Routine Follow-up Research Articles (Page 1)

Everolimus is used in the treatment of patients with advanced neuroendocrine tumors (NET) and is administered at fixed doses despite known interpatient pharmacokinetic variability. This may affect both efficacy and tolerability. We wanted to investigate the relationship between prescribed dose, blood trough concentrations (Ctrough), and toxicity in NET patients receiving everolimus in routine clinical practice. In this prospective observational study NET patients were treated with everolimus, mostly as third- or fourth-line therapy. Dose was adjusted according to adverse effects and tumor response. Concentrations (Ctrough) of everolimus were measured at each routine follow-up and correlated to dose and cumulative adverse event (cAE) scores. Associations were evaluated using linear and generalized linear mixed models which accounted for repeated measurements within patients and varying dose regimens over time. Thirty-six patients were included. Everolimus dose was a significant predictor of Ctrough (p < .001), but considerable interindividual variability was observed. Median Ctrough levels increased with dose: 3.9, 5.1, 7.4, and 16.4 ng/mL for 2.5, 5.0, 7.5, and 10.0 mg per day, respectively. Considerable overlap in blood concentration was observed across dose groups; patients receiving 2.5 mg reached levels as high as 8.6 ng/mL, while those on 5 mg exhibited a wide range from 1.1 to 21.2 ng/mL. Ctrough ≥ 6.0 ng/mL was associated with increased toxicity (p = .03), whereas nominal dose was not a reliable independent predictor of adverse events. Although median blood concentrations increased with higher doses, there was considerable variation between patients, resulting in overlapping concentration ranges across all dose groups. This indicates that fixed-dose regimens may not reliably predict systemic drug exposure. Everolimus blood concentrations were superior to dose levels in predicting adverse events. Therapeutic drug monitoring and individualized dose adjustment may improve the balance between efficacy and toxicity in NET patients treated with everolimus.

Introduction: Appendiceal neuroendocrine neoplasms (aNENs) are the most common malignant appendiceal neoplasms. Localized aNENs are typically managed with an appendectomy; however, right colectomy may be necessary in patients with a high risk of nodal disease. However, the role of right hemicolectomy and the optimal surveillance strategy, particularly for tumors between 1 and 2 cm, remains controversial. Material and Methods: This retrospective, observational study evaluated patients diagnosed with aNENs between January 1995 and July 2015 at two tertiary centers in Ireland and Italy. Data were extracted from a prospectively maintained registry and included clinical, pathological, and therapeutic variables, as well as follow-up outcomes. Results: Forty-three patients (41.8% male; median age 27.5 years) were included, with a median follow-up of 49 months. The median tumor size was 6.4 mm (range: 0.6–40 mm). The majority were G1 tumors (58%), and staging distribution was predominantly Stage I (60%). While no significant differences in demographics or tumor features were observed between centers, completion right hemicolectomies were more frequent in the Irish cohort (p = 0.04). Follow-up practices varied, with more intensive imaging and biochemical monitoring observed in the Italian cohort. Overall prognosis was excellent, with a single case of recurrence during the study period. Conclusions: Most aNENs are effectively managed with appendectomy alone, and routine follow-up may be unnecessary in the absence of adverse pathological features. Accurate risk stratification, driven by comprehensive histopathological assessment, is critical for optimizing management and surveillance strategies.

Cerebrospinal fluid-venous fistulas (CVF) are a common cause of spontaneous intracranial hypotension (SIH) and can be treated with transvenous embolization (TVE). Rebound intracranial hypertension (RIH) is an important periprocedural consideration after TVE and CSF leak closure. The purpose of this study was to determine the incidence and severity of post-procedure RIH among patients with CVFs treated with TVE. This investigation was a single center, retrospective cohort of consecutive patients treated with TVE for SIH due to a CVF. Patients were included who had early (1-3 days post-TVE procedure) clinical follow-up documenting presence/severity of RIH. RIH was classified as absent, mild (i.e. rated 1-4/10 in severity), moderate (i.e. rated 5-7/10), or severe (i.e. rated 8-10/10). Rate of RIH was then determined. Logistic regression analysis was used to evaluate for clinical predictors of moderate-to-severe RIH and need for eventual therapeutic lumbar puncture (LP). In total, 100 consecutive patients (mean age, 59.4 years old, 63% female) who underwent 105 TVE procedures for 132 CVFs were included. RIH of any severity (mild to severe) occurred in 80% of cases after TVE and was moderate-to-severe in 54% of cases. A therapeutic LP was needed for RIH in 8 cases (7.6%). On multivariate regression, TVE of a single CVF (versus >1 CVF) was independently associated with occurrence of moderate-to-severe RIH (OR: 2.8 [CI: 1.04 to 7.85], p=0.04). Furthermore, higher pre-TVE opening pressure (third tertile, 17-28 cmH2O) was associated with eventual need for therapeutic LP (OR: 5.0 [CI: 1.14 to 25.9], p=0.03). Early RIH is common after TVE, with symptoms occurring in 80% of all cases. Approximately half of patients will experience moderate-to-severe RIH early after TVE. These findings underscore the value of routine early follow-up after TVE and emphasize the need for proceduralists to be familiar with management strategies for RIH. TVE＝ Transvenous embolization; RIH = Rebound intracranial hypertension; CVF = cerebrospinal fluid-venous fistula.

