Great Pretender Research Articles

Cats are not small dogs: assessment and stabilisation of emergency presentation

Cats are a common emergency presentation in practice, with a wide range of presenting conditions ranging from trauma caused by road traffic accidents or falling from height, to acute medical conditions or ingestion of toxins. When dealing with feline patients, it is important to remember that cats are not small dogs and therefore, the approach to their assessment and stabilisation must take this into account. Cats have unique behaviour and physiology. They are great pretenders and will often mask clinical signs until they are near-critical. As their response to disease differs to that of dogs, when they are presented to a veterinary clinic they often show non-textbook clinical signs. This, in conjunction with the fact their response to medical therapy can also differ from canine patients, can make them particularly challenging to manage in an emergency. The assessment process should be holistic, and all physical examination findings should be viewed in association with each other.

Feline friendly POCUS: how to implement it into your daily practice.

Cats are great pretenders; they often hide illness until they are critical. This makes patients of this species challenging to assess and manage in the emergency setting where quick and stress-free diagnosis and treatment are necessary. Veterinary point-of-care ultrasound (POCUS) is a rapid, evidence-based, non-invasive, repeatable, cage-side ultrasonographic examination designed to answer clinically driven questions without compromising feline wellbeing. Integrating feline friendly POCUS as an extension of the physical examination to streamline diagnostic and therapeutic interventions, thereby limiting stress and improving overall patient care, is advocated by the authors of this article. Given the multitude of ultrasound machines and probes available that are portable, meaning they can be moved around the clinic and used patient-side, it should be possible for most practitioners to integrate POCUS into daily practice. The authors' preferred equipment for feline POCUS is a microconvex probe and a portable machine with a fixed pre-set. This set-up allows the clinician to complete all POCUS (abdominal, lung and pleural space, and heart) without needing to move the patient, change probes or restrain the patient in a particular position, ultimately saving time, personnel and cost while maintaining patient comfort and safety. This review aims to serve as a valuable resource for veterinarians seeking to improve their feline patient care through the judicious utilisation of POCUS. In this article, the complex challenges posed by cats are addressed, and the different POCUS techniques, applications and clinical recommendations are discussed. This review draws on the published literature, as well as the authors' own collective experience when providing recommendations.

Isolated and fistulized primary appendicular tuberculosis: when a great pretender disguises herself

Tuberculosis in all its forms remains a public health problem in Morocco, despite the efforts of the state in terms of prevention and treatment. Recently, there has been an increase in the number of extra-pulmonary forms of TB. Isolated appendicular localization is very rare, especially since intestinal localization is only ranked 6th among extra-pulmonary localizations. We report the case of a 39 year old female patient admitted for right iliac fossa (RIF) pain evolving for two months, the clinical examination on admission objective a digestive fluid outlet through a fistulous orifice at the level of the RIF; the abdominal CT scan found a plastron with the presence of a fistulous path between a digestive segment and the wall, the surgical exploration found a fistula between the body of the appendix and the wall, an appendectomy was done and the anatomopathological examination confirmed the tuberculosis origin. Our work sheds light on an often-misunderstood form of a well-known pathology.

The great pretenders? Individuals' responses to threats to their remote worker identities.

This study aims to understand (a) how remote workers respond to threats to their identity and (b) the conditions in which each coping response tends to occur more frequently. To this end, we pursued a grounded theory approach, conducting interviews with 71 individuals who chose to work remotely. Our model and theoretical propositions create insights into how remote workers respond to negative stigma from a range of origins. While some responses lead to restructuring the remote workers' identity (identity restructuring responses), others involve keeping the enactment of such identity (identity-preserving responses) or maintaining a paradoxical relationship between restructuring and preserving the identity (paradoxical identity work responses). We also theorise on the conditions under which each response is more likely to occur. We expand the predominant focus on the meso and macro aspects of this type of work to the micro-interactions in which these individuals engage, thus highlighting how identity is made, performed, created, and enacted, within specific boundary conditions. In addition, by reflecting upon remote workers' identity threats in light of the wider macro context. We also explore the conditions under which specific kinds of responses tend to emerge.

