Diagnostic Principles Research Articles

8282 A Diagnostically Challenging Case of Ectopic ACTH Secreting Pancreatic Neuroendocrine Tumor Presenting with Cushing’s Syndrome

Abstract Disclosure: O.A. Aluko: None. S. Patel: None. S.V. Silparshetty: None. T. Gallagher: None. Introduction: Ectopic ACTH mediated Cushing’s syndrome is an uncommon but treatable condition that poses time constrained diagnostic and therapeutic challenge due to severe morbidity as illustrated by our case below. Clinical case:A 65-year-old male was admitted with profound generalized weakness. He became restricted to wheelchair from being able to hike a trail at Yosemite national park 8 weeks prior. Recent history included hospitalization with uncontrolled diabetes and hypertension, new vertebral compression fractures, AKI, hypokalemia, proximal myopathy, anasarca, upper GI bleed and acute upper extremity DVT. Initial testing there revealed hypercortisolemia, elevated ACTH and a normal pituitary MRI. Further workup at our center revealed elevated 24hr urinary cortisol 2598 (n = 5 - 64 μg/24hr), random cortisol 55 (n= 4.2 -22.4 μg/dL) with elevated ACTH 194 (n= 7.2 - 63.3 pg/mL) consistent with ACTH dependent hypercortisolism. IPSS deferred due to AKI, underlying comorbidities and severe cervical stenosis with myelopathy. ACTH and cortisol remained elevated with an 8mg dexamethasone suppression test suggesting ectopic source ACTH. CT with contrast of chest, abdomen and pelvis showed 5mm right lower lobe lung nodule and bilateral adrenal nodularity. Bronchoscopic FNAC was negative for NET.Ketoconazole 400 mg twice daily was started pending localization of culprit lesion with improvement in 24 hr urinary cortisol to 554μg/24 hr however this was stopped within 4 weeks due to acute transaminasemia. Repeat imaging with Gallium-68 dotatate PET CT showed a 1.8 X 2.4 X 1.7 cm pancreatic mass. He underwent distal pancreatectomy with splenectomy. Pathology confirmed a 2.2cm well differentiated neuroendocrine tumor limited to the pancreas with immunohistochemistry strongly for ACTH and weakly for Gastrin. Postoperatively, patient was given hydrocortisone replacement. ACTH was 14.3 pg/mL and cortisol 6.2μg/dL a few weeks later. His diabetes, hypertension, hypokalemia, transaminasemia and proximal myopathy improved. Discussion:Ectopic ACTH mediated Cushing’s syndrome is responsible for about 5 - 20% of all Cushing’s syndrome cases. Pancreatic neuroendocrine tumor secreting Ectopic ACTH is rarer but can be aggressive. Clinical presentation can be confounding due to secretion of >1 neurohormone i.e ACTH and Gastrin in our patient. Gallium-DOTATATE PET/CT tracer has a very high sensitivity and specificity. Early use of this imaging may prevent comorbidity and mortality as surgical resection of ectopic ACTH secreting neuroendocrine tumor is first line therapy. Other diagnostic principles to consider are that severely elevated ACTH levels correlate only with a pituitary macroadenoma, IPSS is invasive and has relative contraindication in sick patients and Desmopressin stimulation test is not widely available. Presentation: 6/1/2024

Upper Extremity Stress Fractures.

Stress injuries are often missed secondary to their insidious onset, milder symptoms, and subtle or initially absent findings when imaged. This review aims to provide strategies for evaluating and treating upper extremity stress fractures. This article outlines the classic presentation of each fracture, the ages during which these injuries often occur, the relevant anatomy and biomechanics, and the mechanism of each injury. Diagnostic imaging and management principles are also discussed, including the use of conservative versus surgical management techniques. Upper extremity stress fractures are often mild injuries that resolve with conservative management but can lead to more serious consequences if ignored. Given their increasing incidence, familiarity with diagnosis and management of these injuries is becoming increasingly pertinent.

