Diagnostic Considerations Research Articles

Serous-like breast carcinomas: immunophenotypic, genetic, and clinicopathologic characterization of a morphologically distinct group of tumours.

Unusual morphologic patterns of breast carcinomas can raise diagnostic consideration for metastasis or special breast cancer subtypes with management implications. We describe rare invasive breast cancers that mimic serous carcinoma of the gynaecologic tract (serous-like breast carcinomas, SLBC) and characterize their clinicopathologic, immunophenotypic, and genetic features. All patients were female (n = 15, median age 49 years) without a history of gynaecologic malignancy. SLBC were characterized histologically by angulated, branched, sometimes anastomosing glands with micropapillary and/or pseudopapillary luminal projections in desmoplastic stroma. Most SLBC were triple-negative (TN, n = 10) or HER2-positive (n = 2) and grade 2 or 3, while some were oestrogen receptor (ER) low-positive/HER2-negative and low-grade (n = 3). CK5/6 was positive irrespective of grade or receptor status (10/10). All SLBC expressed GATA3 (14/15), TRPS1 (7/7), and/or mammaglobin (4/13). SOX10 was positive in most TN (9/10) and all ER low-positive (3/3) cases, but negative in HER2-positive tumours. WT1 was universally negative, and PAX8 was focal in one mammaglobin-positive tumour. All ER-negative SLBC were p53-aberrant and 9/11 were p16-aberrant, whereas ER-positive tumours were wildtype for both markers (3/3). TP53 was the only frequently mutated gene, altered in all ER-negative (10/10) but no ER-positive (0/4) tumours. Clinical behaviour was variable. Only 1/6 patients achieved pathologic complete response to neoadjuvant chemotherapy. SLBC is a rare morphologic pattern of invasive breast carcinoma that mimics metastatic serous gynaecologic carcinoma, a potential diagnostic pitfall. SLBC are heterogeneous with respect to grade, receptor profile, and oncogenic driver alterations, without specific genetic underpinnings identified. Additional studies are warranted to further evaluate the clinical behaviour of these tumours.

Cardiovascular Disease in Patients with Chronic Kidney Disease: Current Understanding, Preventative Strategies, and Future Directions.

Chronic kidney disease (CKD) presents a significant burden on global health, with cardiovascular disease (CVD) being a leading cause of mortality in this population. Despite advancements in pharmacotherapies, preventing CVD in CKD patients remains challenging due to the intricate interplay of traditional risk factors and novel pathophysiological processes. This review aims to elucidate the current understanding of CVD prevention in CKD, encompassing epidemiology, risk factors, diagnostic considerations, and pharmacological therapeutic strategies. CKD patients exhibit a unique cardiovascular risk profile characterized by traditional risk factors such as hypertension and dyslipidemia, as well as CKD-specific factors including albuminuria, vascular calcification, and valvulopathies. The utility of coronary artery calcium scoring in risk stratification and the efficacy of aspirin, lipid-lowering agents, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, and nonsteroidal mineralocorticoid receptor antagonists in CVD prevention are discussed. Despite promising findings, challenges such as lack of specific guidelines and data gaps persist, highlighting the need for multidisciplinary efforts to address the CVD burden in the CKD population effectively. Further research is warranted to optimize preventative strategies and improve outcomes in this high-risk population.

Smoking-Related Interstitial Lung Disease: CT Image-Based Review and Update

Tobacco smoking is the leading cause of preventable deaths in the United States. Beyond the risks of cardiovascular disease and several cancers, smoking contributes to lung inflammation, lung destruction, and smoking-related interstitial lung diseases (SRILD). SRILD describes a broad range of conditions that includes respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, acute eosinophilic pneumonia, idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, interstitial lung abnormality, and smoking-related interstitial fibrosis. Computed tomography (CT) is central to the diagnosis and understanding of clinicopathologic manifestations of smoking-related lung injury. Common features of SRILD on CT include low-attenuation areas, ground-glass opacities, fibrosis, and lung nodules. Although the various SRILDs are often described as distinct entities, they may manifest with nonspecific features or exhibit mixed patterns and may more accurately be described as a continuum of pathology. Understanding the broad range of radiologic features and recognizing the potential coexistence and overlap of disease processes is essential to maintaining an appropriate differential diagnosis. In this article, we review the radiologic findings associated with SRILDs with a focus on diagnostic considerations and challenges when interpreting CT images.

