Man Presenting Research Articles

A case of strongly suspected Lynch syndrome with colorectal neuroendocrine carcinoma

BackgroundNeuroendocrine cell carcinomas (NEC) of the colon and rectum are uncommon, representing ~ 0.1% of all colorectal carcinomas. They are associated with a much worse prognosis compared to adenocarcinoma of the colon and rectum, as death occurs in approximately half of all patients within 1 year. Lynch syndrome (LS) is the most common cause of inherited colorectal cancer, accounting for 2–4% of newly diagnosed colorectal cancer cases. This case is extremely rare which was strongly suspected LS as the background, and NEC as the histological type of colorectal cancer.Case presentationThe patient was a 44-year-old man presenting with vomiting as the main complaint. He had undergone ileocecal resection for cecal cancer at age 29. The diagnosis was obstructive descending colorectal cancer, and colonoscopy revealed tumors in the rectum and sigmoid colon in addition. Due to multiple occurrences of colorectal cancer and its prevalence in the patient’s family, LS was suspected. The operation which was a subtotal proctocolectomy was performed. Pathological analysis revealed complete curative resection and the descending colon cancer of the obstructed portion was at the most advanced pathological Stage IIIC in UICC TNM classification, and the tissue type was a NEC. The Ki-67 index was 70%. The results of the microsatellite instability (MSI) test showed high-frequency MSI. The BRAF V600E variant was negative. The immunoexpression of MLH1 was positive, MSH2 was negative, PMS2 was positive, and MSH6 was negative.ConclusionsExtended surgery is recommended for incipient colorectal cancer in LS cases in order to reliably reduce the risk of developing metachronous colorectal cancer. The survival outcome of surgery alone on digestive tract NECs, even locoregional lesions that are completely resection, is extremely poor. It is currently unclear if digestive tract NECs develop more readily in patients with LS. The accumulation of additional cases is necessary.

Hide and Seek: Dysplasia Camouflage in a Patient With Barrett’s Esophagus

Question: An 84-year-old man presenting with fatigue was referred for endoscopy owing to anemia. On his esophagogastroduodenoscopy, a segment of Barrett’s esophagus (BE) was seen (Prague classification C2M4). Random biopsies were obtained as per the Seattle protocol. Histology revealed at least one specimen harboring high-grade dysplasia. He had ascending colon adenocarcinoma on colonoscopy. The BE segment was subsequently reassessed using white light, narrow band imaging (NBI), acetic acid chromoendoscopy, and high magnification. In a proximal tongue, there was an area appeared to have an irregular microvasculature. This was presumed to be the dysplastic lesion (Figure A; NBI). A clear demarcation line was noted between the distal nondysplastic segment and the irregular microvasculature of the proximal dysplastic area (Figure B; NBI and near focus). A decision was made to initially resect the BE segment using the endoscopic submucosal dissection (ESD) technique and operate the right-sided colon cancer at the same season in the following weeks. He continued his proton pump inhibitor (PPI) in the interim. While reassessing the lesion before performing ESD 0 month later, the previously identified dysplastic lesion was no longer identified (Figure C; white light). What is the most likely explanation and what is the best way to manage the case? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Further careful examination with NBI and magnification revealed an area of brownish discoloration below re-epithelialized mucosa (Figure D). The area to resect could not be ascertained, but the NBI and magnification images combined with the previously known location of the dysplastic area were used as landmarks to proceed with an ESD (Figure E, F). On histology, the dysplastic BE was buried underneath normal appearing squamous cell epithelium (Figure G; stain: hematoxylin and eosin). The dysplastic glandular proliferation showed focally fused glands formed by atypical, mitotically active epithelial cells without goblet cells. The dysplastic elements did not involve the muscularis mucosae nor the submucosa. This unique case demonstrates that re-epithelialization of a Barrett’s mucosa can occur within a short time interval. While managing BE, endoscopists should be aware of the acceleration of re-epithelization and the potential concealing of dysplastic cells under normal-appearing epithelial tissue such as presented here. Some evidence has shown that acid suppression can lead to this occurrence. A study of 26 patients examining the effect of high-dose lansoprazole on BE found that squamous islands were developed in 77% of the patients by the final visit.1Sampliner R.E. Effect of up to 3 years of high-dose lansoprazole on Barrett’s esophagus.Am J Gastroenterol. 1994; 89: 1844-1848PubMed Google Scholar In the study, squamous re-epithelization and subsequent burying of the dysplasia below the surface could be attributed to high-dose PPI use. It is, thus, paramount to carefully inspect the whole BE segment and beyond its obvious extent, especially in patients on a PPI. Likewise, this observation highlights the utmost importance of careful inspection and precise documentation of the location of dysplasia in BE during endoscopy. Applying advanced imaging techniques in addition to the white light may facilitate the visibility and improve the diagnostic and interventional precision.2Qumseya B. Sultan S. Bain P. et al.ASGE guideline on screening and surveillance of Barrett’s esophagus.GIE Journal. 2019; : 335-359Google Scholar

