Years Of Initial Presentation Research Articles

Bilateral osteochondritis dissecans of the knee in pediatric and adolescent patients presenting with unilateral symptoms: An epidemiological and radiographic analysis.

This study aims to determine the prevalence and characteristics of bilateral osteochondritis dissecans of the knee in patients presenting with unilateral symptoms and compare this cohort to patients with unilateral disease. Records of patients ≤18 years old from 2003 to 2016 with a diagnosis of osteochondritis dissecans of the knee and strictly unilateral knee pain were identified. Contralateral (asymptomatic) knee imaging within 1 year of initial presentation was required. Lesion characteristics were evaluated by assessing size, location, and Hefti staging. Both surgical and nonoperative treatments were recorded. Patients with unilateral osteochondritis dissecans were compared to those with bilateral disease. Eighty patients, 63 males (79%) and 17 females (21%), with an average age of 13.1 years old, were included. Twenty (25%) of the presenting/symptomatic lesions were deemed stable on magnetic resonance imaging. A positive correlation between lesion size and Hefti classification was appreciated. Twelve patients (15%) were found to have bilateral osteochondritis dissecans on contralateral imaging. There was no significant difference in skeletal maturity between patients with bilateral versus unilateral disease. Fifty-two patients (77%) with unilateral disease underwent surgical intervention, while 9 (75%) of those with bilateral disease underwent surgery on either knee. In patients with an asymptomatic contralateral lesion, 67% ultimately underwent surgical intervention on the contralateral knee. In patients presenting with unilateral osteochondritis dissecans symptoms, there was a 15% prevalence of bilateral disease, with no difference in age, sex, physeal status, or lesion characteristics between patients with unilateral vs bilateral osteochondritis dissecans lesions. Given the prevalence of asymptomatic contralateral lesions and the required intervention, this study supports early bilateral radiologic knee evaluation. IV, Retrospective Case series.

Inflammatory myofibroblastic tumors: A short series with an emphasis on the diagnostic and therapeutic challenges.

Inflammatory myofibroblastic tumors (IMTs) are a distinct entity of mesenchymal tumors. We present the challenges in their diagnosis and management. A retrospective study with detailed clinical, radiological, and histopathological (HPE) features along with management and outcome of 10 biopsy-proven patients with IMT, between 2001 and 2020. The location included intracranial (5), orbital (4), and spinal (1) with M:F = 7:3. The mean age of onset was in the third decade. The commonest symptom was headache, while proptosis and blurred vision occurred in orbital IMTs. HPE revealed diffuse infiltration of mixed inflammatory cells over proliferating myofibroblasts. Smooth muscle antigen immunoreactivity was noted in fibroblastic spindle cells of all IMTs. However, we did not find anaplastic lymphoma kinase expression in any of our cases, as this is only found in ~50% of all IMTs. Tumor infiltration into adjacent tissue was noted in 4 patients. Surgical excision was limited to orbital IMTs, as most central nervous system (CNS) tumors were not amenable for resection. Steroid administration showed moderate improvement in the IMT-CNS patients but also required additional immunomodulation. Four patients had a median long-term follow-up of 7 years. Two patients had recurrent lesions demonstrated by imaging after 2 years of initial presentation. IMTs are rare and ambiguous tumors of unknown etiology that can occur anywhere in the body. Clinical and radiological features may not be specific to determine the diagnosis, but it should be considered as a differential diagnosis. Extensive thorough workup with histopathology along with the help of immunohistochemistry is conducive to better clinical outcomes. Surgical biopsy with extensive and total resection of these tumors along with steroid and radiotherapy may enhance the survival outcomes.

A case report of multiple relapses of Henoch-Schonlein purpura

Henoch-Schonlein Purpura (HSP) is an acute immunoglobulin A (IgA)–mediated disorder characterized by generalized vasculitis. HSP commonly occurs in children. The annual worldwide incidence is 13-20 per 100,000 children under 17 years of age.1–3 It is characterized by non-thrombocytopenic palpable purpura mostly located on the dependent parts like lower extremities and buttocks, arthralgia/arthritis, bowel angina, and hematuria/proteinuria. HSP pathophysiology is not yet completely understood. Genetic factors are thought to drive the fundamental susceptibility and clinical manifestations. Proposed triggering factors include upper respiratory tract infections, medications, vaccinations, and malignancies. Disease course is usually benign and self-limited. Even though the prognosis is generally good, recurrences or relapses are common within 1 year of initial presentation.4