Chest computed tomography (CT) surpasses chest radiography (CR) in accurately assessing disease severity and detecting early structural pulmonary changes in patients with cystic fibrosis (CF). Chest CT provides detailed visualisation and quantification of CF-specific lung pathologies and can reveal these changes before they manifest clinically or become detectable on CR. The past decade has witnessed the advent and refinement of radiation-reducing techniques in CT which have enabled substantial dose reductions. Our study prospectively evaluates the efficacy of ultra-low dose CT (ULDCT) chest in identifying pulmonary changes within a paediatric patient cohort. Paediatric patients with CF, who presented for routine clinical outpatient follow-up between 01/07/2022, and 01/07/2023 underwent ULDCT and CR (if not recently performed) and image analysis was performed. Radiation dose, subjective and objective image quality and disease severity were recorded. 45 patients (mean age 10.5 years) underwent clinically indicated ULDCT chest ± CR. The mean effective dose was of ULDCT was 0.07 ± 0.01 mSv, a dose that approximates that of a frontal and lateral chest radiograph. The average ULDCT Brody II severity score across the entire cohort was 5.62, with excellent inter-rater reliability and intra-class correlation coefficient (ICC) of 0.98 (95% CI = 0.96, 0.99). The average Chrispin-Norman score on chest radiograph was 0.93 with moderate inter-rater reliability and ICC of 0.64 (95% CI = 0.19, 0.83). In light of its superior diagnostic capabilities, minimal radiation dose penalty, we advocate for ULDCT to be the preferred modality for surveillance imaging in paediatric patients with CF.

This case report describes the clinical process of a patient with a history of nasopharyngeal carcinoma (NPC) who was initially misdiagnosed with a metastatic tumor, later confirmed to be an inflammatory pseudotumor (IPT). The patient was a 68-year-old male individual who was diagnosed with nasopharyngeal carcinoma 4 years ago. The condition was well controlled after regular radiotherapy and chemotherapy. One year ago, a solid mass was found in the left lateral lobe of the liver during routine follow-up. MRI suggested nasopharyngeal carcinoma metastasis. Later, MRI at Peking Union Medical College Hospital also suggested nasopharyngeal carcinoma metastasis. Intrahepatic cholangiocarcinoma was not excluded, and surgical treatment was recommended. Preoperative biopsy was recommended by the multidisciplinary team (MDT); however, the patient declined due to financial constraints and personal preference. The patient underwent laparoscopic left lateral hepatectomy and hilar lymph node dissection at the Affiliated Hospital of Chengde Medical College. Postoperative pathology showed dense infiltration of neutrophils, lymphocytes, and eosinophils, with no malignant components, consistent with an inflammatory pseudotumor. The diagnosis was further confirmed by pathological review and immunohistochemistry at Peking Union Medical College Hospital. The patient recovered well after the operation, and there was no recurrence during 1 year of follow-up. This case suggests that in patients with a history of malignant tumors, even when imaging is highly suspicious of tumors, we should still be vigilant for infectious lesions and avoid anchoring bias. Preoperative biopsy and multidisciplinary comprehensive evaluation (MDT) can help clarify the diagnosis and reduce misdiagnosis and overtreatment.