THE GREAT PRETENDER: COULD A PHEOCHROMOCYTOMA MANIFEST ITSELF AS A SEIZURE?

Objective: Seizures are defined as transient occurrence of signs or symptoms due to the abnormally excessive or synchronous neuronal activity in the cerebral cortex. Pheochromocytomas and paragangliomas (PPGL) are chromaffin cell tumors arising from the adrenal medulla in 80–85% of patients and from extra-adrenal sympathetic tissue in 10–20% of patients. PPGL has been referred to as ‘‘the great mimic’’ disease. We present a patient with pheochromocytoma possibly disguised as seizures. Design and method: A 44 years old woman was referred to University Clinic of Endocrinology by radiologist. Two years earlier she had syncopal crises . She complained of headache, heart palpitation and malaise, heart palpitations and fatigue during exertion and sense of panic. The maximal self-measured blood pressure was 160/100 mmHg, the pulse is 90-100 beats per min. Abdominal US: a hyperechoic change, 76x65mm was seen, then described in the right lobe of the liver. The following year she had two commotional crises of consciousness and spasms of the extremities . She had a non-specific slowing of FC on EEG on the right for 1-2 seconds. MSCT abdomenal : in the right adrenal gland, a mass 144 x 90mm, with clear borders, pressing into the liver and pushing the right kidney,. The 24h urine was collected, which confirmed a norepinephrine secreting pheochromocytoma. We administered long acting alpha blocking agent preoperatively. The complete surgical excision of the right adrenal mass was done, pathohistological diagnosis: Pheochromocytoma. The last EEG after sleep deprivation performed 2 months postoperatively was described as normal. The patient had no headache or seizure. Results: PPGLs have a notable ability of boosting NE levels systemically and hypertension, the most common sign of PPGL could facilitate the permeability of blood brain barrier to NE. Studies showed NE could play its anticonvulsant property at an appropriate concentration but has a proconvulsant effect in either too high or too low concentrations . Conclusions: The definite pathogenetic mechanisms explaining how PPGL can cause seizures are far from being clearly understood, though “the great pretender” should be considered as a possible etiological factor of seizures.

""On Being Sane in Insane Places" … it is a work half done."

""On Being Sane in Insane Places" … it is a work half done."

Lexicon of Metaphors: An Innovative Approach to Detect the Aftermath of Traumatic Childbirth

An innovative approach to help mental health providers identify individuals who may be struggling with the aftermath of birth trauma is to become vigilant in listening for metaphors women may use to describe how they have been feeling. Metaphors can provide a safe bridge for individuals to share and work through painful and challenging feelings. This lexicon of metaphors has four sections: impact birth trauma had on breastfeeding, impaired mother-infant interaction, anniversary of birth trauma, and subsequent childbirth. Examples of these metaphors include empty affair, head in a vise, short fuze, severed ties, great pretender, and mental baggage.

The fiftieth anniversary of the article that shook up psychiatry.

In January 2023, the fiftieth anniversary passes of David Rosenhan's article On being sane in insane places appearing in the prestigious journal "Science". This publication has become one of the most influential psychiatric papers of the second half of the 20th century, achieving 1,276 citations up to mid-2022. In the article, eight healthy persons are described, who came to psychiatric hospitals in the USA, reporting auditory hallucinations. They were all admitted, mainly with suspected schizophrenia, and ordered pharmacological treatment. Their stay ranged from 7-52 (mean 19) days, even though after the admission they did not confirm the symptoms. The article spotlighted an unjustified diagnosis of mental illness, resulting in psychiatric hospitalization in unfavorable conditions. Its consequences were manifold. It augmented the process of psychiatric deinstitutionalization and provided food for anti-psychiatric movements and humanistic psychiatry. However, it did accelerate the inception of an objective system of psychiatric diagnosis in the form of the 3rd edition of the Diagnostic and Statistical Manual (DSM-III), released in 1980. Susannah Cahalan's book The great pretender, published in 2019, undermines the reliability of the article. Based on many interviews and Rosenhan's notes, she pointed out many faults of the experiment. She was not able to retrospectively confirm the identities of the majority of participants, nor to receive the essential information from "Science". On the fiftieth anniversary of the article, its cognitive value for an objective diagnosis of mental illness and the role of psychiatric hospitalization as well as the negative consequences in the form of a drastic reduction of psychiatric beds in the USA are emphasized.

