequency mutation were identified upon applying deep sequencing. Along with highlighting a few aspects of CML biology employing an Eastern-Indian cohort, this data could mark the immense importance of deep sequencing to contribute in the clinical management of CML upon front-line therapy resistance.

120 Terahertz Spectral Imaging for Burn Depth Determination in an in Vivo Porcine Scald Model

Abstract Introduction Clinical evaluation of burns results in about 50–70% accuracy in predicting the final burn progression and healing outcome in partial thickness burns. Early and accurate assessment of burn wounds is critical for determining the course of clinical management. Terahertz (THz) spectral imaging is a promising biomedical imaging modality that has been used to quantitatively determine burn severity in acute rodent models. Here, we hypothesized that the new THz modality can determine burn depth and predict the wound healing outcome of injuries using a standardized porcine model. We developed a handheld THz instrument to obtain diagnostic images from large animal burns with varying severities. The results showed that the THz imaging can differentiate between different burn groups defined by injury depth on days 1–5 post-burn, and predict their ultimate outcome defined by reepithelialization during a 28-day study period (1-way ANOVA, p< 0.05). Methods Multiple 1 inch diameter standardized cutaneous burns were created (n = 20–24 per pig) in 3 anesthetized female domestic pigs (~32kg) using a circulating heated water in replicates. The temperatures were controlled and kept constant at 95 C degrees using thermosensors, while the duration of exposure was varied between 5, 15, or 25 seconds. Burns were covered with a topical antibiotic ointment and frequent dressing changes were performed for 4 weeks. Daily THz scans were obtained from each burn during the first week, corresponding to the peak of the anti-inflammatory response of the burns. After the initial 5 days, weekly scans were obtained until the ultimate healing outcome was determined by an experienced surgeon and a blinded histopathologist. Periodic punch biopsies were taken to determine burn depth, percentage burns reepithelialized within 21 days, and depth of scar at 28 days. Results Attached figures show representative daily visual and THz images of burns with the associated ROI. Bar plots show mean and standard deviation of spectral amplitude (SA) and spectral slope (SS). Low severity burns showed decreasing SA and increasing SS over time, whereas SS from 25 second burns remained negative and SA increased by day 4. Variation in SS suggests changes in density of skin structure as a result of scattering and changes in SA suggests variations in water content. Detailed statistical analysis is in attached table. Conclusions Using the novel handheld THz scanner, analysis of the spectral slopes signal showed the ability of the new Terahertz imaging modality in differentiating between different burn severities (p < 0.05) and evaluating burn progression. Applicability of Research to Practice THz modality can result in improvement in the accuracy of burn triage, which in turn can lead to better wound healing outcomes, reduction in length of hospital stay and improvement in overall recovery of the patients.

Comparing clinical protocols for the treatment of human rabies: the Milwaukee protocol and the Brazilian protocol (Recife).

INTRODUCTION: Rabies is a major and seriously neglected public health problem worldwide. A treatment consisting of supportive therapy with the use of drugs that show antiviral activity is called the Milwaukee Protocol. In Brazil, this protocol was adapted to the national reality and called the Recife Protocol. In this study, we compared the Milwaukee Protocol with the Recife Protocol, assessing the differences and how these differences may change the course of clinical management. METHODS We searched electronic databases for the use of anti-rabies treatments. A total of 65 articles were published between 2004 and 2019. RESULTS: The protocols have similarities in care related to rabies patients and are important for the treatment of patients in intensive care units. Both protocols indicate deep sedation, antiviral use, constant concern with electrolyte balance, and vasoconstriction related to the condition. Many differences were observed in this study. For the Milwaukee Protocol, sedation should be gradually removed after the eighth day, and on the twelfth day, the patient should be without sedation. In the Recife Protocol, in order to avoid immunomodulation, it is recommended to remove sedation according to the titers of neutralizing antibodies to the rabies virus in the cerebral spinal fluid. CONCLUSIONS: In addition to the differences and similarities raised, our findings indicate that these protocols require a large center for rabies treatment, but the disease most often occurs in places where resources and hospital infrastructure are scarce.

Etiology of Coinfections in Children with Influenza during 2015/16 Winter Season in Nepal.