PSUN343 Ectopic Prolactinoma in the Bony Clivus: A Common Disease in an Uncommon Location

Abstract Introduction Ectopic prolactinoma has previously been reported and may be found in various locations, including sphenoid sinus, cavernous sinus, suprasellar region, nasopharynx, and rarely the clivus. We report a case of prolactinoma without any evidence of adenoma in the pituitary, which was subsequently found to be located to be in the bony clivus, after 36 years of initial presentation. Case Description A 66-year-old woman was seen in the clinic for known history of hyperprolactinemia. She was first diagnosed at the age of 30 when she presented with headaches, irregular menstrual cycles, and galactorrhea. MRI Pituitary at that time was not suggestive of a pituitary adenoma. She was thought to have a microadenoma not visualized on imaging and was only treated with dopamine agonist therapy for 2-3 years at that time. Presently, she complained of mild headaches intermittently but denied any symptoms of galactorrhea. Physical examination, including visual field testing, was unremarkable. Lab tests were suggestive of elevated prolactin levels, which had increased to 171ng/ml as compared to 121 ng/ml a year ago (RR: 3.3- 26.7 ng/ml). Chemistry panel, thyroid function test were in the normal range. Given uptrending prolactin levels, MRI Pituitary was repeated, which showed normal pituitary gland for age, and an enhancing mass with intermediate T1 and T2 signal in the bony sella measuring 1.4×1.1×1.5 cm, previously measuring 1.3×1.1×1.2 cm (3y ago), with loss of the normal bony cortex abutting the pituitary gland. Pt subsequently underwent endoscopic transsphenoidal biopsy of the clival lesion. Histopathology and immunochemical staining results showed findings consistent with pituitary adenoma, prolactinoma. Discussion Ectopic pituitary tissue, as well as prolactinoma, have been reported at various locations along the migratory path of the pituitary gland. The craniopharyngeal canal, which provides the opening for oral ectoderm, which is also known as Rathke's pouch, to migrate superiorly into the sella, leaves a bony layer separating the intracranial sella turcica from the extracranial sinuses and nasopharynx. Growing mass in the bony sella, as seen in our patient, is concerning for several rare pathologies with malignant potential, hence requiring biopsy. Tumors of the clivus constitute less than 1% of all intracranial neoplasms- which include chordoma, lymphoma, metastatic carcinoma, chondrosarcoma, meningioma, craniopharyngioma, germ cell tumor, astrocytoma, and pituitary adenoma. Less than 15 cases of clival ectopic prolactinoma have been reported in the past. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Surgical Management of Tubo-Ovarian Abscesses That Failed Percutaneous Drainage

<h3>Study Objective</h3> Report outcomes in the management of tubo-ovarian abscesses (TOA) initially managed with percutaneous drainage. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Tertiary University-affiliated Medical Center. <h3>Patients or Participants</h3> Patients who underwent percutaneous drain placement for TOA from 2003 to 2020 were included. Percutaneous drainage CPT codes were used to retrieve patient cases. Charts were subsequently reviewed manually. Cases with retrospective diagnoses of: Endometriosis or non-genital etiology of TOA were excluded. <h3>Interventions</h3> percutaneous drainage. <h3>Measurements and Main Results</h3> Sixty-six patients were identified, nine met exclusion criteria, and 57 were analyzed. Percutaneous drainage was successful in 42 patients, while surgery was ultimately required in 15 cases. Of 15 surgical cases only 4 occurred during the initial admission, whereas 11 were delayed and performed due to recurrence of TOA (5), persistence of symptomatic mass (3), or development of chronic pelvic pain (3). Three patients underwent salpingo-oophorectomy. Eight underwent hysterectomy with unilateral or bilateral salpingo-oophorectomy. All but one patient who underwent delayed intervention had it within 1 year of initial presentation. <h3>Conclusion</h3> Percutaneous drainage of TOA is initially successful in 93% of patients, however ultimately 26% of patients ultimately require surgical intervention.