DISSEMINATED BLASTOMYCOSIS PRESENTED WITH ADRENAL MASS

DISSEMINATED BLASTOMYCOSIS PRESENTED WITH ADRENAL MASS

The Great pretender: the first case of septic shock due to Capnocytophaga canimorsus in Sardinia. A Case report and review of the literature.

Capnocytophaga canimorsus (C. canimorsus) is an emerging pathogen in critical care. C. canimorsus is a Gram-negative bacillus, commonly isolated as a commensal microorganism of the oral flora of healthy dogs and cats. A 63-year-old woman came to the emergency department with fever, chills, and malaise 2 days after a minor dog bite. After admission to the medicine ward, she developed respiratory failure and livedo reticularis. In the intensive care unit (ICU), she presented full-blown septic shock with thrombocytopenia, coagulopathy, severe acute kidney injury, and liver injury. We describe the first case of septic shock with Multiple Organ Dysfunction Syndrome related to Capnocytophaga canimorsus infection in Sardinia and its treatment in a tertiary hospital ICU. We also review recent literature on the relevance of C. canimorsus in human disease and critical illness.

Imperforate Hymen: Clinical Pearls and Implications of Management.

Imperforate hymen is a common condition that with classic appearance and presentation in puberty. This may be diagnosed in a neonate when mucocolpos is noted. There are many great pretenders of this condition, but the hallmarks include a bulging hymen with blue hue at puberty. If this is not seen on external genital exam, the provider should proceed with magnetic resonance imaging to better assess the reproductive tract anatomy before engaging in surgery. For providers uncomfortable in managing conditions often confused with an imperforate hymen, referral to a Pediatric and Adolescent Gynecologist or specialist comfortable managing these conditions, is recommended.

"The Great Pretender"

"The Great Pretender"

S1810 The Great Pretender: Painless Jaundice Caused by a Non-Hepatobiliary Source

INTRODUCTION: Painless jaundice is a known sign of obstruction from pathologies within the hepatobiliary system. Proliferation of epithelial cells may form a rare tumor known as a cholangiocarcinoma. Colorectal cancer (CRC) may metastasize to the liver parenchyma but there is no prior report of a common bile duct (CBD) tumor leading to the discovery of CRC. We present a case of obstructive jaundice which was initially thought be cholangiocarcinoma based on Computerized Tomography (CT) imaging and Endoscopic retrograde cholangiopancreatography (ERCP), but found to be hilar metastasis from an undiscovered CRC. CASE DESCRIPTION/METHODS: A 61 year-old man with no known medical history presented with complaints of jaundice, nausea, vomiting, dark urine, and right upper abdominal pain for two weeks. He denied fever, itching, weight loss, constipation or diarrhea. He was a tobacco user and had four tattoos. He denied alcohol, intravenous or other drug use. He had no recent use of acetaminophen or herbal medicine. He had no recent travel, exposure to ill contacts, history of hepatitis or risky sexual practices. His vitals were normal on presentation. On general examination the patient was an elderly man with scleral icterus but other systems, including the abdomen, were unremarkable. CT Abdomen revealed a porta hepatis mass at the CBD, concerning for cholangiocarcinoma. There were also multiple focal areas of the liver, involving the right lobe extending into segment 4 worrisome for additional large areas of metastatic cholangiocarcinoma. He was admitted for further work up. ERCP was performed, revealing a tumor extruding from the CBD. The CBD mass and a hepatic mass were biopsied. A biliary stent was placed for symptomatic relief. Immunohistochemical staining of the biopsies were negative for CK7 but positive for CK20 and CDX2, in keeping with a colonic primary. There was no clinical evidence of primary CRC but subsequent colonoscopy revealed a colonic mass with histology showing adenocarcinoma. The patient was scheduled for oncology follow up. DISCUSSION: CRC remains one of the leading causes of cancer worldwide and this case highlights an exceptionally unusual way in which this disease presented. Though a rare presentation, clinicians should be aware that it is possible for a cholangiocarcinoma to not be of primary origin. To our knowledge, this is the first known case of painless jaundice from a bile duct tumor as the initial manifestation of a primary colon cancer.Figure 1.: ERCP image showing tumor extruding from CBD.Figure 2.: Standard H&E stain of a) common bile duct tumor and b) colon carcinoma.Figure 3.: Colonoscopy image showing colon carcinoma.