Safety considerations for spinal surgery in patients with deep brain stimulation devices

PurposeDeep brain stimulation (DBS) has been performed for various brain disorders. However, spinal surgery in patients with DBS was been approached with cautious trepidation due to risk of thermal brain injury and device damage from coagulation devices during surgery. This study presents the cases of successful spinal surgery performed after DBS implantation. MethodsWe retrospectively reviewed the patients who received spinal surgery after DBS implantation between April 2001 and November 2022. We reviewed their demographic data, preoperative evaluations, and surgical strategies employed. ResultsAmong 348 patients who underwent DBS implantation, eight patients received spinal surgery. The methods used for diagnosing their spinal conditions varied: two cases of computed tomography (CT) myelogram, one case of CT scan with pre-DBS magnetic resonance imaging (MRI), one case of CT scan only, and four cases of post-DBS MRI. The location of the spinal surgery were one case of cervical spinal surgery, three cases of thoracolumbar spinal surgery, and four cases of lumbar spinal surgery. We followed diagnostic study guidelines and safety considerations tailored to each surgical step. Monopolar and bipolar coagulation devices were used when necessary. There were no cases of complications caused by spine surgery regarding DBS function or DBS implanted site. ConclusionCareful execution of surgical procedures, adherence to safety guidelines, and the use of MRI for diagnosis can ensure safe and successful spinal surgery in patients with DBS implants, minimizing the risk of damage to the DBS system and the brain.

Selective Mutism in the Context of Autism and Bilingualism.

Juan is a 5-year-old boy who has been followed by a developmental-behavioral pediatrician and pediatric neuropsychologist since being diagnosed with language delay and autism spectrum disorder at age 2 years. He is otherwise healthy and was born at term after a healthy pregnancy. His primary language is Spanish, and he has minimal interactions in English. His first words were at 20 months; they were not functional but rather words related to his interests such as "train." He began using 2 to 3-word phrases shortly after but only to request needs. He began speaking in complete sentences at age 4 years.A neuropsychological evaluation was conducted at age 2 years during which Juan demonstrated repetitive behaviors such as hand-flapping, toe-walking, body rocking, and head banging. He displayed sensory seeking behaviors such as rubbing items on his face and close visual inspection. He did not respond to his name and his use of eye contact was inconsistent. He demonstrated rigidity and difficulty transitioning between activities. He did not engage in social reciprocity, and his facial expressions were limited. Minimal spontaneous language was observed, and expressive language largely consisted of echolalia in both languages. Juan was diagnosed with autism spectrum disorder and applied behavior analysis, speech and language therapy, and occupational therapy were recommended.Developmental-behavioral follow-up over the next 2 years noted improvements in behavior, transitions, and social interactions. He participated in early childhood intervention and early childhood special education with significant advances for speech and language in English and Spanish, demonstrating a large vocabulary. At 4 years, parents noted Juan to have reluctance to speak in English. He stopped speaking in English entirely for 3 weeks, though he continued to speak in Spanish. When he resumed speaking in English, it was only with people he knew well (e.g., parents, teachers, babysitter). In clinic, he did not speak to the English-speaking developmental-behavioral pediatrician but spoke in short sentences to the Spanish-speaking neuropsychologist.A repeat neuropsychological evaluation completed at age 5 years revealed that Juan had stopped speaking in English completely, even among those previously deemed "safe." Results were consistent with average cognitive abilities with a strength in verbal skills. Juan's single-word vocabulary in Spanish was exceptionally high. He did not provide expressive responses in English, but his receptive English vocabulary was high average. He responded to English language with nonverbal gestures or spoken language in Spanish. Parents reported Juan to display increased anxiety accompanied by extreme school refusal, behavioral difficulties, and reluctance to leave the home.Given this information, what are your diagnostic considerations and treatment recommendations?