PREVALENCE AND CLINICAL FEATURES OF BILATERAL OSTEOCHONDRITIS DISSECANS (OCD) OF THE KNEE IN PEDIATRIC AND ADOLESCENT PATIENTS PRESENTING WITH UNILATERAL SYMPTOMS

Background:Osteochondritis dissecans(OCD) is an idiopathic condition primarily involving the subchondral bone with secondary articular cartilage changes, commonly occurring in the knee. The true prevalence of bilateral OCD in patients presenting with unilateral OCD symptoms is unknown.Hypothesis/Purpose:The goals of this study are to determine the prevalence and characteristics of bilateral OCD in patients with unilateral symptoms and compare to those with unilateral disease.Methods:An electronic medical record database was queried from 2003-2016 to identify and retrospectively review patients 18 years or younger presenting to a single pediatric institution with a diagnosis of OCD of the knee and strictly unilateral knee pain. Contralateral knee imaging of the asymptomatic knee within one year of initial presentation was required. Lesion characteristics were evaluated on both x-ray and magnetic resonance imaging(MRI) assessing size, location, and Hefti staging. Treatment(both surgical and non-operative) and outcomes were recorded. Patients with unilateral OCD were compared with those with bilateral disease using appropriate statistical analyses.Results:Eighty consecutive patients, 63 males(79%) and 17 females(21%), average age of 13.1 years old (range:8-18), were included. 71% of symptomatic lesions were located on the medial femoral condyle and 14% on the lateral femoral condyle with 20 lesions(25%) deemed stable on MRI evaluation. A positive correlation was found between increasing lesion size and severity of MRI/Hefti grade(Figure-1). Twelve patients(15%) were found to have bilateral OCD on contralateral imaging, with five of the contralateral lesions(42%) considered stable on MRI. There was no significant difference in skeletal maturity between patients with bilateral vs. unilateral disease. Fifty-two patients(77%) with unilateral disease underwent surgical intervention, while 9(75%) of those with bilateral disease underwent a surgical procedure on either knee. In patients discovered to have an asymptomatic contralateral lesion, 67% ultimately underwent surgical intervention on the contralateral knee. Comparing patients with unilateral and bilateral disease, no statistical differences were found in terms of patient demographics or lesion characteristics.Conclusion:In patients presenting with unilateral OCD symptoms, there was a 15% prevalence of bilateral disease. There was no difference in age, sex, physeal status or lesion characteristics between patients with unilateral vs. bilateral OCD lesions, and we found no difference in rates of surgical intervention. A consistent relationship between lesion size and Hefti classification was appreciated. Given the prevalence of asymptomatic contralateral lesions and required intervention, our study supports the recommendation for bilateral radiologic knee evaluation for pediatric and adolescent patients presenting with unilateral knee OCD.Figure 1.Association between size (via volumetric analysis on magnetic resonance imaging [MRI]) of osteochondritis dissecans (OCD) lesions of the knee and Hefti classification

A Rare Case of Recurrent Lymphocytic Hypophysitis Spanning 8 Years

Background: Lymphocytic Hypophysitis (LH) is predominantly a self-limiting condition. Reports of recurrent LH have been limited to case series, predominantly within first two years of initial presentation (1). There is paucity of data on long term follow up of these cases and late recurrence of LH is considered very rare (2). Clinical Case: We describe the clinical course of a 47-year female, who first presented to us, 8 years back, with headache, visual disturbance and secondary amenorrhea. Her MRI pituitary was suggestive of a pituitary mass, which was removed by trans-sphenoidal surgery. Histopathology of the mass was suggestive of LH. Patient had symptomatic improvement, and remained well on out-patient follow-up, on hormone replacement therapy. She took replacement dose of glucocorticoid for 4 years after the initial surgery and then it was discontinued. However, she re-presented to us with headache and visual disturbance this time associated with xerostomia and xerophthalmia. In this presentation, due to presence of sicca symptoms a suspicion of autoimmune aetiology was kept. Her lab parameters were consistent with pan hypopituitarism along with new appearance of anti-TPO antibodies. She underwent two consecutive trans-sphenoidal surgeries for relief of pressure symptoms, and has been started immunosuppressive doses of glucocorticoids along with methotrexate. Other causes of recurrent hyophysitis, as IgG4 related Hypophysitis, were excluded by immunohistochemistry and normal serum IgG4 level (0.72g/l). She has since been discharged, and remains well on outpatient follow-up with no mass effect. MRI pituitary done at 2 months follow up is not suggestive of residual regrowth or mass effect. Conclusion: This case highlights the importance of long term follow up of LH patients. Other autoimmune aetiology maybe considered in cases unresponsive to standard treatment, necessitating titration of additional immunosuppressive therapy.