Hearing loss is a prevalent condition that impacts on social, mental and physical health, and has a significant economic burden. Hearing aids can improve the quality of life for those living with hearing loss; however, low and inconsistent use remains common. Within the National Health Service (NHS), follow-up care for new hearing aid users is highly variable and often lacks structure, which may contribute to low use. The FAMOUS trial investigates whether a structured care model for follow-up, combined with evidence-based behaviour change interventions, improves hearing aid use compared to usual care. FAMOUS is a multi-centre, two-arm parallel-group cluster randomised controlled trial (CRCT) with integral internal pilot, economic, and process evaluations. The trial involves 36 NHS audiology services and compares two types of follow-up for new adult hearing aid users: structured care, which includes personalised action plans, early monitoring, and routine follow-up at 6weeks post-fitting, to usual care, which includes the offer of a follow-up 6-12weeks after fitting. Recruitment is conducted through participating services over 3 months, with pseudo-anonymised routine data collected from electronic medical records of all patients who attend. Consent and outcomes are then collected from patients at 12weeks post-fitting. For patients who provide consent to future contact, the primary outcome (self-reported daily hearing aid use) is collected at 12months post-fitting. Secondary outcomes (quality-of-life (QoL), hearing-related disability, and economic measures) are collected at both timepoints. Qualitative interviews with a subset of patients and hearing professionals in the intervention arm will assess the acceptability and implementation of the intervention. Statistical analyses, including mixed-effects regression modelling, will be conducted under an intention-to-treat framework. FAMOUS addresses a critical evidence gap regarding the potential benefits of follow-up care for new hearing aid users. If the intervention is successful, it can be rolled out nationally using existing facilities with limited impact on resources, identified in the economic analysis, and would improve hearing aid use and quality of life for those living with hearing loss. Prospectively registered with the International Standard Randomised Controlled Trial Number (ISRCTN) 10589817.Date of registration: 01/09/2022.

Background: Most of the emphases on treatment of Diabetes Mellitus (DM) have been on physical symptoms neglecting the psychological problems that also arise while one suffers Diabetes. Aim: To demonstrate the occurrence of depression and the associated risk factors in patients with type 2 diabetes mellitus (T2DM). Method: It was a cross-sectional study of consecutive DM subjects who came for their routine follow-up visit at the out-patient department of Enugu State University Teaching Hospital (ESUT), Nigeria. They were interviewed with clinical and sociodemographic questionnaire to obtain information about their age, gender and employment status, HbA1c levels, duration of illness (type 2 diabetes), age at diagnosis, comorbidity, complications of diabetes. Patient`s Health Questionnaire-9 (PHQ-9) was used to assess for the presence of depression among the participants. Data collected was analyzed to find the mean, standard deviation and establish associations using Chi-Square test, T-test. Result: About 16% of the participants were depressed, and majority of them (82%) were females. Most of those with complications (73.5%), and comorbid conditions (59.6%) were not depressed. Association of gender, presence of complications and comorbidities, age of onset of diabetes, time duration of diabetes, HbA1c level and employment status to the manifestation of depression were not statistically significant. Conclusion: It is likely that the actual risk factors for depression among the diabetics are internal factors like one’s genetic constitution and/or personality traits in this environment. Therefore, a more elaborate prospective studies considering the contribution of genetic and personality characteristics to development of depression in diabetics is recommended.

Background: Accurate assessment of right ventricular (RV) volume is crucial for monitoring patients with congenital heart defects (CHD). However, due to the RV's complex geometry, 2D transthoracic echocardiography (2D TTE) is challenging, and MRI is commonly used to evaluate RV volume. Despite its accuracy, MRI has several limitations: it lacks bedside imaging, is time-consuming, costly, and often requires sedation in CHD patients. Therefore, this study aimed to develop a reliable, simple, and quick method for calculating RV volume using 2D TTE. Methods: Standard apical four-chamber (4CH) and parasternal short-axis (SAX) views were obtained using 2D TTE in patients with CHD during routine follow-up (Figure 1). RV volumes were calculated using the conventional ellipsoidal shell model formula, a truncated cone model and a novel approach based on a cone model. The results were compared with RV volumes obtained via MRI. Results: Forty CHD patients (median age: 23.1 years) were included. The proposed cone-based formula (CBF) showed excellent correlation with MRI-derived RV volumes (systolic: r = 0.95, 95% CI: 0.91–0.97; diastolic: r = 0.92, 95% CI: 0.86–0.96), with intercepts of 2.5 ml (systolic) and 25.45 ml (diastolic) (Figure 2). The mean difference from MRI volumes was 0.1 ml (0.001%, SD ±13.3) for systolic and 5.2 ml (3%, SD ±28.2) for diastolic volume. Based on root mean square error (RMSE)—considered the most appropriate metric of model fit under linear assumptions—CBF outperformed the ellipsoidal shell model (RMSE 13.2/28.4 ml vs. 20.8/52.6 ml, systolic/diastolic) and the truncated cone model (RMSE 25.1/42.3 ml, systolic/diastolic) (Figure 3). These findings held true even in patients with RV enlargement (mean RVEDVi: 98.6 ml/m2) Conclusion: Our method shows excellent alignment with the data, as indicated by the low y-axis intercept and RSME, while maintaining strong correlation with MRI measurements. It offers an accurate and rapid method for bedside assessment of RV volume, enhancing prompt and precise clinical decision-making.