Chinese expert consensus on the pathological diagnosis of interstitial lung disease with transbronchial lung cryobiopsy specimens

Transbronchial lung cryobiopsy (TBLC) is an applicable technique that can provide a histologic diagnosis of interstitial lung disease(ILD). The general sample size of TBLC is much smaller than that of surgical lung biopsy (SLB), which raises more concerns about the procedure's diagnostic accuracy. A guiding consensus and guidelines on the pathological procedure of ILD with TBLC are required to better guide pathologists in diagnostic practice. The Respiratory Pathology Working Group of the Respiratory Physicians Branch of the Chinese Medical Doctor Association and the Thoracic Diseases Group of the Pathological Branch of the Chinese Medical Association, jointly organized by experts, have worked together to discuss and formulated the consensus. The consensus is based on literature review, clinical practice, collection of clinical issues, and discussion during a series of meetings. Experts approved the final proposed consensus with more than 70% of votes in favor (Delphi). The consensus summarized the delivery requirements, quality evaluation and artificial phenomena of TBLC specimens. It also proposed the diagnostic principles and procedures, types of ILD corresponding to major pathological changes, and major corresponding differential diagnoses of TBLC specimens. Finally, the consensus formed 14 recommendations for clinical diagnosis and multidisciplinary discussion.The recommendations are addressed as follows.Recommendation 1: We suggest that the TBLC clinical manipulators should observe and measure the size of the specimen in time. The specimen size should be greater than 5 mm in diameter, and multiple pieces(3 to 5 pieces)are recommended.Recommendation 2: Pathologists should record the number of blocks of tissue submitted for examination and the volume, color, and texture of each specimen. Evaluation of the proportion of alveolar parenchyma/airway components under the microscope, analysis of the type and distribution of lesions will facilitate making diagnostic suggestions.Recommendation 3: The size of TBLC specimens is significantly smaller than SLB and may not show sufficient features of ILD or secondary changes. It is more necessary to combine the evaluation of clinical changes and lesion distribution assessed by HRCT for a comprehensive diagnosis.Recommendation 4: Common microscopic artefacts of TBLC specimen are mass of red blood cells, proteinaceous fluid and fibrin exudation. In the absence of hemosiderin cells or clinical signs of hemoptysis symptoms, the diagnosis of pulmonary hemorrhagic disease should be considered with caution.Recommendation 5: TBLC is not a suggested diagnosis when the pathological changes are mainly located in the pleural or subpleural lung tissues, e.g., pleuroparenchymal fibroelastosis.Recommendation 6: The principle of pathological diagnosis of ILD in TBLC is consistent with SLB, with a description of the main pathological morphological change and a tendentious pathological diagnosis; if the lesion is not fully shown, only a pathological description is given.Recommendation 7: A well-sampled TBLC specimen may show patchy fibrosis and fibroblast foci in UIP, supporting a pathological diagnosis of a probable UIP pattern. TBLC may not display sufficient features of the distribution of subpleural and peripheral lung lesions in UIP, as well as secondary lesions.Recommendation 8: TBLC specimens show diffuse inflammation and fibrosis with well-preserved lung tissue structure, which may support a pathological diagnosis of NSIP; if the distribution of lesions and lung tissue structure are difficult to evaluate, it is recommended that a pathological diagnosis of fibrotic ILD or cellular ILD be made.Recommendation 9: TBLC specimens may show pathological features of NSIP accompanied by organization, but it is difficult to accurately evaluate the proportion of organization area. In this scenario, a descriptive diagnosis of NSIP accompanied by organization is suggested.Recommendation 10: It is recommended to diagnose organizing pneumonia if only distal airway organization is present in TBLC; in addition to organization, if pathological histology is accompanied by obvious interstitial fibrosis and lung tissue remodelling, granuloma formation, obvious neutrophil infiltration or accompanied with abscess formation, obvious eosinophil infiltration, tissue necrosis, hyaline membrane formation or vasculitis, secondary OP should be considered.Recommendation 11: It is recommended to diagnose acute fibrinous and organizing pneumonia (AFOP) if lesions on TBLC show features of organizing pneumonia and fibrin balls.Recommendation 12: A diagnosis of smoking-related ILD (RB-ILD or DIP) is suggested when a good sampling of TBLC shows a significant accumulation of histocytes or smoker's macrophages in the alveolar spaces, and without specific changes sufficient for other diagnoses. If the lesions are confined to the lumen of respiratory bronchioles and the immediate peribronchiolar airspaces, RB-ILD is supported; if the distribution is diffuse, DIP should be considered. If it is difficult to determine the distribution of the lesions, it is necessary to integrate clinical and chest CT imaging findings to differentiate RB-ILD from DIP.Recommendation 13: A well-sampled TBLC specimen can display the pathological features of DAD and then also support such a pathological diagnosis.Recommendation 14: Lymphoid interstitial pneumonia (LIP) should show diffuse lymphocyte infiltration and lymphoid follicle formation in the lung interstitium in TBLC specimens. It is recommended that chest CT imaging be combined to determine whether the lesion is diffuse to differentiate from other lymphoproliferative diseases.