Acinic Cell Carcinoma of Parotid Gland Presenting as Disseminated Cutaneous and Subcutaneous Metastasis after 20 Years of Initial Presentation

AbstractAcinic cell carcinoma (ACC) is an uncommon variety of salivary gland neoplasms, constituting about 17% of all salivary gland malignancies. Although ACC is a low-grade tumor, approximately 35% of patients experience recurrence and 16% have distant metastasis, often decades after the initial presentation. We report a rare case of disseminated metastatic ACC in skin and subcutaneous tissue in a 50-year-old male, with a history of surgery in parotid region 20 years back. After thorough search of literature, this is the second case being reported, to the best of our knowledge.

A prospective study of repetition of self-harm following deliberate self-poisoning in rural Sri Lanka.

IntroductionRepetition of deliberate self-harm is an important predictor of subsequent suicide. Repetition rates in Asian countries appear to be significantly lower than in western high-income countries. Methodological differences in studies, and the impact of access to means of self-harm with comparatively higher lethality have been suggested as reasons for these reported differences. This prospective study determines the rates and demographic patterns of deliberate self-poisoning (DSP), suicide and repeated deliberate self-harm resulting non-fatal and fatal outcomes in rural Sri Lanka.MethodsDetails of DSP admission in all hospitals (n = 46) and suicides reported to all police stations (n = 28) in a rural district were collected for the years 2011, 2012 and 2013. Demographic details of the cohort of patients admitted to all hospitals in 2011 due to deliberate self-poisoning (N = 4022), were screened to link with patient records and police reports of the successive two years with high sensitivity using a computer program. Then high specificity manual matching of all screened links was performed to identify repetition within 2 years of initial presentation. Life time repetition was assessed in a randomly selected subset of DSP patients (n = 433).ResultsThere were 15,639 DSP admissions, aged more than 9 years, and 1078 suicides during the study period. The incidence of deliberate self-poisoning and suicide in the population within the study area were 248.3/100,000 and 20.7/100,000 respectively, in 2012. Repetition rates at four weeks, one-year and two-years were 1.9% (95% CI 1.5–2.3%), 5.7% (95% CI 5.0–6.4) and 7.9% (95% CI 7.1–8.8) respectively. The median interval between two attempts were 92 (IQR 10–238) and 191 (IQR 29–419.5) days for the one and two-year repetition groups. The majority of patients used the same poison in the repeat attempt. The age and duration of hospital stay of individuals with repetitive events were not significantly different from those who had no repetitive events. The rate of suicide at two years following DSP was 0.7% (95% CI 0.4–0.9%). The reported life time history of deliberate self-harm attempts was 9.5% (95% CI 6.7–12.2%).ConclusionsThe comparatively low rates of repetition in rural Sri Lanka was not explained by higher rates of suicide, access to more lethal means or differences in study methodology.

Predicting Likelihood of Surgery Before First Visit in Patients With Back and Lower Extremity Symptoms: A Simple Mathematical Model Based on More Than 8,000 Patients.

Retrospective analysis of prospectively collected data. To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within 1 year of presentation. Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained before the initial physician-patient encounter to direct patients to the optimal physician type. We analyzed patient-reported data from 8006 patients with a chief complaint of low back pain and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within 1 year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%. The baseline 1-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in nontriaged patients and a 29% improvement from our institution's existing triage system. The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood-11), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within 1 year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or nonoperative spine specialists. 4.

Abstract 717: Diagnosis of basal like breast cancer using DNA methylation markers at the promoters of long noncoding RNAs