DSOG Guideline Bulletin: Diagnostic approach for patients with endometriosis

The aim of this guideline was to update an existing guideline from 2012. An update was evident due to the scientific progress and political focus on endometriosis in recent years. Based on recent evidence, we aimed to provide clinical recommendations for training and use of ultrasound, magnetic resonance imaging (MRI), computed tomography, and diagnostic scoring systems, as well as diagnostic considerations when evaluating patients suspected for endometriosis. Current literature was searched for consensus and discrepancies. A total of eight research questions were formulated to review different aspects, when diagnosing endometriosis. The level of evidence was graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence and up- or downgraded depending on the study quality. According to the current literature, no diagnostic imaging tool can replace histologic verification of endometriosis except ultrasound when diagnosing lesions in the abdominal wall. Skills for diagnosing endometriosis in the posterior compartment with transvaginal ultrasound (TVUS) can be achieved within 50-60 scans. TVUS seems equivalent to MRI when endometriosis is suspected in the vagina, the sacrouterine ligaments, the rectovaginal fascia, and the rectosigmoid. Additionally, ultrasound has a high sensitivity for diagnosing endometriotic lesions in the abdominal wall, while MRI seems superior for deep infiltrating endometriosis (DIE) in the bladder, the ureter, the lumbosacral plexus, lungs and oral segment of the colon starting from the rectosigmoid. No biomarkers are currently recommended for diagnosing endometriosis. When considering bowel involvement, 60-96% of DIE in the colon is localized in the rectum with decreasing rates in the oral segments with a prevalence of affected appendix of 2.6-4.1%. Measuring the distance from the anocutaneus transition to the nodule is feasible with TVUS. The most promising grading systems for endometriosis are the EFI, #ENZIAN and AAGL scoring systems. The level of evidence across studies ranged from 1b to 5.

Giant Angiomyofibroblastoma With a Florid Lipomatous Component: A Report and Review of Diagnostic Considerations.

Angiomyofibroblastoma is a benign, usually small neoplasm typically constituted by spindle-shaped and epithelioid cells in a vascularized, myxoid-fibrous stromal background. It is most often seen in the superficial genitalia of female patients of reproductive age. However, various clinical and histologic features have been reported, including tumors in male patients, malignant transformation, extragenital sites, huge sizes, and a prominent lipomatous pattern. We report the clinical and pathologic features of one such tumor: a 23.5 cm lipomatous angiomyofibroblastoma of the vulva in a 40-year-old female patient. We also discuss important diagnostic considerations when approaching such large tumors, particularly in the setting of a biopsy specimen.

Malignant Brenner Tumor of the Ovary: A Critical Reappraisal

Malignant Brenner tumors (MBTs) are rare epithelial tumors of the ovary, most likely arising from benign and borderline Brenner tumors. MBTs may be misdiagnosed as other primary carcinomas or nonepithelial tumors of the ovary as well as metastatic carcinomas. Accurate diagnosis usually requires clinical-radiologic correlation, extensive sampling, and immunohistochemical studies. Treatment is not standardized and may include surgery with or without chemotherapy. More than half of MBTs are diagnosed at stage I, with 47.7% and at least 20% recurrence and mortality rates, respectively. Awareness of key diagnostic features and pitfalls is essential to differentiate MBT from its mimics and ensure optimal clinical management. This comprehensive review includes classification, etiopathogenesis, historical overview, epidemiology, clinical features, treatment, prognosis, gross pathology, key morphologic features, ancillary testing, and differential diagnostic considerations for ovarian MBTs.

How Eyelid Changes May Impact on Tears.