Comment on "Chinese expert consensus on the pathological diagnosis of interstitial lung disease with transbronchial lung cryobiopsy specimens"

As one of the pathological biopsy methods, the transbronchial lung cryobiopsy (TBLC) for interstitial lung disease has been widely used in clinical practice. While TBLC causes less trauma or complications for patients than surgical lung biopsy (SLB), pathologists are sometimes less confident in making diagnosis due to the smaller specimen size of TBLC. In an effort to alleviate the problem, this issue of the journal published "Chinese expert consensus on the pathological diagnosis of interstitial lung disease with transbronchial lung cryobiopsy specimens". The consensus addressed issues related to TBLC delivery, quality evaluation, artificial phenomena, and pathological diagnostic principles. More importantly, physicians and pathologists need to work together to improve the diagnosis of TBLC.

The latest IC3D classification of corneal dystrophies-Overview and changes of the 3rd edition

The International Committee on Classification of Corneal Dystrophies (IC3D) was founded in 2005 to address difficulties arising from the outdated nomenclature for corneal dystrophies (CD) and to correct misconceptions in the literature. For each of the 22CDs, aseparate template was created to represent the current clinical, pathological and genetic knowledge of the disease. In addition, each template contains representative clinical photographs as well as light and electron microscopic images and, if available, confocal microscopic and coherence tomographic images of the respective CD. After the first edition was published in 2008, the revised version followed in 2015. The third edition of the IC3D was published as open access in February 2024. The latest edition is intended to serve as areference work in everyday clinical practice and facilitate the diagnosis of CD, which might sometimes be difficult. This article provides an overview of the diagnostic and treatment principles of CD and presents the IC3D and its changes over time.

Ayurvedic management of Schizophrenia (Unmada) – A case report

Schizophrenia is a chronic, severe mental disorder with symptoms such as hallucinations, delusions, and lack of emotional expression requiring lifelong care and treatment to help people manage their symptoms. Treatment usually involves medications, psychotherapy, and social support. Antipsychotics are the management of choice. In Ayurveda, symptoms of schizophrenia resemble with those explained under Unmada, which is manifested due to derangement of the mind caused by imbalance or vitiation of Doshas. Yuktivyapashraya chikitsa along with Satvavajaya plays an important role in improving the symptoms and thereby the quality of life of patients. This report deals with a case of Schizophrenia, which was diagnosed as Kaphaja pittanubandha unmada according to the diagnostic principles of Ayurveda. A 36-year-old male patient presented with increased anxiety, decreased sleep, and mingling with others and was assessed using the Positive and Negative Syndrome Scale (PANSS). Panchakarma procedures including Virechana, Nasya, and Basti along with internal Ayurvedic medicines were given and improvement was noted in symptoms. Scores in the PANSS scale before and after the treatment were 79 and 59, respectively, inferring the importance of Ayurveda management approaches in addressing manifestations like Schizophrenia.

Sleep disorders and diabetes mellitus. Literature review and own data

The article presents analysis of current research on sleep disorders in patients with type 2 diabetes mellitus (T2DM). The mechanisms underlying the relationship between insomnia and glycemic control are complex, as both DM can cause sleep disorders and insomnia can worsen the course of diabetes. It is well known that both short (< 6 hours) and long (> 8 hours) sleep durations are associated with an elevated risk of diabetes development. The reported prevalence of sleep disorders in diabetes patients ranges between 28.0% and 59.1%. Our investigation performed in Lviv with the use of Pittsburgh Sleep Quality Index (PSQI) questionnaire, identified that 46.2% of T2DM patients experienced sleep disorders. A comprehensive literature review also unveils association between DM and diverse sleep disorders such as insomnia, circadian rhythm disturbances, obstructive sleep apnea (OSA), and restless legs syndrome (RLS). The article furnishes insights into the classification, diagnostic principles, and treatment modalities for these disorders. Referral of patients to sleep specialists for the management of sleep disorders and the integration of sleep hygiene into diabetes care can effectively mitigate symptoms, forestall DM complications, and enhance patients’ quality of life. Circadian molecules like nobiletin, REV‑ERB agonists, and CRY stabilizers have demonstrated efficacy in preclinical studies and hold potential for the development of novel treatments for conditions associated with circadian dysregulation. Considering the frequency of detection of sleep disorders in T2DM patients according to the modern literary sources and own research, the study of this problem is important for the development of an algorithm for the examination of such patients, namely the need for endocrinologists to pay attention to the sleep status of patients and, if necessary, to refer them to somnologists. Further investigation into the etiology of sleep disorders in T2DM patients and their correlation with carbohydrate metabolism indicators exhibits promise. It is imperative to explore avenues to address these causes by complementing the primary therapy for T2DM.