051 Heavy menstrual bleeding in teenagers: Haematological issues

Up to one in three adolescent girls who present to the gynecologist with heavy menstrual bleeding (HMB) may have an underlying bleeding disorder [ [1] Zia A. Jain S. Kouides P. Zhang S. Gao A. Salas N. et al. Bleeding disorders in adolescents with heavy menstrual bleeding in a multicenter prospective US cohort. Haematologica. 2020; 105: 1969-1976 Crossref PubMed Scopus (18) Google Scholar ]. Unfortunately, this often remains unrecognized evidenced by an average diagnostic delay of 14–16 years for women who are diagnosed with a congenital bleeding disorder [ 2 Kirtava A. Crudder S. Dilley A. Lally C. Evatt B. Trends in clinical management of women with von Willebrand disease: a survey of 75 women enrolled in haemophilia treatment centers in the United States. Haemophilia. 2004; 10: 158-161 Crossref PubMed Scopus (91) Google Scholar , 3 Atiq F. et al. Major differences in clinical presentation, diagnosis and management of men and women with autosomal inherited bleeding disorders. EClinicalMedicine. 2021; 32: 100726 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar ]. Even in the high resource setting, screening rates for von Willebrand disease, the most common inherited bleeding disorder, are strikingly low, despite ACOG recommendations [ [4] Jacobson A.E. Vesely S.K. Brien S.H.O. Campbell J. Patterns of von Willebrand disease screening in girls and adolescents with heavy menstrual bleeding. Obstet Gynecol. 2018; 131: 1121-1129 Crossref PubMed Scopus (15) Google Scholar ]. Missed diagnosis may lead to social impairment, psychological and physical problems caused by inadequate treatment and subsequent complications.

Call to Action for Enhanced Equity: Racial/Ethnic Diversity and Sex Differences in Stroke Symptoms

BackgroundFundamental aspects of human identity may play a role in the presentation of stroke symptoms and, consequently, stroke recognition. Strokes must be recognized and treated expeditiously, as delays result in poorer outcomes. It is known that sex plays a role in the presentation of symptoms, such that non-traditional symptoms are more commonly observed among women. However, factors such as geographical location and race/ethnicity, and the interactions between these various factors, need to be considered. This will provide an intersectional approach.MethodsA systematic review and meta-analysis of the literature was conducted to investigate differences in the presentation of stroke symptoms between sexes. Using PubMed and Embase, a search involving the components sex, symptoms and stroke was completed and yielded 26 full-text manuscripts.ResultsOur findings indicate that there is substantial overlap in stroke symptom presentation in men and women. Nonetheless, some differences in the clinical manifestations of stroke were observed. In addition, it was discovered that only three studies were conducted outside of North America and Europe. Furthermore, only two studies reported symptoms based on both sex and racial/ethnic group.ConclusionThese findings indicate a research gap and call for increased research in order to uncover the possible interactions between sex and race/ethnicity in an intersectional approach. Resultantly, stroke recognition could be improved and greater equity in healthcare can be achieved.