This article examines the impact of eyelid margin diseases on tear film composition and associated ocular surface disorders. It highlights the prevalence of blepharitis and meibomian gland dysfunction, discussing risk factors and diagnostic considerations. Various therapeutic approaches, including eyelid hygiene, antibiotics, and innovative treatments, are explored. Emphasizing the chronic nature of these conditions, the article underscores the need for patient compliance. Overall, it provides a concise overview of eyelid-related issues and potential management strategies.

Intercontinental insights into autism spectrum disorder: a synthesis of environmental influences and DNA methylation

Abstract Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder characterized by a broad range of symptoms. The etiology of ASD is thought to involve complex gene–environment interactions, which are crucial to understanding its various causes and symptoms. DNA methylation is an epigenetic mechanism that potentially links genetic predispositions to environmental factors in the development of ASD. This review provides a global perspective on ASD, focusing on how DNA methylation studies may reveal gene–environment interactions characteristic of specific geographical regions. It delves into the role of DNA methylation in influencing the causes and prevalence of ASD in regions where environmental influences vary significantly. We also address potential explanations for the high ASD prevalence in North America, considering lifestyle factors, environmental toxins, and diagnostic considerations. Asian and European studies offer insights into endocrine-disrupting compounds, persistent organic pollutants, maternal smoking, and their associations with DNA methylation alterations in ASD. In areas with limited data on DNA methylation and ASD, such as Africa, Oceania, and South America, we discuss prevalent environmental factors based on epidemiological studies. Additionally, the review integrates global and country-specific prevalence data from various studies, providing a comprehensive picture of the variables influencing ASD diagnoses over region and year of assessment. This prevalence data, coupled with regional environmental variables and DNA methylation studies, provides a perspective on the complexities of ASD research. Integrating global prevalence data, we underscore the need for a comprehensive global understanding of ASD’s complex etiology. Expanded research into epigenetic mechanisms of ASD is needed, particularly in underrepresented populations and locations, to enhance biomarker development for diagnosis and intervention strategies for ASD that reflect the varied environmental and genetic landscapes worldwide.

The Limping Child: A Guide for the Trainees.

Limping is a common presenting complaint in children. Despite this, it remains to be a diagnostic challenge for treating physicians due to an expanded list of etiologies. It arises from a spectrum of disorders, ranging from physiological variations of gait at different stages of development to systemic causes, such as inflammatory diseases or musculoskeletal infections. On rare occasions, non-musculoskeletal causes could result in limping. The diagnostic challenge increases in younger age children where a detailed physical examination that helps identify the exact source of pathology may not be possible. In older patients who have a well-developed gait cycle, the physical assessment might be easier. Clinical assessment in a child presenting with a limp includes gait analysis, which is essential to guide the appropriate request of diagnostic laboratory tests and imaging studies. In this paper, we provide a practical guide for a trainee in General Pediatric and Pediatric Rheumatology on an approach to a limping child, aiming to identify the common causes of limping and to describe normal and abnormal gait cycles. We also discuss other diagnostic considerations in the assessment of these children.

Coronary Artery Vasculitis and Encasement: Multimodality Imaging Findings and Mimics.

Coronary artery vasculitis (CAV) and coronary artery encasement are rarely diagnosed conditions that are important diagnostic considerations, particularly in patients with acute coronary syndrome without traditional cardiovascular risk factors or systemic illness. Vasculitis refers to inflammation of the blood vessel walls, which can be primary or secondary. This process should be distinguished from neoplastic involvement of the coronary arteries, termed coronary artery encasement. Prospective diagnosis of these diseases is challenging, often requiring multidisciplinary workup with careful attention to clinical presentation and multiorgan findings. While CAV and coronary artery encasement can be indistinguishable at coronary CT angiography, certain imaging features help order the differential diagnosis. CAV should be considered when there is smooth wall thickening that is circumferential and/or continuous. A diagnosis of coronary artery encasement is favored when there is irregular or nodular wall thickening that is eccentric to the vessel lumen. Epicardial fat stranding may also appear more extensive compared with CAV. Potential mimics of CAV include atherosclerosis, acute plaque rupture, coronary artery aneurysm, and spontaneous coronary artery dissection. Detection and diagnosis of CAV may help avoid complications related to accelerated atherosclerosis and infarction. Radiologists should be familiar with the range of pathologic conditions that can affect the coronary arteries beyond atherosclerosis as they may be the first to raise such diagnostic possibilities, guiding next steps in patient workup and management. ©RSNA, 2024 Supplemental material is available for this article.