Background: The American Heart Association’s Life Essential 8 (LE8) framework quantifies cardiovascular health (CVH) across key modifiable factors. Patients with prior history of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) have an elevated risk of repeat adverse cardiovascular events. While LE8 scores have been used to assess overall CVH, the impact of revascularization on LE8 scores and their relationship to revascularization risk (RevR) in this population remains unclear. Methods: Post-procedure PCI (n=428) and CABG (n = 137) patients from the NIH’s updated All of Us Research program Version 8 (2017-2023) were included. Overall LE8 and component scores, excluding diet, were calculated per AHA methods (range 0-100, higher = better CVH). Individual scores were assigned to time-after-revascularization intervals and analyzed longitudinally by revascularization method. Patients were then stratified into one of four LE8 tiers: ≤ 50, &gt;50-&lt;60, 60-&lt;70, and ≥ 70. Logistic regression models, adjusted for age, sex, race, and socioeconomic status were used to estimate odds ratios (OR) of repeat revascularization, using LE8 ≥70 as the reference group. Results: The mean overall LE8 score for the combined population was low at 56.6(PCI: 56.7, 95% CI 56.0-57.9; CABG: 55.2, 95% CI 53.8-56.7). Average nicotine (PCI: 47.1; CABG: 39.2), sleep (PCI: 62.8; CABG: 60.1), BMI (PCI: 51.6; CABG: 54.8), blood pressure (PCI: 61.1; CABG: 58.8), and blood glucose (PCI: 57.5; CABG: 55.5) scores were significantly lower than those of the general population. Post-procedure blood lipid and blood pressure scores remained significantly low over a 10 year period (Figure 1A, 1C). HbA1c score remained largely unchanged over the same period (Figure 1B). Patients with LE8 scores &lt;50 had significantly higher odds of repeat revascularization compared to those with scores ≥70 (OR: 3.19, 95% CI 1.07-9.72, p=0.037). No significant differences in RevR were observed for patients with LE8 scores between &gt;50 -&lt;60, 60 -&lt;70, and ≥70 (Figure 2). Conclusions: Post-procedure PCI and CABG patients with lower LE8 scores had significantly higher odds of revascularization, particularly those with scores ≤50. Adverse scores in nicotine use, sleep, blood pressure, and blood glucose were most prominent compared to the general population. Integrating LE8 assessments into routine follow-up may help identify at-risk patients and guide targeted interventions to reduce repeat procedures.

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been shown to reduce weight. However, the degree to which this involves loss of fat and/or lean muscle mass remains uncertain, as does the potential for exercise to mitigate these effects. Aims: To evaluate changes in body composition among patients on GLP-1RAs who completed a structured exercise program of cardiac rehabilitation (CR), compared to patients on GLP-1RAs alone. Hypothesis: We hypothesized that completion of CR while on a GLP-1RA would be associated with preservation of muscle mass and greater reductions in body fat than GLP-1RA therapy alone. Methods: We performed a retrospective review of patients who completed CR at our institution between June 2018 and April 2025, identifying 51 patients on a GLP-1RA that underwent bioelectrical impedance analysis (BIA) of body composition before and after CR (GLP-1RA+CR group). A comparison group consisted of patients on GLP-1RAs who did not participate in CR and who underwent BIA during routine follow-up (GLP-1RA group). Demographic and clinical data were obtained from the electronic medical record. Descriptive statistics included chi-square analysis for categorical variables and non-parametric Kruskal-Wallis tests and proportion t-tests for quantitative variables (RStudio, v 2024.12.1+563). Results: The GLP-1RA+CR and GLP-1RA groups were similar in age (mean 65 vs 61 years; p=0.246) and racial composition, though the GLP-1RA+CR group had more men (76% vs 39%; p&lt;0.001). Median time between BIA analyses was 3 months for the GLP-1RA+CR group and 4 months for the GLP-1RA group. Both groups had similar rates of diabetes (80% vs 83%). Baseline BMI was comparable (mean 30.9 kg/m2 in GLP-1RA+CR group vs 31.2 kg/m2 in GLP-1RA group), with both groups’ BMI dropping 0.5 kg/m2. However, the GLP-1RA+CR group experienced greater percent body fat loss (mean -1.3% vs -0.3%; p=0.026). Notably, skeletal muscle mass increased in the GLP-1RA+CR group (+0.4lbs) but decreased in the GLP-1RA group (-0.7lbs; p=0.041), with greater appendicular muscle mass loss (-2.9lbs vs +0.2lbs; p=0.045). Sex differences were noted such that in women, the GLP-1RA+CR group had even greater body fat loss (-2.1% vs -0.4%; p=0.015) and skeletal muscle gain (1.2lbs vs -0.6lbs; p=0.014). Conclusions: Our findings suggest exercise may prevent GLP-1RAs from causing skeletal muscle mass loss, while also decreasing markers of adiposity, such as BMI and percent body fat, particularly in women.