PD13-09 TRENDS IN SURVIVAL FOR MEN WITH DE NOVO METASTATIC PROSTATE CANCER

You have accessJournal of UrologyCME1 May 2022PD13-09 TRENDS IN SURVIVAL FOR MEN WITH DE NOVO METASTATIC PROSTATE CANCER Nina Wyatt, and Christopher Filson Nina WyattNina Wyatt More articles by this author , and Christopher FilsonChristopher Filson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002545.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The USPSTF recommended against routine prostate cancer screening in 2008 (men >75 years) and 2011 (all men). After 2010, novel therapies were approved for men with metastatic prostate cancer, such as abiraterone. We examined the characteristics and survival of the men presenting with metastatic prostate cancer before and after those time periods. We hypothesized that men diagnosed more recently would have improved survival compared to men diagnosed long ago. METHODS: Using SEER cancer registry data, we identified men newly diagnosed with metastatic prostate cancer diagnosis from 2004–2018. Our outcome of interest was prostate cancer specific survival. Primary exposure was time period of diagnosis (2004–2008; 2009–2012; 2013–2016; 2017–2018). We evaluated factors including age, race/ethnicity, registry, and PSA level. We performed survival analysis to generate Kaplan-Meier curves for men eligible for at least 3 years follow up (diagnosed 2004–2016) (Figure). Multivariable Cox proportional hazard model provided adjusted estimates for cancer specific survival. RESULTS: Among 840,852 prostate cancer patients, 47,343 (5.6%) had metastatic disease. This proportion increased from 4.2% in 2004–2008 to 8.1% in 2017–2018 (p <0.001). Over time, a greater proportion of men with metastatic prostate cancer were Asian/Hispanic (16.0% in 2004–2008 to 17.7% in 2017–2018, p <0.001). Survival after 1 year was most common for men diagnosed in 2017–2018 (81.3% vs 67.9% alive in 2004–2008, p <0.001). Median cancer-specific survival was longest for men diagnosed from 2013–2016 (36 vs 31 months for 2004–2008, p <0.001). After adjusting for other factors, men diagnosed in 2013–2016 had 15% improved survival compared to those diagnosed earlier (vs 2004-2008; adjusted HR 0.85, 95% CI 0.82–0.88). CONCLUSIONS: Men presenting with metastatic prostate cancer in more recent years are living longer. More work will need to evaluate the relative contribution to this finding from therapeutic successes with novel systemic therapies, stage migration with adoption of PET scans, and the impact of earlier cancer detection with screening. Source of Funding: ACS MRSG 18-1-CPHPS © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e254 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nina Wyatt More articles by this author Christopher Filson More articles by this author Expand All Advertisement PDF DownloadLoading ...

Abnormal Electrocardiogram in a Man Presenting With Dyspnea and Chest Pain.

A 70-year-old man with a history of smoking presented at the emergency department with dyspnea and a 24-hour history of intermittent chest pain that had acutely worsened. His heart rate was 128 beats/min; blood pressure, 114/81 mmHg; respiratory rate, 24 breaths/min; and oxygen saturation, 85% on 4 L of oxygen. He had bibasilar crackles and a grade 3/6 holosystolic murmur over the left sternal border. A basic metabolic panel showed nothing unusual. A coronavirus nasopharyngeal swab test was negative. The patient's N-terminal pro-brain-type natriuretic peptide level was 1,583 pg/mL (normal, &lt;100 pg/mL), and his cardiac troponin I level was 39 ng/mL (normal, ≤0.04 ng/mL). He became hypoxic and needed intubation. He was started on intravenous vasopressors and was taken to the cardiac catheterization laboratory, where an intra-aortic balloon pump was placed. His presenting electrocardiogram (ECG) is shown below (Fig. 1).In addition to ST-segment-elevation myocardial infarction (STEMI), what diagnosis should be suspected from this ECG?B) Ventricular septal ruptureIn cases of delayed STEMI, mechanical complications can occur. The differential diagnosis in acute myocardial infarction (AMI) complicated by a holosystolic murmur includes papillary muscle rupture (PMR) and ventricular septal rupture (VSR). Free wall rupture would not present with a holosystolic murmur, and aortic dissection resulting in aortic regurgitation would cause a diastolic murmur. Patients with acute PMR typically present with shock and acute pulmonary edema. In acute PMR, the systolic murmur may be soft or absent, given pressure equalization between the left ventricle and left atrium; conversely, in VSR, there is hemodynamic compromise and a harsh systolic precordial murmur.Inferior and anterior STE with inferior Q waves, such as in our patient's ECG, should raise suspicion for VSR.1 Hayashi and colleagues2 observed STE in the inferior and anterior leads in 42.9% of patients who had VSR, but in only 3.6% of patients without VSR. Moreover, abnormal Q waves appeared in all inferior leads (II, III, and aVF) in 44.4% of patients with VSR but in only 4% of those without.2 Whereas the ventricular septum receives a dual blood supply from the left anterior descending coronary artery (LAD) and right coronary artery, in a dominant “wrap-around” LAD, the ventricular apex is supplied only by the LAD. Occlusion of the LAD (Fig. 2, arrow) results in necrosis of the anterior and inferior walls, leading to STE in the anterior and inferior leads, and a risk of VSR (Fig. 3, arrow) if reperfusion is delayed.3 This case highlights that, in AMI, an ECG showing STE in the anterior and inferior leads with inferior Q waves should raise suspicion for VSR.Conflicts of interest: NoneFunding: None