Extensive pathological ST-T segment abnormalities in an asymptomatic middle-aged male: diagnostic and differential diagnosis considerations

Extensive pathological ST-T segment abnormalities in an asymptomatic middle-aged male: diagnostic and differential diagnosis considerations

Acquired hemophilia A: a narrative review and management approach in the emicizumab era

Acquired hemophilia A (AHA) is a rare bleeding disorder caused by inhibitory autoantibodies to factor (F)VIII. The goals of treatment are 2-fold, namely immunosuppressive therapy to eradicate the inhibitor and hemostatic management to control bleeding. Emicizumab, a bispecific antibody that acts as a FVIIIa-mimetic, has seen growing use in AHA following its approval for congenital hemophilia A. This review provides an overview of the epidemiology, pathophysiology, diagnosis, and treatment of AHA. Registry, trial, and case series data are assimilated and summarized with an emphasis on a standardized approach that integrates the use of emicizumab. With recent registry data suggesting the need to focus on immunosuppression-related mortality in AHA, we provide treatment recommendations in an algorithmic format that have become the standard of care at our institution. These recommendations are intended to minimize hemostatic product usage and potential toxicity related to immunosuppressive therapy while reducing morbidity and rehospitalization rates for bleeding. The proposed treatment algorithm, which includes key interventions by phase of therapy, can be readily implemented at centers that have rapid access to plasma FVIII activity using a one-stage assay. A case is presented to illustrate the proposed diagnostic and management considerations.

Metastatic Mesothelioma of the Tunica Vaginalis Presenting as Scrotal and Abdominal Nodules: A Case Report and Review of the Literature.

Mesothelioma of the tunica vaginalis testis (MMTVT) is a rare neoplasm comprising <3% of all cases of malignant mesothelioma (MM). MMTVT derives from the tunica vaginalis testis, an outpouching of the mesothelial-lined abdominal peritoneum that detaches from the abdominal cavity after the descent of the testis. Similar to pleural mesothelioma, asbestos exposure is a known risk factor. However, MMTVT has a better prognosis than pleural mesothelioma. Cutaneous metastases from MMTVT are exceedingly rare. Herein, we describe a case of a 67-year-old man with a history of asbestos exposure presenting with scrotal pain and indurated plaques on his lower abdomen and scrotum. Histologic sections showed a sheet-like dermal proliferation comprising epithelioid cells with necrosis and increased mitotic activity. The clinical and histologic differential diagnosis was broad, including metastatic carcinoma, melanoma, sarcoma, germ cell tumor, hematologic malignancy, neuroendocrine carcinoma, and malignant mesothelioma. By immunohistochemistry, the neoplastic cells were positive for WT1, D2-40, and AE1/AE3, with rare positivity for calretinin, consistent with a diagnosis of mesothelioma. Additional immunohistochemical studies provided no support for the other diagnostic considerations listed above. BAP1 showed retained nuclear expression (normal) by immunohistochemistry. A DNA sequencing panel identified copy number losses in CDKN2A, MTAP, CDKN2B, and NF2, which are frequently identified genetic alterations in malignant mesothelioma. Subsequent testicular imaging demonstrated a diffusely thickened scrotal wall with an enlarged left testicle. Overall, this represents a case of malignant mesothelioma presenting with cutaneous metastases to the scrotum and lower abdomen, with clinical and imaging features suggestive of primary MMTVT. The International Mesothelioma Interest Group recommends using at least 2 mesothelial markers, such as calretinin, WT1, CK5/6 or D2-40, and 2 epithelial markers, such as claudin-4, CEA, MOC-31, as well as a broad-spectrum cytokeratin stain (AE1/AE3) as part of an initial immunohistochemical panel. Metastatic mesothelioma should be included in the differential diagnosis of malignant epithelioid dermal tumors with unusual staining patterns.

