Recent Worsening Research Articles

L’échinococcose alvéolaire hépatique : une cause exceptionnelle de douleurs abdominales récurrentes, chirurgicalement curable, chez l’enfant

Hepatic alveolar echinococcosis is a rare parasitic zoonosis, potentially lethal in childhood. It is due to Echinococcosis multilocularis whose larva insidiously develops in the liver. We report the case of a 13-year-old girl, living in the Vosges Mountains, followed for recurrent abdominal pain, with recent worsening. Diagnosis of alveolar echinococcosis was immediately suspected based on the liver ultrasound scan and then confirmed by imaging (CT scan, NMR) and serology. A curative surgical treatment (segmentectomy) was performed 3 months after diagnosis, under oral albendazole treatment, maintained for at least 2 years. Hepatic alveolar echinococcosis usually has a negative prognosis, except if diagnosed early, which allows rapid surgical treatment, as in our patient.

Low-Dose Aripiprazole in the Treatment of SSRI-Induced Bruxism

Low-Dose Aripiprazole in the Treatment of SSRI-Induced Bruxism

Facial nerve palsy in the setting of malignant hypertension: a link not to be missed

A 38-year-old truck driver presented to our department with 1-week history of blurred vision and recent worsening of frontal headaches, which had been present for 6 months. He had no significant past medical history but could not recall if his blood pressure had ever been measured. His older sister had been diagnosed with malignant hypertension 4 years ago. He smoked 20 cigarettes per day. On examination, he was alert and orientated with a blood pressure of 242/150 mmHg. Visual acuity was decreased to 6/36 bilaterally and fundoscopy revealed bilateral papilloedema with exudates and haemorrhages. Neurological and systemic examination was otherwise unremarkable. Initial tests demonstrated renal impairment (creatinine 142 μmol/l), blood and protein in the urine and electrocardiographic evidence of left ventricular hypertrophy. A computerised tomogram (CT) of the brain was normal. A diagnosis of malignant hypertension was made and the patient’s blood pressure was lowered gradually with a combination of oral modified-release nifedipine, bisoprolol and bendroflumethiazide. Two days after admission the patient developed acute-onset left-sided facial weakness. Examination revealed …

IgG4-related Sclerosing Disease of the Small Bowel Presenting as Necrotizing Mesenteric Arteritis and a Solitary Jejunal Ulcer

Since first described in the mid 1990s, there has been burgeoning literature on IgG4-related sclerosing disease. The number of sites that may be involved is ever increasing, with the pancreas, salivary glands, and lymph nodes being the most commonly affected organs. There are no well-documented cases arising in the gastrointestinal tract. In this report, we present the first case to our knowledge of IgG4-related sclerosing disease involving the small bowel with a distinctly unusual clinicopathologic presentation. A previously well 46-year-old woman presented with a 2-year history of intermittent abdominal pain with recent worsening due to small bowel obstruction. Following imaging, which showed jejunitis with surrounding mesenteric inflammatory changes, she proceeded to a segmental small bowel resection. The resected jejunum revealed an isolated, stenosing chronic ulcer associated with a necrotizing mesenteric arteritis. A transmural inflammatory infiltrate rich in IgG4 plasma cells was seen in the wall of the bowel and mesenteric artery. Abundant IgG4 interfollicular plasma cells were also identified in a mesenteric lymph node. The serum IgG4 level was elevated at >800 mg/dL (reference range 8 to 140 mg/dL). Although phlebitis is an almost constant feature of this disease, arteritis is not described other than in the lung and aorta. In this report, we also discuss the diagnostic pitfalls and the differential diagnoses that should be considered when this condition arises in the gastrointestinal tract.

Chronic Migraine-Like Headache Caused by a Demyelinating Lesion in the Brain Stem

To the Editor: The term “chronic migraine” officially appeared for the first time in the International Classification of Headache Disorders, 2nd Edition criteria (ICHD-II) [1]. Now, the 2006 revised diagnostic criteria for chronic migraine [2] are preferred to the official 2004 ICHD-II criteria [1]. Clinically isolated syndrome (CIS) has been defined as a single neurological episode at first presentation with suspected underlying inflammatory demyelinating disease [3]. Headache associated with demyelinating lesions is characterized by clinical features that, in most cases, meet the ICHD-II criteria [1] for tension headache or migraine. Because these headaches cannot be regarded, by definition, as “primary,” they are commonly defined as “tension-like headaches” or “migraine-like headaches.” Here, we describe the case of a 16-year-old girl who showed the onset of chronic migraine-like headache in association with the appearance of a T2-hyperintense lesion localized in the right dorsolateral pons and the right middle cerebellar peduncle (MCP). On March 2, 2009, the girl came to our attention for a recent progressive worsening of a 5-month history of right-sided nuchal-occipital throbbing headache, nausea, vomiting, and drowsiness. Two days before, she had developed hypoesthesia in the region of the second branch of the trigeminal nerve on the right side. Her past medical history was significant for a migraine without aura [1] …