Acute respiratory infections (ARIs) are one of the major public health problems in developing countries like Nepal. Besides the influenza, several other pathogens are responsible for acute respiratory infection in children. Etiology of infections is poorly characterized at the course of clinical management, and hence empirical antimicrobial agents are used. The objective of this study was to characterize the influenza and other respiratory pathogens by real-time PCR assay. A total of 175 throat swab specimens of influenza-positive cases collected at National Influenza Center, Nepal, during the 2015/16 winter season were selected for detecting other respiratory copathogens. Total nucleic acid was extracted using Pure Link viral RNA/DNA mini kit (Invitrogen), and multiplex RT-PCR assays were performed. Influenza A and B viruses were found in 120 (68.6%) and 55 (31.4%) specimens, respectively, among which coinfections were found in 106 (60.6%) specimens. Among the influenza A-positive cases, 25 (20.8%) were A/H1N1 pdm09 and 95 (79.2%) were A/H3 subtypes. Viruses coinfected frequently with influenza virus in children were rhinovirus (26; 14.8%), respiratory syncytial virus A/B (19; 10.8%), adenovirus (14; 8.0%), coronavirus (CoV)-HKU1 (14; 8.0%), CoV-OC43 (5; 2.9%), CoV-229E (2; 1.1%), metapneumovirus A/B (5; 2.9%), bocavirus (6; 3.4%), enterovirus (5; 2.9%), parainfluenza virus-1 (3; 1.7%), and parainfluenza virus-3 (2; 1.1%). Coinfection of Mycoplasma pneumoniae with influenza virus was found in children (5; 2.8%). Most of the viral infection occurred in young children below 5 years of age. In addition to influenza virus, nine different respiratory pathogens were detected, of which coinfections of rhinovirus and respiratory syncytial virus A/B were predominantly found in children. This study gives us better information on the respiratory pathogen profile and coinfection combinations which are important for diagnosis and treatment of ARIs.

Optical Coherence Tomography–Guided Decisions in Retinoblastoma Management

Assess the role of handheld optical coherence tomography (OCT) in guiding management decisions during diagnosis, treatment, and follow-up of eyes affected by retinoblastoma. Retrospective, noncomparative, single-institution case series. All children newly diagnosed with retinoblastoma from January 2011 to December 2015 who had an OCT session during their active treatment at The Hospital for Sick Children (SickKids) in Toronto, Canada. The OCT sessions for fellow eyes of unilateral retinoblastoma without any suspicious lesion and those performed more than 6 months after the last treatment were excluded. Data collected included age at presentation, sex, family history, RB1 mutation status, 8th edition TNMH cancer staging and International Intraocular Retinoblastoma Classification (IIRC), and number of OCT sessions per eye. Details of each session were scored for indication-related details (informative or not) and assessed for guidance (directive or not), diagnosis (staging changed, new tumors found or excluded), treatment (modified, stopped, or modality shifted), or follow-up modified. Frequency of OCT-guided management decisions, stratified by indication and type of guidance (confirmatory vs. influential). Sixty-three eyes of 44 children had 339 OCT sessions over the course of clinical management (median number of OCT scans per eye, 5; range, 1-15). The age at presentation and presence of a heritable RB1 mutation significantly correlated with an increased number of OCT sessions. Indications included evaluation of post-treatment scar (55%) or fovea (16%), and posterior pole scanning for new tumors (11%). Of all sessions, 92% (312/339) were informative; 19 of 27 noninformative sessions had large, elevated lesions; of these, 14 of 19 were T2a or T2b (IIRC group C or D) eyes. In 94% (293/312) of the informative sessions, OCT directed treatment decisions (58%), diagnosis (16%), and follow-up (26%). Optical coherence tomography influenced and changed management from pre-OCT clinical plans in 15% of all OCT sessions and 17% of directive sessions. Optical coherence tomography improves the accuracy of clinical evaluation in retinoblastoma management.