Guidelines for radioiodine therapy in differentiated thyroid cancer and post-therapeutic follow-up

The radioiodine therapy is a one of the basic elements at combined treatment of differentiated thyroid cancer and is an alternative method for patients with distant metastases and a potentially high risk of tumor recurrence. It has been used in clinical practice for more than 80 years. The first report on the phenomenon of accumulation of 130I/131I in a metastatic focus of differentiated thyroid cancer was published by A. Keston et al. in 1942, and in 1946, the production of 131I was established, and the drug became available. In our country, radioiodine therapy has been widely used for the treatment of differentiated thyroid cancer since 1982.This article presents methodological recommendations for radioiodine therapy of patients with differentiated thyroid cancer, provides a modern examination algorithm, discusses the basic principles of laboratory, instrumental diagnostics and treatment approaches treatment of this disease.

Diagnostic Assessment in L2 Reading Based on Diagnostic Principles

Diagnostic Assessment in L2 Reading Based on Diagnostic Principles

Экспериментальные исследования акустического поля поперечных волн в модели биологической ткани

This article develops the ultrasound diagnostics principles using elastography technology and presents the experimental setup diagram. Biological tissue is modeled using silicone material. Research has been carried out and the longitudinal and transverse sound speeds have been determined. Further research will create a database of pathological and healthy tissues various samples.

Unveiling a foreign body masquerading as periarticular calcification: a case report

IntroductionEvaluating isolated extremity discomfort can be challenging when initial imaging and exams provide limited information. Though subtle patient history hints often underlie occult pathologies, benign symptoms are frequently miscategorized as idiopathic.Case presentationWe present a case of retained glass obscuring as acute calcific periarthritis on imaging. A 48-year-old White male with vague fifth metacarpophalangeal joint pain had unrevealing exams, but radiographs showed periarticular calcification concerning inflammation. Surgical exploration unexpectedly revealed an encapsulated glass fragment eroding bone. Further history uncovered a forgotten glass laceration decade prior. The foreign body was removed, resolving symptoms.DiscussionThis case reveals two imperative diagnostic principles for nonspecific extremity pain: (1) advanced imaging lacks specificity to differentiate inflammatory arthropathies from alternate intra-articular processes such as foreign bodies, and (2) obscure patient history questions unearth causal subtleties that direct accurate diagnosis. Though initial scans suggested acute calcific periarthritis, exhaustive revisiting of the patient’s subtle decade-old glass cut proved pivotal in illuminating the underlying driver of symptoms.ConclusionOur findings underscore the critical limitations of imaging and the vital role that meticulous history-taking plays in clarifying ambiguous chronic limb presentations. They spotlight the imperative of probing even distant trauma when symptoms seem disconnected from causative events. This case reinforces the comprehensive evaluation of all subtle patient clues as key in illuminating elusive extremity pain etiologies.

Adrenocortical cancer: principles of morphological diagnostics for the endocrinologist

Adrenocortical cancer (ACС) is a rare malignant endocrine neoplasm from adrenocortical cells. Despite the orphan character of the disease, the increase of incidentalomas in modern clinical practice requires endocrinologist's awareness of the principles of diagnostics and tactics of patient management. This disease is characterized by highly variable biological behavior. This peculiarity of ACC necessitates a personalized approach for each clinical case, which should be ensured not only by interdisciplinary interaction between oncologists, surgeons and endocrinologists, but also by analysis of the pathomorphological features of each tumor. The present article highlights the current views on the morphological diagnosis of ACC, obtained as a result of research in the last decade, which should be taken into account by the endocrinologist.

Managing female stress urinary incontinence in a post mesh era: What to do and when to refer.