Physical Therapists Referring Patients to Physicians: A Review of Case Reports and Series

Descriptive. An important role for physical therapists in the healthcare delivery system is to recognize when patient referral to a physician or other healthcare provider is indicated. Few studies exist describing physical therapists' evaluative and diagnostic processes leading to patient referral to a physician. To summarize published patient case reports that described physical therapist/patient episodes of care that resulted in the referral of the patient to a physician and a subsequent diagnosis of medical disease. A literature search identified 78 case reports describing physical therapist referral of patients to physicians with subsequent diagnosis of a medical condition. Two evaluators reviewed the cases and summarized (1) how and when patients accessed physical therapy services, (2) timing of patient referral to a physician, (3) resultant medical diagnoses, (4) physical therapists' role in referral of patients for diagnostic testing, and (5) relevant patient symptom description, health history, review of systems, and physical examination findings. Fifty-eight (74.4%) of 78 patients had been referred to a physical therapist by their physician, while the remaining 20 patients accessed physical therapy services via direct access. The patients' primary presenting symptoms included pain (n = 60), weakness (n = 4), tingling/numbness (n = 2), or a combination (n = 12). Patient referrals to a physician occurred at the initial physical therapy session in 58 (74.4%) of 78 cases. A majority of patient referrals to a physician (n = 65) were related to primary presenting symptoms, including manifestations inconsistent with physician diagnosis, recent worsening without cause, unusual accompanying symptoms such as fatigue and/or weakness, and inadequate response to treatment. Resultant diagnoses included neuromusculoskeletal disorders (n = 53; fractures and tumors most common), visceral disorders (n = 14; cardiovascular involvement most common), and medication-related disorders (n = 3). This review of published patient case reports provides numerous examples of physical therapists using effective multifactorial screening strategies for referred and direct-access patients, leading to timely patient referrals to physicians. The therapist-initiated patient referral to a physician led to subsequent diagnosis of a wide range of conditions and pathological processes.

Intradural disc herniation - a case report

Intradural disc herniation is a rare entity that occurs most commonly in the lumbar spine particularly at L4-L5 region. Most often it is diagnosed intraoperatively in a case of simple intervertebral disc herniation. Contrast enhanced MRI is mandatory for pre operative diagnosis. We describe a case of a 40-year-old female who presented to us with pain lower back, pain in both lower limbs and urinary retention after a fall. She had previously been diagnosed as a case of prolapsed intervertebral disc disease and was being managed conservatively. An unenhanced MRI revealed a large disc herniation at L4-L5 level. L4 and L5 laminectomy was performed and a hard intradural mass was palpable. On opening the dura a fragment of intervertebral disc was found with a small rent in the anterior dura. The fragment was removed and the rent was sutured. The patient recovered well from the surgery. Intradural disc herniations must be considered in the differential diagnosis of prolapsed intervertebral disc disease especially with recent worsening of symptoms and mismatch of unenhanced MRI findings with intraoperative findings.

Noninvasive Positive Pressure Ventilation against Reperfusion Pulmonary Edema following Percutaneous Transluminal Pulmonary Angioplasty

A 69-year-old man with chronic thromboembolic pulmonary hypertension (CTEPH) was on amblatory oxygen inhalation therapy (3 L/min) and scheduled for percutaneous transluminal pulmonary angioplasty (PTPA). The patient's New York Heart Association functional status was class III with recent worsening of dyspnea and apparent leg edema. Transthoracic echocardiography revealed right ventricular enlargement with mean pulmonary artery pressure of 42 mmHg. After PTPA, he was complicated with postoperative reperfusion pulmonary edema, and noninvasive positive pressure ventilation (NPPV) was applied immediately. Hypoxemia was successfully treated with 15 days of NPPV. Although mean pulmonary artery pressure was unchanged, his brain natriuretic peptide level decreased from preoperative 390.3 to postoperative 44.3 pg/dL. In addition, total pulmonary resistance decreased from preoperative 18 to postoperative 9.6 wood unit·m2. The patient was discharged on day 25 with SpO2 of 95% on 5 L/min of oxygen inhalation. Because pulmonary edema is a postsurgical life-threatening complication following PTPA, application of NPPV should be considered.