A 59-Year-Old Man Presenting with Dyspnea and Limb Paralysis

A 59-Year-Old Man Presenting with Dyspnea and Limb Paralysis

Delayed asymptomatic blunt traumatic diaphragmatic hernia: an unusual case report

IntroductionTraumatic diaphragmatic hernia (TDH) is uncommon, being encountered in around 0.8%-8% of patients with blunt abdominal trauma. Severe comorbidities such as fractures and thoraco-abdominal or head injuries that accompany TDH, are responsible for poor prognosis and often mask diaphragmatic injury itself. Objective of this case report was to highlight rare blunt TDH case to avoid missed diagnosis leading to complications. Case descriptionSixty seven-year old man presenting with right chest pain without difficulty of breathing after falling from stairs 1 hour before hospital admission. On clinical examination, vitals were stable, but with decreased breath sounds on right lower side of chest. Patient had history of trauma from being crushed by elevator 40 years ago without any proven diaphragmatic injury. Initial erect chest X-ray findings were inhomogeneous opacity shadow on lower right hemithorax suspected to be diaphragmatic hernia and 7th right rib fracture with pleural effusion. Thorax CT scan showed herniated right lobe of liver, gall bladder, and mesenteric fat on right hemithorax causing displacement of mediastinal structures. Patient was diagnosed with delayed TDH and hemothorax caused by newly fractured rib. Patient was referred to a better-equipped facility due to the limited surgical facilities in referring hospital. ConclusionDelayed TDHs are not common, but can lead to serious consequences. Blunt TDH occurs more often on left than on right side, in ratio of approximately 3:1. Traumatic diaphragmatic hernia is sometimes diagnosed many years after traumatic event due to latent phase of disease possibly ranging from days to years.

Age and sex trends among mental health-related emergency department visits in North Carolina

Whether patients present to the emergency department (ED) with physical ailments and comorbid psychiatric needs or primary psychiatric complaints, understanding differences in clinically relevant age and sex patterns over time is crucial to optimal psychiatric care in the ED setting. We used population-level surveillance data provided by the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) from January 1, 2008, through December 31, 2014. Mental health-related (MHR) ED visits were identified by International Classification of Diseases, Clinical Modification 9th revision (ICD-9-CM) codes analyzed in the Agency for Healthcare Research and Quality (AHRQ) clinical classification software groupings of related diagnostic categories. Trends were assessed based on total and average annual visit counts. We identified approximately 4 million MHR ED visits. The average number of visits per year was highest among 50-year-olds, while patients over the age of 90 had the highest proportion of their ED visits associated with an MHR code. Mood disorders were more prevalent among females, while substance use disorders were more prevalent among males. Within MHR categories, age-related peaks did not differ by sex except for suicide and self-inflicted injury. Whether it be a teenage boy presenting with suicidal ideation, a middle-aged man presenting with alcohol abuse, or an elderly female presenting with dementia, ED MHR visits’ needs vary across the lifespan. Understanding these trends is important to holistic patient care.

An Approach to the Management of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia.