G280 Clinical management for senior paediatric trainees – putting theory into practice:

Background Paediatric trainees have variable training experience in clinical management before they become consultants. While there has been increased awareness in recent years of the need to incorporate this into training, there is no agreed way across all deaneries. Aims To pilot a clinical management course for level 3 trainees (ST6–8) in our deanery with the help of Keele University for 2 years (2012–14). To survey other deaneries on clinical management training for level 3 paediatric trainees. Methods We drew up a 4 day paediatric bespoke clinical management course with Keele University in 2012. The main course topics were history and structure of the NHS, financing healthcare, personality types, leading and motivating teams, leadership style and handling conflict, writing a successful business case and the basics of service improvement projects (SIPS). All attendees were expected to complete a SIP and present it to their group on the last day. We reviewed feedback after 2 cohorts of trainees (total 42) completed the course. An email questionnaire was sent to all paediatric Head of Schools (HOSs) in October 2014. Results Feedback for our course was consistently positive and all trainees felt they gained insight into topics that are not usually covered during their training. They appreciated the main course topics. We received 7 replies to our email questionnaire. 6/7 deaneries allocated an annual £400–£600 study leave budget per senior trainee including life support courses. 4 deaneries provided management courses combined with other specialties but the trainees were not expected to complete SIPs. 3 deaneries did not offer formal course on management. Conclusions After review of feedback, we made a few modifications and have decided to run this course yearly for the next 5 years. A structured clinical management programme by deaneries would improve knowledge and confidence amongst trainees to help lead changes in the future.

Reviewing neurosurgical management of brain metastases : Three case reports

Introduction: Brain metastasis is a major cause of morbidity and mortality in patients with systemic malignancies. Newer imaging and treatment modalities have improved clinical outcome in last few decades.Objective: It reviews recent advances in the field of epidemiology, neuroimaging, neurosurgery, radiation therapy and other interventions affecting the clinical outcome of a patient with brain metastasis.Materials and Methods: Case record files of 3 patients operated by the author were reviewed for analyzing clinical and radiological presentations and outcome following neurosurgical intervention. Pre and post-operative clinical evaluation, neuroimaging, neurosurgical resection and histopathological confirmation of the metastasis followed by chemoradiation therapy were done in all cases.Results: Headache, seizures and neurological deficit were common presentations of patients with brain metastases. MRI brain with Gadolinium enhancement and MR spectroscopy were the investigations of choice. All three patients underwent neurosurgery for tumor decompression and histopathological confirmation of metastasis. Neurosurgery followed by chemoradiation therapy was beneficial in all cases.Conclusion: The course of clinical management of a patient with brain metastasis is guided by the prognostic indicators. About five decades ago, steroids, cerebral decongestants and whole brain radiotherapy (WBRT) was the mainstay of the treatment of brain metastasis. Newer treatment options include brachytherapy, chemotherapy, stereotactic radiosurgery (SRS), stereotactic radiotherapy (SRT), stereotactic biopsy and neurosurgical excision. Aims of the neurosurgical excision are reduction of the intracranial pressure, improvement in neurological status and histopathological confirmation of the diagnosis.

Routine MRI Assessment Immediately Following Transsphenoidal Resection of Nonfunctional Pituitary Macroadenomas Does Not Alter the Course of Clinical Management

Routine MRI Assessment Immediately Following Transsphenoidal Resection of Nonfunctional Pituitary Macroadenomas Does Not Alter the Course of Clinical Management

Ovarian failure in HAX1‐deficient patients: is there a gender‐specific difference in pubertal development in severe congenital neutropenia or Kostmann disease?

Severe congenital neutropenia (SCN) is a rare disorder of myelopoiesis characterized by neutropenia, recurrent bacterial infections and a maturation arrest of the myelopoiesis in the bone marrow. Homozygous mutations in the HAX1 gene were described in patients with autosomal recessive SCN or Kostmann disease. Some of these patients display neurological disease. We noted, during the course of clinical management of patients with Kostmann disease, insufficient pubertal development in female patients, but not in our male patients. The study objective was to provide a detailed account of this phenotype and its possible relation to HAX1 mutations. Detailed clinical histories and laboratory investigations of three patients with Kostmann disease belonging to the original kindred in northern Sweden described by Rolf Kostmann are reported. We report one male patient with normal puberty and two female patients with insufficient pubertal development. Elevated levels of LH and FSH were recorded in both patients. All three patients harbour the same p.Glu190X mutation in the HAX1 gene. We show for the first time that female patients with Kostmann disease display primary gonadal insufficiency. This suggests a possible role for HAX1 in the development and/or function of the human ovary.