Ranolazine-Tacrolimus Interaction

To report the case of a kidney allograft recipient on a stable regimen of tacrolimus who exhibited increased tacrolimus concentrations within 24 hours of initiating ranolazine. A 64-year-old kidney allograft recipient on a stable dose of tacrolimus (10 mg twice daily) was admitted for recent worsening of her chronic anginal pain. The patient was initiated on ranolazine 500 mg twice daily on hospital day 2. Tacrolimus concentrations rose from 7.0-10.1 ng/mL preadmission to 17.8 ng/mL within 24 hours of ranolazine initiation. Ranolazine therapy was continued due to the patient's beneficial response; therefore, the tacrolimus dose was eventually decreased by 70% to 3 mg twice daily to maintain steady-state trough concentrations between 6.6 and 7.9 ng/mL with ranolazine therapy. Ranolazine dechallenge on a subsequent admission produced subtherapeutic tacrolimus concentrations requiring dosage increases. Ranolazine, an antianginal agent, is both a substrate and a weak inhibitor of CYP3A as well as a substrate and moderate inhibitor of the P-glycoprotein (P-GP) efflux transport system. Tacrolimus, an immunosuppressant, is also a substrate of CYP3A and P-GP. Through possible inhibition of both P-GP- and CYP3A-mediated first-pass metabolism and CYP3A systemic metabolism, ranolazine may have significantly increased serum concentrations of tacrolimus necessitating an eventual 70% decrease in the tacrolimus dose. Based on the Horn Drug Interaction Probability Scale, this interaction is possible. We suggest that the eventual 70% decrease in tacrolimus dose after ranolazine initiation may indicate that ranolazine decreases the metabolism and clearance of tacrolimus, causing an elevation in tacrolimus concentrations and the potential for tacrolimus toxicity. Clinicians should be aware of this possible interaction when initiating ranolazine in patients on tacrolimus.

Plasmapheresis Does Not Affect Polysomnographic Parameters in Patients With Myasthenia Gravis: A Case Series Study

The purpose of this study was to evaluate the influence of plasmapheresis on sleep in patients with generalized myasthenia gravis and no respiratory symptoms. Seven myasthenia gravis patients, four women and three men, aged 24-52 years, underwent plasmapheresis treatment because of recent worsening of clinical weakness and poor response to previous treatments. We prospectively recorded the myasthenia gravis score, measured acetylcholine-receptor antibody concentration, performed polysomnography, and checked the Epworth Sleepiness Scale at baseline and 1 day after completion of the last session of plasmapheresis. Myasthenic weakness was ameliorated following plasmapheresis in all patients with a median decrease in myasthenia gravis score of 2 points (P = 0.0002) and a median clearance of 43.3% of acetylcholine-receptor antibody. However, there was no significant change in polysomnographic parameters, except for a trend toward shorter duration of the longest apnea period (P = 0.0763) following the treatment. Plasmapheresis did not affect polysomnographic parameters despite improved clinical weakness along with decreased myasthenia gravis score and acetylcholine-receptor antibody concentration.

Irreversible Optic Neuropathy in Wernicke Encephalopathy and Leber Hereditary Optic Neuropathy

A 52-year-old woman with alcohol abuse presented with recent worsening of vision, imbalance, and confusion. Examination revealed counting fingers acuity in both eyes with central scotomas, color vision loss, horizontal nystagmus, and gait ataxia. Thiamine was initiated as treatment for a presumptive diagnosis of Wernicke encephalopathy (WE). Brain MRI revealed high T2 signal in the dorsal midbrain and thalami characteristic of WE. The lack of optic disc edema, usually present in patients with WE who have severe optic neuropathy, and lack of visual loss reversibility with thiamine treatment, led to the suspicion of coexisting Leber hereditary optic neuropathy (LHON), which was later confirmed when testing revealed the 14484 mitochondrial DNA mutation. Over the ensuing months, vision did not recover despite improvement of other neurologic findings. Irreversible optic neuropathy in WE should prompt consideration of a coexisting mitochondrial disorder such as LHON.