Benign prostatic hyperplasia (BPH) is a condition that affects up to 50% of men over the age of 50; the condition’s prevalence increases with age, particularly after the age of 40. BPH can lead to lower urinary tract symptoms (LUTS) which can have a significant negative impact on health-related quality of life (HRQoL). Men presenting with a gradual onset of LUTS are often suspected to have BPH. However, the clinician must recognize that LUTS possess many different aetiologies. This article aims to provide medical students with a stepwise approach to the diagnosis and management of LUTS that are secondary to BPH. The outlined approach describes the differential diagnoses, required investigations, and management-related details for LUTS that are secondary to BPH. This approach is based off of relevant Canadian, American, and European urological association guidelines.

Catastrophic Case of suppurative, Embolic and Fistulating Infective Endocarditis Causing Complete Heart Block

Complete heart block, aortic root abscess and aortic valve regurgitation are well-recognized complications of infective endocarditis of the aortic valve. Splenic abscess and aorto-cavitary fistula are rarer phenomena and are indicative of calamitous infection. The authors present the case of an otherwise healthy 61-year-old man presenting with a 2-month history of non-specific symptoms, who developed suppurative endocarditis with a fistulating aortic root abscess, combined with severe sepsis, splenic embolization and complete heart block. Staphylococcus lugdunensis was the causative bacterium identified. The combination of these sequelae in the same patient is sparsely reported, is exceedingly rare and carries a significant risk of mortality.

Age- and sex-related differences in community-acquired pneumonia at presentation to the emergency department: a retrospective cohort study.

Because of its associated high morbidity and mortality, early identification and treatment of community-acquired pneumonia (CAP) are essential. To investigate age- and sex-related differences in clinical symptoms, radiologic findings and outcomes in patients presenting to the emergency department (ED) with CAP. Retrospective cohort study. Patients admitted to one Swiss ED with radiologically confirmed CAP between 1 January 2017 and 31 December 2018. Primary aim was to evaluate differences in clinical and radiologic presentation of men vs. women and patients >65 years vs. <65 years with CAP. Secondary outcomes were age- and sex-related differences in terms of Pneumonia Severity Index (PSI) risk class, need for ICU referral, mechanical ventilation, in-hospital mortality, 30-day readmission and 180-day pneumonia recurrence. In total 467 patients with CAP were included. 211 were women (45%). 317 were ≥65 years (68%), of which 145 were women (46%). Older patients less commonly reported chest pain (13 vs. 27%; effect size 14%; 95% CI, 0.07-0.23), fever (39 vs. 53%, effect size 14%; 95% CI, 0.05-0.24), chills (6 vs. 20%; effect size 14%; 95% CI, 0.08-0.0.214), cough (44 vs. 57%; effect size 13%; 95% CI, 0.03-0.22), headache (5 vs. 15%, effect size 10%, 95% CI, 0.04-0.17) and myalgias (5 vs. 19%; effect size 14%; 95% CI, 0.07-0.21). However, 85% of patients with no symptoms were ≥65 years. PSI was lower in women [95 (SD 31) vs. 104 (SD 31); 95% CI, -14.44 to 2.35] and sputum was more common in men (32 vs. 22%; effect size 10%; 95% CI, -0.18 to -0.02). Raw mortality was higher in elderly patients [14 vs. 3%; odds ratio (OR), 4.67; 95% CI, 1.81-12.05], whereas it was similar in men and women (11 vs. 10%; OR, 1.22; 95% CI, 0.67-2.23). Patients, less than 65 years with CAP presenting to the ED had significantly more typical symptoms such as chest pain, fever, chills, cough, headache and myalgias than those being above 65 years. No relevant differences between men and women were found in clinical presentation, except for PSI on admission, and radiologic findings and neither age nor sex was a predictor for mortality in CAP.

A Case of Maple Syrup Urine Disease Diagnosed in Adulthood

Classic maple syrup urine disease (MSUD) is typically diagnosed in newborns, whereas nonclassic forms may manifest at any age. We describe a 58-year-old man presenting with recurrent encephalopathy, found with a nonclassic form of MSUD. This patient case highlights the importance of considering inborn errors of metabolism in the differential diagnosis of adult patients presenting with neurologic symptoms of unclear cause.