SOX17 Expression in Mesotheliomas and Benign Mesothelial Proliferations: Implications for Differential Diagnosis With Gynecologic Carcinomas.

SOX17 has recently emerged as a novel immunohistochemical marker for cancers of endometrial and ovarian origin with improved specificity compared with the widely used Mullerian marker PAX8. However, evaluation of SOX17 in benign and malignant peritoneal mesothelial proliferations remains limited, and these may mimic gynecologic carcinomas, particularly on small biopsies. We evaluated SOX17 and PAX8 expression in 20 benign mesothelial lesions (5 adenomatoid tumors, 5 well-differentiated papillary mesothelial tumors, and 10 peritoneal inclusion cysts) and 16 epithelioid peritoneal mesotheliomas. The 17 female and 3 male patients with benign mesothelial lesions ranged from 20 to 80yr (median: 56.5yr), while the 9 females and 7 males with mesothelioma ranged from 47 to 85yr (median: 57.5yr). SOX17 was positive in 5 (25%) benign lesions (2 adenomatoid tumors, 3 peritoneal inclusion cysts) and 2 (13%) mesotheliomas, while PAX8 stained 8 (40%) benign lesions (1 adenomatoid tumor, 1 well-differentiated papillary mesothelial tumor, 6 peritoneal inclusion cysts), and 2 (13%) mesotheliomas. Results for the 2 stains showed incomplete concordance, with agreement in 15 (75%) benign proliferations and 14 (88%) mesotheliomas. Our findings suggest that SOX17 positivity alone is insufficient to confirm a diagnosis of gynecologic carcinoma over a mesothelial proliferation and pathologists should exercise caution when these entities are diagnostic considerations.

A sex-based analysis of complete blood count features during acute, untreated Lyme disease.

Although lymphopenia has been described in acute Lyme disease (LD), the complete blood count (CBC) has not been comprehensively examined, nor have sex-based analyses been conducted. We analyzed CBC values and identified sex-based trends among patients with early LD by comparing both to controls without a history of LD and to patients' pre-morbid values. We enrolled participants from the Mid-Atlantic US with diagnostic erythema migrans and controls with no history of LD. CBC results were obtained, and patient information was recorded using standardized instruments. We also calculated a neutrophil-to-lymphocyte ratio (NLR). We used linear regression to test that CBC results would differ (a) between antibiotic-naive patients with early LD and controls and (b) by measures of acute disease severity. We also performed stratified analyses to assess sex-based differences. In total, 236 antibiotic-naive patients with early LD had significantly lower lymphocytes (β = -0.34, p < 0.001) and significantly higher monocytes (β = 0.09, p = 0.002) and NLRs (β = 0.99, p < 0.001) than 61 controls in adjusted analyses. Lymphocytes, monocytes, and NLRs also changed significantly from pre-morbid to acute LD (p < 0.001 for all). Only the NLR was consistently significantly associated with disease severity. A higher proportion of male patients with early LD had acute lymphopenia than female patients with early LD (31.93% vs. 19.66%, p = 0.03); this difference was not present among controls. The presence of lymphopenia and the absence of an elevated total white blood cell count make LD an important diagnostic consideration in patients presenting with undiagnosed infectious syndromes in endemic regions. This may be especially true for male patients.