Primary parotid gland lymphoma: pitfalls in the use of ultrasound imaging by a great pretender

The aim of this study was to highlight several misleading imaging and clinical aspects of parotid gland lymphoma, taking our personal experience and relevant literature reports into consideration. The records of all patients diagnosed with lymphoma in the parotid gland between 2005 and 2017 were examined retrospectively. Sixty-seven patients were included in this study. The mean age was 61.4 years. The most frequent histological entities were marginal zone B-cell lymphoma (31.3%) and follicular lymphoma (28.4%). The tumour was stage I in 35 cases (52.2%), stage II in 13 cases (19.4%), stage III in 11 cases (16.4%), and stage IV in eight cases (11.9%). B symptoms were seen in only three patients (4.5%). The diagnosis was made after parotidectomy in 51 cases (76.1%), by core needle biopsy in 14 cases (20.9%), and by means of open biopsy in the remaining two cases (3.0%). Parotid gland lymphoma represents a diagnostically challenging, multifaceted entity that can easily mimic both benign and malignant conditions. This entity should be included in the differential diagnosis of almost all types of parotid lesion, as it seems to play the role of a great pretender.

It is not Appendicitis! It is Appendicitis Epiploica, the Great Pretender

Appendicitis epiploica or epiploicae appendagitis, an uncommon cause of abdominal pain, is usually per-operatively diagnosed. The pedunculated fat-filled small pouches or appendices epiploicae on the serosal surface of the colon often become twisted and sometimes spontaneous thrombosis occurs. Such events lead to ischemia and inflammation at the base of the fatty lobes i.e., Appendicitis epiploicae. Symptoms include sharp localized pain in either iliac fossae and in some cases there is elevated temperature and white blood cell count. In a quarter of the patients there is rebound tenderness and very rarely nausea and vomiting, diarrhoea or constipation. This condition is more common among middle aged males and given its non-specific symptoms. It is usually confused with other more common conditions such as Meckel’s diverticulitis and appendicitis. Less than 8% of patients suspected of having appendicitis or diverticulitis are found to actually have appendicitis epiploicae. Here we report two extremely rare cases of appendicitis epiploica in Bangladesh.
 Journal of Surgical Sciences (2019) Vol. 23(2): 95-97

Undercover in the asylum The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness Susannah Cahalan Grand Central Publishing, 2019. 400 pp.