Hémangioendothéliome épithélioïde pleural, une tumeur rare de diagnostic difficile : à propos d’un cas et revue de la littérature

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor that develops in various organs. Primary pleural epithelioid hemangioendothelioma is an exceptional occurrence, with only forty cases reported in the literature. On account of its rarity, pleural EHE is difficult to diagnose. Differential diagnoses such as malignant pleural mesothelioma or lung carcinoma are often initially suspected. We herein describe the case of a 52-year-old man presenting with a primary pleural epithelioid hemangioendothelioma revealed by thoracic pain and having evolved for three months. Having reviewed the literature, we consider the clinical presentation and diagnosis modalities of this rare tumor. After an initial diagnosis of lung carcinoma, an ultrasound-guided biopsy was performed, confirming the diagnosis of pleural EHE in our patient. Ours is the first case of pleural EHE to be diagnosed with ultrasound-guided echography. Presentation of pleural EHE is often clinically and radiologically nonspecific. Most diagnoses are obtained by thoracoscopy, which allows for targeted biopsies and evacuation of pleural effusion. The diagnostic process for this rare tumor must be rigorous. Ultrasound-guided biopsy may be considered, provided that the lesions are accessible.

A Rare Case of Elevated Osmolar Gap in Diabetic Ketoacidosis/Hyperosmolar Hyperglycaemic State in the Absence of Concomitant Toxic Alcohol Ingestion

The serum osmolar gap, defined as the difference between measured osmolality and calculated osmolarity, is a convenient method to screen for toxins in serum. In normal circumstances, the difference between the two is 6–10 mol/kg. Typical contributors to serum osmolarity are sodium bicarbonate, sodium chloride, glucose and urea. An elevated gap, defined as a difference >10 mol/kg, can occur if a sufficient quantity of an additional solute other than those mentioned above is present in the serum or there are inaccuracies in sodium measurement secondary to hyperlipidaemia and hyperproteinaemia. An elevated serum osmolar gap should thus prompt clinicians to check for toxic alcohol levels. Treatment with fomepizole should not be delayed if suspicion is high. Isolated diabetic ketoacidosis can occasionally present with an elevated osmolar gap in the absence of concomitant alcohol ingestion. This finding is attributed to the production of acetone and glycerol.We describe the case of a 62-year-old man presenting with diabetic ketoacidosis/hyperosmolar hyperglycaemic state and an elevated osmolar gap in the absence of toxic alcohol ingestion.LEARNING POINTSThe osmolar gap is the difference between the measured and the calculated serum osmolarity and should be calculated in all patients presenting with elevated serum osmolarity; if elevated, toxic alcohol ingestion should be considered and prophylactic treatment with fomepizole immediately administered if the index of suspicion is high.Although toxic alcohol ingestion is one of the common causes of an elevated osmolar gap, hyperlipidaemia, hyperproteinaemia and less occasionally lactic acidosis and ketoacidosis have also been implicated.In the setting of ketoacidosis, the osmolar gap can be elevated in the absence of toxic alcohol ingestion, is attributed to increased production of acetone and glycerol, and is responsive to treatment with insulin and intravenous fluids.

Cholesterol Granuloma: An Underrecognized Cause of Benign Lung Granuloma.

A cholesterol granuloma is a benign lesion that can occur in various organs, mimicking other pathologies. We present the case of a 35-year-old man presenting with asymptomatic lung and pleural lesions which were suspected to be pulmonary tuberculosis but found to be cholesterol granuloma on biopsy. Cholesterol granulomas are a rare mimic of common lung pathology and should be considered in the differential diagnosis if the initial investigations are not informative.LEARNING POINTSPulmonary cholesterol granuloma is a benign lesion that radiologically mimics many sinister pathologies.The pathogenesis of pulmonary cholesterol granuloma remains obscure and extensive work-up is usually needed to rule out malignancy and infectious aetiology.