Diagnostic considerations and orthodontic treatment approaches of adolescents with the dentoalveolar form of class II malocclusion

Relevance. Class II malocclusion (distal occlusion) is a common pathology of the maxillofacial region in the sagittal plane and is one of the most prevalent malocclusions. Studies confirm that Class II malocclusion in adolescents exhibits significant variability, prompting the development of various treatment approaches using both removable and fixed orthodontic appliances. The challenges of adolescence include concurrent physiological and psychological changes, which can complicate the treatment process.Purpose. To enhance the effectiveness of orthodontic treatment for patients with the dentoalveolar form of Class II malocclusion by utilizing the Rotation-Torque Index (RTI).Material and methods. A study was conducted on 49 residents of St. Petersburg with physiological occlusion types, who were included in the control group. The main group comprised 95 adolescents (aged 12-18) with the dentoalveolar form of Class II malocclusion classified into three levels of severity, based on the proposed working prognostic classification.Results. A new method was developed to calculate a coefficient that describes the relationship between the position of the upper and lower jaws and the torque of the central incisors. This coefficient helps predict treatment outcomes and guides the selection of the optimal treatment strategy. The Rotation-Torque Index (RTI) was introduced to quantify the relationship between the position of the jaws in the skull (SNA, SNB) and the inclination of the central incisors of the upper jaw relative to the nasal line (NL) and those of the lower jaw relative to the mandibular line (ML).Conclusions. Based on the Rotation-Torque Index (RTI), a working prognostic classification and treatment strategies for patients with the dentoalveolar form of Class II malocclusion were proposed.

Distribution Patterns of Tumors and Tumor-Like Lesions of the Forefoot and Midfoot A 12.5-Year Study at a University Hospital.

Masses in the forefoot and midfoot are common reasons for medical presentation and can be caused by various pathological conditions. The challenge in clinical practice is to distinguish the multitude of trivialities from the few malignant entities and to arrive at a reliable clinical diagnosis in a reasonable amount of time with a moderate use of diagnostic tools. In a retrospective analysis, tumors, tumor-like lesions, and pseudotumors distal to the Chopart joint presented to our multidisciplinary university tumor board between January 2010 und June 2023 were analyzed concerning entity, location, age, and sex. Of the 167 cases included, 18 were osseous and 149 were soft tissue lesions. Overall, the metatarsal region was most frequently affected, accounting for 42.5% of all cases. Osseous lesions showed a preference for the phalanges and soft-tissue lesions occurring more frequently in the metatarsal region. In total, 88.0% of all cases were benign. All 20 malignant cases derived from soft tissue, occurred in all sections of the forefoot and midfoot and comprised 13 entities. Most lesions affected middle-aged patients, but cases occurred in almost every age group. In the examined patient population of a German university hospital, most cases were benign soft tissue lesions with a substantial share of pseudotumors and tumor-like lesions. However, the malignancy rate of 12.0% highlights the importance of differential diagnostic considerations. In cases of uncertain results, it is crucial to refer individuals with unclear masses to a specialized center for musculoskeletal tumor care early on in their treatment process. III.

Traumatic brain injury rehabilitation for warfighters with post-traumatic stress.

While there is extensive empirical support and clinical guidance for the treatment of mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) individually, less is known about treating the comorbid presentation of both conditions. The purpose of this review article is to provide information on the mental health treatment needs of service members (SMs) engaged in traumatic brain injury (TBI) rehabilitation. It also aims to offer a framework for an integrated treatment approach to address the cognitive and psychological health needs of warfighters. We review the prevalence and outcomes associated with comorbid TBI and PTSD and present relevant access to care considerations. Additionally, we identify an integrated approach to TBI treatment which takes psychological trauma into consideration. We introduce a trauma-informed care (TIC) model with specified diagnostic and treatment considerations for the service member and veteran (SM/V) communities. TIC is a strengths-based framework that raises the system-wide awareness of treatment facilities to the impact of psychological trauma on behavioral health. A comprehensive diagnostic approach is recommended with considerations for symptom etiology. Clinical considerations derived from available guidelines are identified to meet critical treatment needs for SM/Vs presenting for TBI treatment with a remote history of mTBI and psychological trauma or known PTSD. Clinical practice guidelines are used to inform an integrated TBI treatment model and maximize rehabilitation efforts for warfighters. Given the prevalence of comorbid TBI and PTSD among SM/Vs and its impact on outcomes, this review presents the integration of appropriate diagnostics and treatment practices, including the incorporation of clinical practice guidelines (CPGs) into TBI rehabilitation.