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality among U.S. Veterans, with uncontrolled low-density lipoprotein cholesterol (LDL-C) contributing to adverse outcomes. The Louis A. Johnson VA Medical Center (LAJVAMC) VA is one of 50 VA sites participating in a national quality improvement initiative called the VALOR QI: VA Lipid Optimization Reimagined Quality Improvement Project. VALOR-QI is a collaborative project between the VA and the American Heart Association (AHA) with the goal of positively impacting Veterans’ cardiovascular (CV) health. As part of the program, VA sites work with AHA QI Consultants to develop and deploy a local quality improvement plan to help overcome site specific barriers preventing Veterans from achieving optimal cholesterol levels. Veterans with ASCVD and baseline LDL-C &gt;70 mg/dL were identified across primary care, cardiology, and pharmacy-led clinics. The intervention integrated health coaching, routine follow-up by a multidisciplinary provider network, and oversight from a clinical champion. Emphasis was placed on individualized care planning, lifestyle modification, and pharmacologic optimization (Table 1). The program launched in August 2023; interim data through May 2025 were analyzed. A total of 96 Veterans were included in the interim analysis. There was a total of 41 veterans in the baseline analysis. At baseline, August 2023, no patients had LDL-C levels below 70 mg/dL, and 78% had levels above 100 mg/dL. By May 2025, 33% had reached the target of LDL-C &lt;70 mg/dL, and the proportion with levels &gt;100 mg/dL dropped to 49% (Table 2). These results represent a substantial improvement in LDL-C control over the course of the intervention. Our VALOR-QI strategy at LAJVAMC showed encouraging results, but it is premature to make final conclusions. Initial results demonstrate the clinical utility of incorporating a whole health approach into lipid management for high-risk veterans. By integrating behavioral support, shared decision-making, and multidisciplinary follow-up into routine care, this model produced meaningful early reductions in LDL-C. These findings underscore the potential for broader implementation of whole health strategies to optimize CV risk reduction. Future research will evaluate long-term outcomes, sustainability, and scalability of this approach within the LAJVAMC and beyond.

Background&amp;Objective: Visit-to-visit blood pressure variability (VVBPV) has emerged as an independent predictor of cardiovascular and renal outcomes, but its prognostic significance in kidney transplant recipients—especially in Asian populations—remains unclear. We aimed to assess whether elevated VVBPV predicts adverse long-term outcomes in Korean kidney transplant recipients, using a nationwide cohort to provide real-world evidence in this underrepresented population. Methods: We analyzed 5,532 adult recipients from the Korea Organ Transplantation Registry (2014–2022). VVBPV was calculated as the average real variability (ARV), standard deviation (SD), and coefficient of variation (CV) of systolic blood pressure (SBP) measured during routine post-transplant follow-up. Patients were stratified into tertiles based on ARV. The primary composite outcome included graft loss, new-onset cardiovascular disease (CVD), or ≥50% decline in estimated glomerular filtration rate (eGFR). Cox proportional hazards models were adjusted for age, sex, BMI, comorbidities, and 6-month post-transplant clinical variables. Results: During a median follow-up of 55.4 months, 541 patients (9.8%) experienced the primary outcome. Graft loss occurred in 200 patients (3.6%), incident CVD in 176 (3.2%), and ≥50% eGFR decline in 337 (6.1%). Compared with Group 1 (lowest ARV), Group 3 (highest ARV) had a significantly increased risk of the composite outcome (HR 1.755; 95% CI 1.401–2.198; p&lt;0.001). SD and CV showed consistent results (SD: HR 1.483; 95% CI 1.194–1.841; CV: HR 1.558; 95% CI 1.256–1.932; all p&lt;0.001). Group 3 also had elevated risk for secondary outcomes including graft loss (HR 1.716; 95% CI 1.242–2.372; p&lt;0.001), dialysis dependence (HR 1.822; 95% CI 1.312–2.526; p&lt;0.001), and &gt;30% eGFR decline (HR 1.641; 95% CI 1.306–2.062; p&lt;0.001). Subgroup analyses revealed more pronounced associations in patients with diabetes (HR 2.13) and those with pre-existing CVD (HR 1.96), although interaction p-values were not statistically significant. Kaplan-Meier analysis showed reduced event-free survival in higher VVBPV groups (log-rank p&lt;0.001). Conclusion: VVBPV may be a clinically relevant prognostic indicator in kidney transplant recipients. Prospective studies are needed to validate these associations and explore potential interventions. These findings suggest that VVBPV may also serve as a useful risk stratification marker in long-term transplant care.