Urinary incontinence is a common presentation in general practice and can significantly affect a patient's quality of life. Stress urinary incontinence (SUI) is defined by the International Continence Society as 'the complaint of any involuntary loss of urine on effort or physical exertion (egsporting activities), or on sneezing or coughing'. There is a key role for primary care providers in the assessment and management of female SUI. To highlight the key diagnostic and management principles of female SUIingeneral practice and discuss management options. SUI can usually be diagnosed based upon clinical history and targeted physical examination. Pelvic floor physiotherapy and lifestyle interventions, including weight modification and management of co-morbidities, are important first-line therapies. Surgical options for both persistent or complex SUI include urethral bulking agents, Burch colposuspension and pubovaginal fascial slings. Synthetic (mesh) mid-urethral slings remain a viable surgical option for women suffering SUI.

Fusion neutron diagnostics with CVD diamond detectors

The measurement of Deuterium–Deuterium (DD) and Deuterium–Tritium (DT)-fusion neutrons is crucial for plasma diagnostics at nuclear fusion facilities, such as ITER. Elevated temperatures and high radiation levels challenge radiation detectors. Chemical Vapour Deposition (CVD) diamond withstands harsh environments and is a distinguished candidate for reliable plasma instrumentation (Angelone et al., 2021 and Passeri et al., 2021). Neutron-induced nuclear reactions on Carbon nuclei of diamond substrates are the basis for fusion neutron detection with CVD diamond detectors. DD-fusion neutrons have an energy of 2.45 MeV. The corresponding response function of diamond sensors is purely elastic scattering and has a characteristic shape. DT-fusion neutrons have 14.1 MeV kinetic energy, and their response function reveals different nuclear reactions. The 12C(n, α)9Be peak is the most prominent structure in this response function. The principles of neutron diagnostics with CVD diamond detectors are discussed in this paper and the measured response functions of diamond sensors for 2.45 MeV and 14.1 MeV neutrons are presented, as well as the fusion neutron measurement using a proton-recoil telescope.

Latest Insights and Therapeutic Advances in Myelodysplastic Neoplasms.

Myelodysplastic syndromes/neoplasms (MDSs) encompass a range of hematopoietic malignancies, commonly affecting elderly individuals. Molecular alterations in the hematopoietic stem cell compartment drive disease pathogenesis. Recent advancements in genomic profiling have provided valuable insights into the biological underpinnings of MDSs and have expanded therapeutic options, particularly for specific molecularly defined subgroups. This review highlights the diagnostic principles, classification updates, prognostic stratification systems, and novel treatments, which could inform future clinical trials and enhance the management of adult MDS patients, particularly for specific molecularly defined subgroups.

Differentiated thyroid carcinoma: what the nonspecialists needs to know.

Differentiated thyroid carcinoma (DTC) accounts for most cases of thyroid cancer, and the heterogeneity of DTC requires that management decisions be taken by a multidisciplinary team involving endocrinologists, head and neck surgeons, nuclear medicine physicians, pathologists, radiologists, radiation oncologists, and medical oncologists. It is important for nonspecialists to recognize and refer patients with DTC who will benefit from a specialized approach. Recent advances in knowledge and changes in management of DTC call for the need to raise awareness on the part of these nonspecialist physicians, including general endocrinologists and medical oncologists at large. We provide an overview of diagnostic and therapeutic principles in DTC, especially those that bear direct implication on day-to-day management of these patients by generalists. Patients with DTC may be broadly categorized as having localized, locally persistent/recurrent, or metastatic disease. Current recommendations for DTC include a three-tiered system that classifies patients with localized disease into low, intermediate, or high risk of persistent or recurrent disease. Risk stratification should be performed at baseline and repeated on an ongoing basis, depending on clinical evolution. One of the overarching goals in the management of DTC is the need to personalize treatment by tailoring its modality and intensity according to ongoing prognostic stratification, evolving knowledge about the disease, and patient characteristics and preference. In metastatic disease that is refractory to radioactive iodine, thyroid tumors are being reclassified into molecular subtypes that better reflect their biological properties and for which molecular alterations can be targeted with specific agents.

Trigger Thumb, Trigger Finger and Clasped Thumb.

Finger deformities are a common reason for medical observation in children. Subtle clinical differences can have a significant impact on the diagnosis and treatment of these patients. Identification of the basic diagnostic and treatment principles of trigger thumb, trigger finger, and clasped thumb is of paramount importance to all general practitioners, pediatricians, and orthopedic surgeons who are involved in the care of children. The purpose of this article is to review the most important concepts regarding these important topics, focusing on etiology, epidemiology, clinical presentation, diagnosis, treatment and prognosis.