A defining antipsychiatry text comes under fire

A FLORIST'S OCCUPATIONAL EXPOSURE

SESSION TITLE: Chest Infections: Find the Fungus SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Pulmonary infections have been reported in up to 79% of patients with blastomycosis. Often known as a “great pretender” given the large variability in presentation, pulmonary blastomycosis is a diagnostic dilemma even in endemic areas. Here we report a case of acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO) in an immunosuppressed patient working as a florist with no travel history to an endemic area. CASE PRESENTATION: 54 year old male from central New York with history of autoimmune hepatitis on azathioprine and corticosteroids, presented with worsening cough, dyspnea and fever. He denied any sick contacts or travel history and worked as a florist. He failed outpatient pneumonia treatment with azithromycin and then doxycycline. His symptoms continued to progress, and was admitted to the ICU with acute hypoxic respiratory failure, requiring mechanical ventilation. Chest x-ray revealed patchy bilateral airspace disease and he was started on broad spectrum antibiotics and voriconazole. CT Chest showed extensive consolidation in right lower and middle lobe, left lower lobe and lingula, with mediastinal lymphadenopathy. He progressed to ARDS with worsening respiratory status despite maximal ventilator support and paralytics, and was emergently placed on ECMO. A bronchoscopy revealed thick copious mucous plugs and both bronchial washings and lavage were sent for culture. Initial blood cultures and bronchoscopy cultures returned negative for pathogens, however 10 days after bronchoscopy, lavage culture grew mold, later identified as Blastomyces dermatiditis. He was started on amphotericin B, and later changed to itraconazole. After initiation of an anti-fungal the patient clinically improved and was decannulated from ECMO, with eventual discharge to rehab. DISCUSSION: The diagnosis of pulmonary blastomycosis can range from an asymptomatic infection to pneumonia or to ARDS. The lung is often the primary inoculation site after exposure to disrupted soil. However this diagnosis requires a high degree of clinical suspicion even in endemic sites or those with a travel history to such areas. This case highlights a diagnostic dilemma in an immunocompromised patient, who presented with fulminant respiratory failure due to blastomycosis, with no travel history to an endemic area. Here we see a case of an occupational exposure to soil given his profession as a florist as his likely source, with his immunocompromised state leading to devastating disease. This emphasizes the importance of identifying occupational exposures especially when combined with those who are immunosuppressed, as early diagnosis and treatment will be lifesaving. CONCLUSIONS: ARDS due to pulmonary blastomycosis carries a high mortality rate highlighting the vital importance of early diagnosis and treatment. Reference #1: McBride JA, Gauthier GM, Klein BS. Clinical Manifestations and Treatment of Blastomycosis. Clin Chest Med. 2017;38(3):435-449. Reference #2: Moore NM, Proia LA. Severe acute respiratory distress syndrome in a liver transplant patient. Med Mycol Case Rep. 2018;21:1-3. Published 2018 Mar 6. https://doi.org/10.1016/j.mmcr.2018.03.005 Reference #3: Salzer H, J, F, Burchard G, Cornely O, A, Lange C, Rolling T, Schmiedel S, Libman M, Capone D, Le T, Dalcolmo M, P, Heyckendorf J: Diagnosis and Management of Systemic Endemic Mycoses Causing Pulmonary Disease. Respiration 2018;96:283-301. https://doi.org/10.1159/000489501 DISCLOSURES: No relevant relationships by Hassan Al Khalisy, source=Web Response No relevant relationships by Ioana Amzuta, source=Web Response No relevant relationships by Ritu Modi, source=Web Response

P07.06: The great pretender: a case of a broad ligament lipoma in a postmenopausal woman

P07.06: The great pretender: a case of a broad ligament lipoma in a postmenopausal woman

A CONTINGÊNCIA DA POLÍTICA E A NECESSIDADE DA HIPOCRISIA EM O PRÍNCIPE DE MAQUIAVEL

In his most famous work, Machiavelli showed how the prince is neverassessed by what he is, but according to what he appears to be. Therefore, thepolitician needs to act as a hypocrite, as a ‘great pretender and dissembler’, tomaintain the support of the people on which his power relies. However, hypocrisydoes not simply mean deception of the ruled by the rulers. Given the social divisionwhich underlies the state, it actually plays a fundamental role in the imaginaryconstitution of a sovereign power capable of imposing unity and stability oncollective life. Our aim is to question the use of hypocrisy in order to emphasize thedistinction introduced by Machiavelli between moral virtue and political ‘virtù’.Furthermore, we will try to demonstrate how it is presented as part of a broaderstrategy against the unpredictable effects of time, symbolized by the metaphor of‘Fortuna’.

The great pretender: Diagnosing tuberculosis in the second trimester

The great pretender: Diagnosing tuberculosis in the second trimester