Introduction/Background - Research Questions/Hypothesis: There is a notable lack of robust evidence regarding imaging follow-up in Fontan patients from resource-limited settings, where access to advanced imaging modalities remains scarce. This study aims to describe the prevalence of cardiac magnetic resonance (CMR) use, key findings, and associated clinical outcomes in a Latin American cohort of Fontan patients. Methods/Approach: A retrospective, observational, single-center study included patients who underwent Fontan procedure completion and had an available postoperative cardiac magnetic resonance scan performed between 2006 and 2024. Data were analyzed descriptively using means ± SD, and frequencies (%). Results: Of 174 Fontan surgeries performed in our center, we included 27 (12.7%) with a follow-up CMR, spanning all age groups. The cohort comprised 15 males (55.6%), with a mean age at the time of CMR of 23.4 years. The most prevalent congenital defect was tricuspid atresia (55.6%), and in 88.8% of patients, the left ventricle was the systemic ventricle. For the Fontan pathway the extracardiac conduit was the preferred surgical technique (92.5%) and fenestration was present in 48.1% of patients. CMR was performed 19 ± 7.4 years after Fontan completion, revealing a mean indexed systemic ventricular end-diastolic volume of 101.7 ± 44.9 mL/m2 and a mean indexed end-systolic volume of 52.8 ± 30.8 mL/m2. The mean ventricular ejection fraction was 49.7% ± 7.2%, and the mean cardiac index was 4.25 ± 1.78 L/min/m2. Among those with a documented fenestration, 7.4% remained patent at time of CMR. Venovenous collaterals were present in 55.5% of the cohort. With 29.6% having more than moderate atrioventricular valve regurgitation. Venovenous collaterals were identified in 55.5% of patients, and 29.6% had more than moderate atrioventricular valve regurgitation. Findings consistent with Fontan-associated liver disease were present in 55.6% of patients, and 7.4% were diagnosed with hepatocellular carcinoma all of whom died, yielding an overall mortality rate of 7.4%. Conclusion(s): Despite limitations, our findings highlight that few Fontan patients undergo routine CMR follow-up. The high prevalence of complications suggests that CMR surveillance may be occurring too late to enable timely interventions. These results underscore the need for guideline-adherent imaging protocols to improve outcomes in this high-risk population.

Background: Echocardiography is frequently used as a first-line imaging tool for aortic evaluation, but its susceptibility to artifacts can lead to false-positive findings. Aortic dissection is a critical diagnosis that requires confirmation with advanced imaging before initiating treatment. This case report highlights the clinical importance of clinical correlation and confirmatory imaging when echocardiographic findings suggest aortic dissection in the absence of symptoms. Case presentation: A 12-year-old male with a remote history of self-resolving dyspnea and previously noted trivial mitral regurgitation presented for routine follow-up. He was clinically well with no cardiac symptoms, normal vital signs, and an unremarkable physical exam. Echocardiography revealed an apparent intimal flap (Figure 1-3) in the proximal ascending aorta, raising concern for aortic dissection. There was no associated turbulent flow, pericardial effusion, or signs of hemodynamic compromise. Due to the gravity of potential dissection, a contrast-enhanced computed tomography (CT) aortogram was performed. CT imaging showed normal aortic anatomy with no evidence of dissection, intimal flap, aneurysm, or other structural abnormalities. Retrospective echocardiographic image review suggested the finding was likely an artifact, possibly due to reverberation or suboptimal transducer angulation. A repeat echocardiogram three months later showed a persistent but less prominent artifact. No intervention was required, and the patient remained asymptomatic. Conclusion: This case demonstrates that echocardiographic artifacts can mimic life-threatening conditions such as aortic dissection. CT aortography remains the gold standard in confirming aortic pathology, particularly in cases where echocardiographic findings are incongruent with the clinical presentation. Incorporating clinical judgment and confirmatory imaging prevents unnecessary anxiety, testing, and interventions, especially in pediatric patients.