Without Your Therapist: Contemplative Prayer During Treatment as a Religious Exposure Intervention to Reduce Religious Struggle and Anxious God Representation

This case study focuses on the treatment of a 44-year-old Dutch man presenting with an anxious God representation and religious struggles according to DSM-5 criteria. Having received prior treatment for a panic disorder and alcohol use disorder, the patient was given a 60-day treatment in which the Jesus Prayer intervention was used to address his religious and spiritual problems. To our knowledge, this is the first case study involving the Jesus Prayer in the treatment of a patient. The intervention had positive effects on the patient’s religious and spiritual problems concerning an anxious God representation, religious struggles, stress levels and surrender to God. The intervention may also play a supporting role in decreasing symptoms of depression and anxiety and in promoting global mental health, as reliable change index analyses revealed symptom reduction between baseline levels and at post-assessment levels for all measured symptoms, with a semi-gradual decrease over the course of treatment. These improvements were continued in a 3-month follow-up assessment, suggesting promise for the Jesus Prayer as an effective treatment method for religious and spiritual problems. Recommendations regarding the importance of assessing the religious life of patients and implementing spiritual interventions are discussed, as well as the relevance of the therapist’s own assumptions when treating a religious or spiritual problem.

Robotic surgical management for extremely high-risk prostate cancer: case report and overview of recent literature evidences in the setting

Radical prostatectomy is recommended as a part of the multimodal treatment of high-risk or clinically advanced non-metastatic prostate cancer (PCa). In those cases, surgery could be challenging due to the possible cancerous invasion of peri-prostatic tissues that adversely affect the exposition and dissection. Moreover, a prior hormonal therapy may alter the plane between the rectum and prostate, likely resulting in an increased rate of local complications (ie rectal perforation) [1, 2]. According to the EAU Guidelines, the definition of high-risk cancer includes a PSA value exceeding 20 ng/ml. We describe the case of a young man presenting with a PSA value of 188 ng/ml, managed through robotic radical prostatectomy (RALP) at a referral center as a part of multimodal approach.

Sex-Differences in Oral Anticoagulant-Related Intracerebral Hemorrhage.

Introduction and AimData remain limited on sex-differences in patients with oral anticoagulant (OAC)-related intracerebral hemorrhage (ICH). We aim to explore similarities and differences in risk factors, acute presentation, treatments, and outcome in men and women admitted with OAC-related ICH.MethodThis study was a retrospective observational study based on 401 consecutive patients with OAC-related ICH admitted within 24 h of symptom onset. The study was registered on osf.io. We performed logarithmic regression and cox-regression adjusting for age, hematoma volume, Charlson Comorbidity Index (CCI), and pre-stroke modified Ranking Scale (mRS). Gender and age were excluded from CHA2DS2-VASc and CCI was not adjusted for age.ResultsA total of 226 men and 175 women were identified. More men were pre-treated with vitamin K-antagonists (73.5% men vs. 60.6% women) and more women with non-vitamin K-antagonist oral anticoagulants (26.5% men vs. 39.4% women), p = 0.009. Women were older (mean age 81.9 vs. 76.9 years, p < 0.001). CHA2DS2-VASc and CCI were similar in men and women.Hematoma volumes (22.1 ml in men and 19.1 ml in women) and National Institute of Health Stroke Scale (NIHSS) scores (13 vs. 13) were not statistically different, while median Glasgow Coma Scale (GCS) was lower in women, (14 [8;15] vs. 14 [10;15] p = 0.003).Women's probability of receiving reversal agents was significantly lower (adjusted odds ratio [aOR] = 0.52, p = 0.007) but not for surgical clot removal (aOR = 0.56, p = 0.25). Women had higher odds of receiving do-not-resuscitate (DNR) orders within a week (aOR = 1.67, p = 0.04). There were no sex-differences in neurological deterioration (aOR = 1.48, p = 0.10), ability to walk at 3 months (aOR = 0.69, p = 0.21) or 1-year mortality (adjusted hazard ratio = 1.18, p = 0.27).ConclusionSignificant sex-differences were observed in age, risk factors, access to treatment, and DNRs while no significant differences were observed in comorbidity burden, stroke severity, or hematoma volume. Outcomes, such as adjusted mortality, ability to walk, and neurological deterioration, were comparable. This study supports the presence of sex-differences in risk factors and care but not in presentation and outcomes.

Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR.

Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. TCAR was undertaken for a 58year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10months of follow-up. This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.