Olanzapine and pancytopenia with severe folate deficiency

To the editor: Olanzapine, a thienobenzodiazepine serotonin-dopamine antagonist, is a recent atypical antipsychotic agent, with a structural and pharmacologic profile similar to that of clozapine. Although clozapine is effective in refractory schizophrenia, its use is limited by the occurrence of hematologic adverse effects, such as agranulocytosis, which occurs in 0.5–2% of treated patients [1]. Many studies have suggested a better hematologic safety profile for olanzapine, but impaired granulocytopoiesis and thrombocytopenia have recently been reported [2-6]. No case of pancytopenia with megaloblastic anemia has been described with the use of olanzapine. We report a case of pancytopenia with severe folate deficiency in a schizophrenic patient treated with olanzapine. A 56-year-old man, who worked as a painter, was a heavy smoker, had bad dental health, and a history of chronic psychosis was hospitalized on 11 August 2008 with severe pancytopenia, suggested by purpura. He had been living with his brother and had been treated for many years with haloperidol decanoate (3 mg every 3 weeks), loxapine (100 mg/day), amisulpride (800 mg/day), tropatepine (10 mg/day), diazepam (10 mg/day), and clorazepate (50 mg/day). Because of recent worsening of his psychotic symptoms, olanzapine was introduced (20 mg/day) in May 2008. The laboratory data on admission and during the early period of hospitalization are shown in Table 1. The hemogram and reticulocyte count revealed pancytopenia with macrocytic normochromic aregenerative anemia. The folate plasmatic level was dramatically decreased, total protein and cobalamin were slightly decreased, and renal and hepatic functions were normal. Shortly after admission, only olanzapine was discontinued. The patient received probabilist cobalamin supplementation with no immediate hematologic improvement. On 14 August, he began to receive intravenous folate supplementation (50 mg/day). Ten days later, a huge reticulocyte crisis was observed, whereas the white blood cell and platelet counts were significantly increased (Table 1). Meanwhile, the results of bone marrow aspiration confirmed the diagnosis of megaloblastic anemia. The patient was supplemented with folic acid over 2 weeks. Because the medical staff decided against restarting olanzapine, the loxapine dosage was increased to 150 mg/day with a good response. Computerized tomography imaging showed hepatic abnormalities consistent with portal hypertension. On 4 September, the macrocytic anemia recovered and folate supplementation was discontinued. One month after admission, gastric endoscopy revealed grade I peptic esophagitis without esophageal varix. The biopsies were all negative, thus ruling out celiac disease. At this time, his laboratory data only showed a slight macrocytosis with no anemia. At the 3-month follow-up, olanzapine had not been restarted and the patient had a perfect clinical examination, despite discontinuation of folate supplementation. F. Maurier : J.-F. Guichard Department of Internal Medicine, Vascular Medicine and Clinical Immunology, Ste Blandine Hospital, Metz, France

Endoscopic features of short-term progression of esophageal intramural pseudodiverticulosis

year history of intermittent dysphagia. There was no other relevant medical history. A barium esophagogram revealed a stenotic lesion in the middle and lower thoracic esophagus with multiple intramural tracks [1]. Endoscopic examination revealed an annular stricture of the esophagus extending from 27 cm to 40 cm from the incisors, aswell asmultiple small orifices (● Fig. 1). A diagnosis of esophageal intramural pseudodiverticulosis (EIPD) was suspected. As the patient did not have diabetes, candidal esophagitis, or esophageal carcinoma, and because esophageal inflammation has been reported in up to 90% of patients with EIPD [2], we prescribed a proton-pump inhibitor to suppress gastric acid secretion. However, after 7 months, the patient could barely swallow food, and repeat endoscopy showed that the lesions had clearly progressed. The multiple diverticula had enlarged and the lumen was criss-crossed by multiple mucosal bridges (● Fig. 2). Computed tomography of the chest showed marked thickening of the esophageal wall with intramural air sacs running parallel to the lumen of the upper to lower thoracic esophagus (● Fig. 3). A subtotal esophagectomywas carried out in view of the recent worsening of symptoms and endoscopic findings. On histological examination, the esophageal wall was remarkably thickened by submucosal fibrosis and hypertrophic muscularis propria. Dilated excretory ducts were seen extending from the mucosal epithelium to the submucosal layer (● Fig. 4). There were no features of malignancy in the esophageal wall or the regional lymph nodes, and a final diagnosis of EIPD was made. After surgery, the patient’s dysphagia improved, and he has remained asymptomatic on follow up. To our knowledge, this is the first report of EIPD with a hypertrophic muscular layer in the esophageal wall, as demonstrated in a full-thickness histological specimen [3,4]. Furthermore, with serial endoscopy, we observed the progression of EIPD in the short term.