Abstract Introduction Gout is a very common inflammatory arthritis caused by the deposition of monosodium urate crystals in the joint, which is normally managed by urate-lowering therapy like allopurinol or febuxostat. A major therapeutic challenge is refractory gout, especially in older patients who have renal impairment, gastrointestinal sensitivity, and cardiovascular disease. This case is particularly challenging due to the elderly patient having multiple comorbidities and drug intolerances, which highlights the limitations of conventional therapy and the need to consider biologic agents for difficult-to-treat cases. Case description We report the case of a 70-year-old gentleman referred to the rheumatology clinic for management of refractory gouty arthritis. The patient had a history of intolerance to standard urate-lowering therapies, including allopurinol and colchicine, both of which caused severe diarrhoea. His extensive comorbidities included type 2 diabetes mellitus, ischaemic heart disease (status post-CABG and stenting), hypertension, hyperlipidaemia, osteoporosis, heart failure, irritable bowel syndrome, and a prior stroke. Following a recent myocardial infarction, he developed multiple gout flares during his hospital stay and was treated with prednisolone 40 mg, resulting in symptomatic improvement. However, he declined benzbromarone initially. At a routine two-year follow-up, he was tried on probenecid, which resulted in a severe itchy rash over the bilateral lower limbs. A subsequent trial of benzbromarone again led to severe diarrhoea. Sulfinpyrazone was also attempted but resulted in similar gastrointestinal intolerance. His serum uric acid remained elevated at 516 µmol/L. Allopurinol was cautiously reintroduced, along with low-dose prednisolone (5 mg), but he continued to experience diarrhoea and frequent flareups affecting the knees, ankles, hands, and shoulders. He required intermittent courses of prednisolone (up to 30 mg), which he tapered but was unable to discontinue completely due to recurrent attacks. He then had a fall and sustained a vertebra fracture. Three months later, he still reports two additional flares managed with a tapering course of prednisolone. Examination revealed ankle tenderness without active synovitis; serum urate remained elevated at 489 µmol/L. Due to the patient’s refractory disease and treatment intolerance, biologic therapies such as anakinra or rasburicase were considered. Tragically, before these could be initiated, the patient suffered a right thalamic haemorrhage and passed away several months later. This case highlights the significant management challenges in treating refractory gout in patients with multiple comorbidities and limited pharmacological options. Discussion Gout is a treatable inflammatory arthritis caused by urate crystal deposition in joints. The long-term management of gout involves urate-lowering therapy with a xanthine oxidase inhibitor, allopurinol, or febuxostat. This patient poses a clinical challenge as he develops gastrointestinal manifestations with the first-line treatment allopurinol and colchicine. Given his multiple comorbidities, non-steroidal agents would be risky, and he was intolerant to colchicine too, leaving only steroids as options for flares. Febuxostat was not initiated due to ischaemic heart disease. The second challenge arises when he develops a cutaneous reaction to probenecid, followed by a gastrointestinal reaction to benzbromarone and sulfinpyrazone. Despite a cautious rechallenge with allopurinol, the patient was still unable to tolerate it. Interleukin-1 inhibitor may be considered for this patient. However, this treatment might not be feasible for a frail elderly patient with multiple comorbidities. The limited therapeutic option in this patient led to steroid dependence, which led to vertebra fractures and frequent gouty flares. This case demonstrates the need for early identification of treatment intolerance, close monitoring of urate levels, and a tailored approach. Unfortunately, before advanced therapies could be initiated, the patient suffered a fatal thalamic haemorrhage—likely influenced by underlying vascular disease and prolonged steroid exposure. Key learning points Management of gout can be challenging, especially in patients with multiple comorbidities and intolerant to first-line treatment. Steroid-dependent individuals demonstrate poor disease control and can lead to multiple complications, including fractures and cardiovascular risk. A personalised, multidisciplinary approach is very crucial for managing complex gout cases, especially for elderly patients with polypharmacy.