Структура сенсибілізації до риби та морепродуктів у дітей

In recent years, about 4% of children and 1% of adults in the world have suffered from food allergies to fish and seafood. About 40% of children have a high level of threat of systemic reactions. Literature data on the prevalence of FA on fish and seafood in the world are summarized, the principles of modern diagnostics are defined, taking into account the possibilities of molecular component diagnostics of fish and seafood allergen molecules. Purpose – To analyze the prevalence of allergies to fish and seafood in children; determine the structure of sensitization to the main allergens of these products using molecular component diagnostics. Materials and methods. 29 children aged from 3 to 18 years with clinical signs of allergies to fish and seafood were examined, with confirmation of sensitization to them using the ALEX-2 molecular component diagnostic method (Macro Array Diagnostics GmbH, Austria). Levels of specific IgE were determined. Results. Among those examined, children with food allergies to fish and seafood aged 3-6 years predominated (41.4%). 18 (62.1%) children had a severe allergy history. 19 (65.5%) children had oral allergy syndrome; 18 (62.1%) children had a papular rash with itching. Difficulty breathing was observed in 16 (55.2%) children. About half of the subjects were sensitized to fish allergens, most often to β-parvalbumin. Only 4 (13.8%) children were sensitized to fish enolase and eldolase. Among seafood, sensitization to squid predominated in children - in 18 (62.1%) children, while sensitization to tropomyosin was low - 1 (3.4%) case. Conclusions. The problem of the appearance of fish and seafood is relevant today, especially among children aged 3-6 years (41.4%). In children with fish allergy, sensitization to β-parvalbumin of different fish species predominated, namely to salmon (51.7%), mackerel (51.7%), herring (48.3%), carp (48.3%), tuna (48.3%), cod (41.4%). As a result of sensitization to seafood, sIGE was more often recorded to extracts of squid (62.1%), oyster (27.6%), lobster (20.7%), mussels (20.7%), clam (17.2%). The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Health Screening Strategies for Artisanal and Small-Scale Miners for Tuberculosis, Human Immunodeficiency Virus and Silicosis: A Case of the USAID-Supported Kunda Nqob'iTB Project in Zimbabwe.

Artisanal and small-scale mining is characterized by excessive exposure to physical, chemical, ergonomic, psychosocial and biological hazards. There is a high burden of tuberculosis (TB), human immunodeficiency virus (HIV) infections and silicosis among artisanal and small-scale miners (ASMs). The aim of this project report is to describe lessons learned from strategies implemented to reach ASMs with screening services for TB, HIV and silicosis in Zimbabwe through the Kunda-Nqob'i TB (KNTB) project supported by the United States Agency for International Development (USAID). The intervention package for screening ASMs for TB, HIV and silicosis included service provision through two occupational health clinics at two provincial hospitals and a mobile workplace-based screening (WBS) facility at the mining sites. From 1 October 2020 to 30 September 2023, 10,668 ASMs were screened, with a high number of cases of silicosis (21%) and TB (7.4%). There was a high burden of HIV (30%) in ASMs attending the occupational health clinics. The two occupational health clinics screened 3453 ASMs, while the mobile WBS activities screened 7215 ASMs during the period. A total of 370 healthcare workers (doctors/clinical officers, nurses, environmental health technicians and district tuberculosis and Leprosy control officers) were trained on TB and the fundamental diagnostic principles of silicosis. The KNTB project has been successful in reaching out to many ASMs operating in remote and hard-to-reach mining areas. The KNTB project has brought to light the positive health-seeking behavior of ASMs operating in remote areas. The project has brought to the fore the effectiveness of multi-stakeholder engagement and collaboration in reaching out to ASMs in remote areas with health screening services. There is a high burden of TB, HIV and silicosis in ASMs. Screening for TB, HIV and silicosis using workplace-based screening and occupational health clinics is an effective strategy and should be rolled out to all areas with high artisanal and small-scale mining activity.

Lesser tuberosity humerus fracture in combination with fracture scapular spine: A case report with literature review

Abstract Fractures of the lesser tuberosity (LT) in combination with scapular spine fractures have a rare presentation, typically resulting from high-energy trauma. In this case study, we present a 37-year-old active male who approached us with complaints of a left shoulder injury. Upon diagnosis, he was found to have fractures of the LT and the scapular spine on the ipsilateral side. We discuss the mode of trauma, diagnostic principles, and various management options for this fracture. Additionally, we provide valuable guidance to surgeons for managing similar injuries.