Medical Screening and Evacuation: Cauda Equina Syndrome in a Combat Zone

Resident's case problem. Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential. A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit. This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery. Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999.

Drug eluting stent induced coronary artery aneurysm repair by exclusion. Where are we headed?

We present a case of left anterior descending (LAD) coronary artery aneurysm at the site of previous stent placement 3 years previously. The patient presented with recent worsening of angina. Angiography and 64 slice CT angiography confirmed the presence of 6mm aneurysm of LAD at the site of previous stent involving the origin of diagonal, with thrombus proximal and distal to the stent. This patient was successfully managed by taking the posterior wall of the anterior descending artery while suturing the heel of the left internal mammary artery (LIMA)-LAD anastomosis. The idea was to create severe stenosis upstream to prevent distal embolisation from the site of aneurysm. The diagonal was grafted with a saphenous venous graft. Follow-up angiogram at 3 months demonstrated successful exclusion of the aneurysm and unobstructed flow through the grafts.

A woman with abdominal pain and headache

We describe a case of a 27-year-old woman who came to the Emergency Department presenting severe abdominal pain. She was evaluated by a gynaecologist and submitted to pelvic ecography without finding relevant alterations. In the successive hours, she presented severe headache in occipital region and in the posterior neck, poorly responsive to analgesic drugs. A cerebral CT scan was performed and was normal, and the patient came to our Department of Neurology. The neurological examination on admission was normal. This woman had a 7 years of long-lasting history of headache, diagnosed in another hospital as migraine without aura, and she referred a recent and progressive worsening of both the frequency and the severity of the headache. In the suspect of subarachnoidal haemorrhage, a lumbar puncture was performed, and was negative for bleeding, showing only a mild increase in the number of cells (12 leucocytes). Following the lumbar puncture, the patient presented a dramatic improvement of the headache. In the successive days, she lamented sellar hypoesthesia and, when asked, she referred a recent history of urinary and faecal retention. She was, therefore, submitted to an NMR of the lumbar and sacral medulla with evidence of a voluminous extradural formation in the sacral region suggestive for extradural sacral meningeal cyst. She was finally dispatched to the Department of Neurosurgery for surgical asportation of the cyst.

The ketogenic diet improves recently worsened focal epilepsy

We observed a dramatic response to the ketogenic diet in several patients with highly refractory epilepsy whose seizure frequency had recently worsened. This study aimed to identify whether this characteristic was a useful indication for the ketogenic diet. From the 70 patients who received the ketogenic diet during a 3-year period at our institution, we retrospectively selected patients with focal epilepsy. There were 22 children, 13 females and nine males, aged from 5 months to 18 years 6 months (mean 6y 9mo, SD 5y 11mo). Fifteen had symptomatic and seven had cryptogenic focal epilepsy. Seizure frequency 1 week before initiating the ketogenic diet was compared with that at 1 month and at the last visit on the diet. Eleven patients were responders (defined as reduction of seizures by more than 50%) at 1 month. Responders were higher (p=0.046) in the group with a recent worsening of seizures than in those with stable seizure frequency. Seven patients were still seizure-free at 6 months on the diet. Tolerability was excellent in 10 patients. Five patients stopped the diet because of early side effects. The ketogenic diet may be a valuable therapeutic option for children with pharmacoresistant focal epilepsy, particularly those with a recent deterioration of seizure control and neurological status. Because of its rapid effect, the ketogenic diet may be a useful support to intravenous emergency drugs in such a situation.