Abstract Introduction Tocilizumab is a monoclonal antibody that targets the IL-6 receptor and has demonstrated significant efficacy in the treatment of both rheumatoid arthritis and COVID-19. Reports have emerged regarding invasive aspergillosis or bronchopulmonary aspergillosis following the administration of tocilizumab in patients with COVID-19. This is a very rare case of aspergilloma in a patient with rheumatoid arthritis receiving tocilizumab. Case description We present a case of a 64-year-old Caucasian female diagnosed with seropositive rheumatoid arthritis, who had been treated with tocilizumab and methotrexate for two years after unsuccessful treatments with adalimumab and rituximab. During routine clinic follow-up, the patient reported unintentional weight loss, haematochezia, abdominal discomfort, haemoptysis, and fever following rituximab use. Additionally, the patient has a significant smoking history of 35 pack-years and is employed in an office environment. Initial laboratory investigations, including full blood count, inflammatory markers, faecal studies, T-spot, and CMV serology, were unremarkable. A colonoscopy revealed diverticulosis accompanied by non-specific mild colitis, with no evidence of cytomegalovirus (CMV) in the tissue biopsy. Results from gastroscopy showed a hiatus hernia. A CT scan of the thorax demonstrated right apical scarring with associated soft tissue calcification, a 3 mm pleural-based nodule in the right upper lobe, and emphysema. Bronchoscopy revealed purulent secretions. A PET-CT scan identified a speculated, metabolically active soft tissue mass in the right upper lobe, potentially indicative of bronchogenic carcinoma, with a maximum uptake measuring 1 cm and classified as T1aN0M0. Pulmonary function tests indicated an obstructive pattern. Following a multidisciplinary team (MDT) discussion, a right upper lobectomy was performed. Histopathology revealed a fungal ball composed of septate hyphae consistent with Aspergillus, confirming the diagnosis of aspergilloma. The follow-up clinic revealed no more haemoptysis and stable weight. She was then discharged from the respiratory clinic, as lobectomy is curative management for aspergilloma. However, her RA activity worsened with a DAS28 score is 6.61 (from 5.54 four months ago), VAS 100/100 and pain scale of 9.9/10, as both tocilizumab and methotrexate were withheld. Methotrexate was restarted at 2.5 mg/2 weekly, going up to 20 mg weekly, and leading to a reduction of DAS28 score to 3.73 with a VAS score of 70. Discussion Aspergilloma is a fungal mass that typically develops in pre-existing lung conditions such as pulmonary tuberculosis and sarcoidosis. The challenging aspect of diagnosing aspergilloma arises because many patients may be asymptomatic, while others might exhibit symptoms such as fever, coughing, chest pain, and haemoptysis. This case presents a complex scenario involving an immunocompromised patient who was admitted with systemic symptoms, including haemoptysis and haematochezia. The initial differential diagnosis encompassed CMV colitis, tuberculosis, various bacterial infections, and malignancy. It is not uncommon for healthcare professionals to overlook fungal infections when considering differential diagnoses. Recently, the use of tocilizumab in patients with COVID pneumonia has increased, alongside a rise in reported cases of invasive pulmonary aspergillosis. Consequently, we needed to promptly conduct sputum cultures, a beta-D-glucan test, BAL aspergillus antigen testing and an early respiratory MDT approach to aid in our diagnosis. The next challenging part about this case involves the future management of this patient’s rheumatoid arthritis after being diagnosed with aspergilloma. While only a limited number of cases of invasive aspergillosis and allergic bronchopulmonary aspergillosis have been documented, this instance appears to represent the first recorded case of an aspergilloma developing in a patient with rheumatoid arthritis undergoing treatment with tocilizumab. Key learning points This case represents a rare occurrence of aspergilloma in a patient with rheumatoid arthritis who is receiving tocilizumab. The patient, undergoing biologic treatment, was presented with respiratory symptoms such as cough and haemoptysis, which should raise clinical suspicion of aspergillus infection. Recent guidelines stipulate that all patients must be screened for tuberculosis prior to initiating tocilizumab; however, should routine Aspergillus serology screening also be performed for all patients commencing biologic therapies, particularly those who smoke or exhibit abnormal chest radiographs? In addition, management aspergilloma should involve an MDT approach with the respiratory team, especially when considering restarting biologic drugs.

Adrenal vein sampling with continuous infusion of cosyntropin for identifying surgically curable cases of primary aldosteronism.

Physical examinations and whole-body imaging versus physical examinations alone during follow-up after radical surgery of stage IIB-C and III cutaneous malignant melanoma (TRIM): an interim analysis of a multicentre, randomised, phase 3 trial in Sweden.

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumors arising from pancreatic tissue, predominantly affecting young women and possessing low malignant potential. Extrapancreatic SPNs are exceedingly uncommon. According to data from the English literature, only 30 cases of extrapancreatic SPNs had been reported by 1990, accounting for less than 1% of all reported SPNs from 2004 to 2018. The testis, paratesticular region, and ovary are the more frequently documented sites of these tumors [1,2]. Notably, to the best of our knowledge, no cases of SPN originating in the diaphragm have been reported in the English literature to date. The prevailing theory suggests that SPNs behave similarly regardless of whether they originate in the pancreas or in extrapancreatic locations. We present the case of a 79-year-old female with a history of lung and endometrial cancer, who was diagnosed with a liver lesion during a routine follow-up 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT). During surgery, the lesion was resected from the diaphragm and was confirmed to be consistent with the pathological findings of SPN.

Practical strategies for environmentally sustainable practices in gynecologic oncology.