A Narrative Review of Evidence‐Based Recommendations for the Physical Examination of the Lumbar Spine, Sacroiliac and Hip Joint Complex

Non-specific low back pain is a frequent complaint in primary care, but the differential diagnosis for low back pain can be complex. Despite advances in diagnostic imaging, a specific pathoanatomical source of low back pain can remain elusive in up to 85% of individuals. Best practice guidelines recommend that clinicians conduct a focused physical examination to help to identify patients with non-specific low back pain and an evidence-based course of clinical management. The use of sensitive and specific clinical methods to assess the lumbar spine, sacroiliac and hip joints is critical for effective physical examination. Psychosocial factors also play an important role in the evaluation of individuals with low back pain, but are not included in this narrative review of physical examination methods. Physical examination of the lumbar spine, sacroiliac and hip joints is presented, organized around patient position for efficient and effective clinical assessment.

A Failure of Heart in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic disease we treat with medications that have systemic effects. It is becoming increasingly clear that patients with RA have accelerated atherosclerosis and that RA is an independent risk factor for the development of atherosclerotic coronary artery disease1. What is less clear is whether the presence of RA and its therapies modulates the course of coronary artery disease and its complications. In this issue of The Journal Myasoedova, et al use their extensive database from the Mayo Clinic to explore heart failure in patients with RA2. The relationship between heart failure and RA is not clear-cut. Some studies suggest that heart failure may be more frequent in patients with RA3, whereas other studies suggest the opposite4. Some of these differences can be explained by the more specific questions that the investigators are asking. Moreover, most studies of this problem are observational and depend on clinical diagnoses made during the course of clinical management, like the one in this issue. Thus, the presence or absence of heart failure is not systematically examined with questionnaires or echocardiograms, for example. This can be problematic in our effort to understand heart failure in RA patients since patients and physicians may ascribe symptoms such as ankle swelling as well as functional limitations to RA that may instead be a consequence of heart failure. Interestingly, … Address correspondence to Dr. Francis; E-mail: mark.francis{at}ttuhsc.edu

A case of a huge placental lake; prenatal differential diagnosis and clinical management

Placental lakes are sonolucent or hypoechoic areas in images of the placenta, usually considered a physiological dilation of intervillous space with a rather good obstetrical outcome. However, diagnostic criteria for and the clinical significance of placental lakes are yet to be completely established, because of a wide variety of ultrasound findings, especially on color Doppler examination. We experienced a case of a huge placental lake, larger than the total placental area, located in an entire retroplacental space, concomitant with several penetrations of artery type blood flow. The antenatal differential diagnosis and course of clinical management are reported.

Clinical management course for staff and associate specialist doctors

Keele University’s clinical management course has been specially developed to meet the needs of staff grade (now specialty) doctors and associate specialist (SAS) doctors in the NHS. The course is intended to help prepare these doctors for a move to consultant posts, and it helps to give a deeper insight into NHS management issues for doctors who are considering article 14 application (certificate of eligibility for specialist registration) to join the General Medical Council’s specialist register. It is not specialty specific and is built on Keele University’s experience of providing clinical management courses for specialist registrars. Before the course, which was a three …

Intrahepatic Air: Pneumobilia vs. Portal Venous Gas

The finding of intrahepatic air on computed tomography scan is a potentially ominous radiographic sign that is usually attributed to either pneumobilia or portal venous gas. In this article, we present a case of each of the aforementioned conditions. Pneumobilia is typically visualized as a large confluence of air located within the central portion of the liver and is most commonly seen in patients following procedures involving the biliary tract. Management may be either surgical or non-operative, depending on the etiology and clinical presentation. Portal venous gas manifests as small air densities in the periphery of the liver located predominantly in the left lobe. This entity is most commonly caused by mesenteric ischemia and carries a mortality rate of 75-90%. Treatment entails emergent laparotomy with possible resection of the affected segment of bowel. In the absence of findings of bowel ischemia, portal venous gas may be managed non-operative. Early diagnosis and treatment is based on correlation of the clinical presentation and a high index of suspicion on radiographic evaluation. CT findings of intrahepatic air should be carefully evaluated to determine an appropriate course of clinical management.