Cystic Fibrosis Diagnosed at Age 45 Based on Symptoms of Acute Pancreatitis

13 CASE PRESENTATION A 45-year-old Caucasian woman was hospitalized because of progressively worsening midepigastric abdominal pain for 5 days. The pain, which was insidious in onset, was described as constant, nonradiating, nonpositional, and exacerbated by eating and drinking. She also had fever, chills, night sweats, nausea, and nonbilious vomiting for 1 day. She denied biliary colic, jaundice, scleral icterus, abdominal distention, hematemesis, melena, hematochezia, diarrhea, menorrhagia, or metromenorrhagia. She had had recurrent streptococcal and Pseudomonas sp. pneumonias since childhood. She was a nonsmoker, was diagnosed with bronchiectasis several years earlier, and had a chronic cough productive of yellow sputum. She had Mycobacterium avium pulmonary infection at age 40 and nasal polyps at age 42. She took minocycline for approximately 1 year for acne and levofloxacin orally for recent worsening of her chronic productive cough. Both her mother and father had type II diabetes mellitus. She did not drink alcohol, smoke, or use illicit drugs. She had no tattoos and no history of sexually transmitted diseases or blood transfusions. On admission, her temperature was 98.7°F; heart rate, 93 beats per minute; blood pressure, 129/77 mm Hg; respiratory rate, 18 breaths per minute; and arterial oxygen saturation, 98% on room air. Her body mass index was 29.4 kg/m2. She was mildly distressed due to abdominal pain. She was not jaundiced. Her mucus membranes were dry and pink. The neck was supple, with no jugular venous distention, thyromegaly, or lymphadenopathy. Her abdomen was soft and nondistended, and bowel sounds were diminished. There was exquisite tenderness to palpation in the midepigastrium approximately 4 cm above the umbilicus, with no rebound or guarding. Murphy’s, Cullen’s, and Grey Turner’s signs were not present. She had no hepatosplenomegaly, suprapubic tenderness, or palpable masses. The patient’s white blood cell count was 13,600 cells/mm3. Serum amylase and lipase levels were 477 and 512 units/L, respectively. Serum triglyceride and calcium levels were 46 and 8.9 mg/dL, respectively. Computed tomography of the abdomen/pelvis was significant for acute pancreatitis (Figure 1) without necrosis or abscess. No gallstones, strictures, or bile duct dilatation were visualized; bronchiectasis (Figure 2) was present in the lingula and right middle lobe. Endoscopic ultrasound disclosed no abnormalities. The common bile duct was 5.8 mm in diameter. Sputum cultures were positive for Pseudomonas aeruginosa. The patient was placed on bowel rest and given 0.9% normal saline at 200 cc/h and intravenous morphine as needed for pain. Her 10-day regimen of oral levofloxacin was continued. The patient’s abdominal pain lessened within the first 48 hours of admission, and an oral diet was initiated on hospital day 3. Her amylase and lipase levels decreased to normal by hospital

Suspicion of elder abuse in South Eastern Spain: The extent and risk factors

Elder abuse is recognized internationally as a growing problem. Recent years have seen an increase in the number of authors recommending that the MDs systematically question old people concerning possible abuse. The aim of our study was to ascertain the extent of suspicion of elder abuse and the different types of abuse. We design a cross-sectional survey including 460 patients ≥65 years at different health centers (South East Spain). A face-to-face interview and a physical examination was carried out. Extent of suspected abuse was 44.6%. Female sex, ≥75 years, widowhood, living alone or with children, accommodation in house of relatives and income ≤300€/month were the associated sociodemographic variables. The risk factors associated are recent worsening of health, living with a mentally ill person, excessive consumption of alcohol or illegal drugs, arguing frequently with relatives or the dependence on someone to carry out a daily activity. The signs in the physical examination associated are dehydration/malnutrition, pressure ulcers and poor body and/or mouth hygiene. There is a high extent of suspicion of elder abuse and the keyword in this respect is prevention.

Characteristics of hepatocellular carcinoma in India: a retrospective analysis of 191 cases

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The outcome of the disease is related to the stage of presentation. A comprehensive analysis of patients with this disease is not available in India. Retrospective chart review of 246 patients with HCC was done. One hundred ninety-one patients (male 160, female 31; median age 52 years, range 9-85 years) fulfilling diagnostic criteria for HCC adopted by Barcelona-2000 EASL conference were analyzed for clinical, etiological, radiological and cytohistological profile. Underlying cirrhosis was seen in 60% cases with hepatitis B being the most common etiologic agent. HCC caused new onset ascites and recent worsening in three-fourth cases with ascites. Paraneoplastic syndrome was a rare event in HCC in India. Diagnostic level of serum AFP was seen in only 46% with significant difference between cirrhosis HCC patients compared with non-cirrhosis HCC patients (53% vs. 26%; P = 0.046). Most cases (83%) presented at advanced stage (Okuda III or IV) and cytohistology was the best method to diagnose HCC. Vascular invasion was seen in half the patients (53%) by the time they presented with extrahepatic spread of tumor in 13% cases. The prevalence of advanced stage HCC makes most of the detectable lesions unsuitable for curative resection. However, universal hepatitis B vaccination program may become the most effective preventive measure to control this disease in India.