Abstract Background: Patients with basal-like breast cancer (BLBC) have poor overall survival and suffer a high rate of metastasis to the brain or lung within three to five years of initial presentation. Absence of a cure for advanced BLBC warrants early detection of BLBC, which might save more lives, especially those of women of African ancestry who are disproportionately affected by young onset BLBC. Aberrant DNA methylation is frequently observed in BLBC. DNA methylation is the most robust epigenetic marks and can be analyzed using clinical specimens including FFPE, tumor biopsies and liquid biopsies. Because expression of long non-coding RNAs (lncRNAs) is controlled temporally in response to neoplastic stimuli, we investigated the potential for lncRNA promoter methylation marks to be used for detection and prediction of BLBC development and progression in African Americans. Methods: To identify lncRNAs dysregulated in BLBC, we performed a Ribo-Zero RNA-seq or microarray analysis on breast tissues isolated from African American (n=63) and European American patients (n=14). Differentially methylated and hydroxymethylated regions of lncRNA genes were identified in African American samples (n=30) using our chemical methods to assay 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC). The Cancer Genome Atlas (TCGA) datasets were utilized to validate our results. To functionally annotate lncRNAs, we knocked down lncRNAs using LNA-antisense oligonucleotides (ASO) and performed Caspase 3/7 assays, flow cytometry, and qRT-PCR. We also utilized the CRISPR-Cas9 editing tools to knock out lncRNAs. Results: LncRNAs displayed distinct expression patterns between tumors and normal breast tissues. Out of hundreds of lncRNAs specifically expressed in BLBC tumors, we selected two lncRNAs, lnc19 and lnc98, which represent, respectively, a significantly increased and decreased lncRNA in BLBC tumors, compared to normal breast tissues and other subtype tumors. Lnc19 is highly up-regulated (a 39-fold increase) whereas lnc98 is dramatically down-regulated (a 59-fold decrease) in BLBC tumors. Methylation analysis showed significantly lower levels of promoter methylation for lnc19 and higher levels for lnc98 in BLBC tumors. A significant inverse correlation between methylation and expression of lnc19 was observed. Depletion of lnc19 resulted in rapid cell death of BLBC cells, with increased sensitivity to chemotherapy drugs. The data suggests that chemo-resistance of BLBC might be partly due to lnc19 overexpression, which is mediated through epigenetic control. Conclusion: We identified two epigenetically dysregulated lncRNAs in BLBC tumors, which contribute to chemo-resistance of these tumors. Our findings on the regulation of lncRNAs by cytosine methylation raise the possibility of new epigenetic biomarkers for diagnosis and prognosis of aggressive BLBC tumors. Citation Format: Yoo J. Han, Sonja M. Boatman, Jing Zhang, Albert C. Yeh, Yonglan Zheng, Olufunmilayo I. Olopade. Diagnosis of basal like breast cancer using DNA methylation markers at the promoters of long noncoding RNAs [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 717. doi:10.1158/1538-7445.AM2017-717

Risk Factors for Priapism Readmission

IntroductionPriapism is a urologic emergency with a tendency to recur in some patients. The frequency of, time to, and risk factors for priapism recurrence have not been well characterized. AimTo identify predictors of priapism readmission. MethodsWe used the New York Statewide Planning and Research Cooperative System database to identify patients presenting to emergency departments with priapism from 2005 through 2014. Patients were tracked up to 12 months after initial presentation. Proportional hazards regression was used to identify risk factors for priapism readmission. Main Outcome MeasuresReadmissions for priapism. ResultsThe analytic cohort included 3,372 men with a diagnosis of priapism. The average age at first presentation was 39 ± 18 years and 40% were black. Within 1 year, 24% of patients were readmitted for recurrent priapism, 68% of whom were readmitted within 60 days. On multivariate analysis, sickle cell disease (hazard ratio [HR] = 2.5, 95% CI = 2.0–3.0), drug abuse or psychiatric disease (HR = 1.9, 95% CI = 1.6–2.2), erectile dysfunction history (HR = 1.9, 95% CI = 1.5–2.3), other than commercial medical insurance (HR = 1.2, 95% CI = 1.0–1.4), and inpatient admission for initial priapism event (HR = 0.5, 95% CI = 0.4–0.6) were significant risk factors for readmission. ConclusionNearly one fourth of patients with priapism were readmitted for recurrent priapism within 1 year of initial presentation. Most readmissions were within 60 days. Future research should focus on strategies to decrease recurrences in high-risk patients.

Results of Yet Another Antibiotics vs Appendectomy Randomized Trial: Still Not Enough to Change My Practice.

RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of −27.0% (95% CI, −31.6% to) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment.

Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis

Importance An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis. Objective To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT). Design, Setting, and Participants The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period. Interventions Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy. Main Outcomes and Measures The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period. Results There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of −27.0% (95% CI, −31.6% to ∞) ( P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment. Conclusions and Relevance Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications. Trial Registration clinicaltrials.gov Identifier:NCT01022567

Multiple cutaneous, oropharyngeal and pulmonary nodules

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis defined by heterogeneous multiorgan involvement. Due to the rarity of this disease strong evidence-based therapies have yet to be established and prognosis has previously been considered to be poor, with more than half of patients dying within 3years of initial presentation. We describe an 86-year-old woman with a 34-year history of extensive cutaneous and internal nodules with typical pathological and immunophenotypical (CD68(+) /CD1a(-) ) features of ECD without evidence of the BRAF V600E mutation. The cosmetic appearance of cutaneous nodules and hoarse voice caused by vocal cord nodules has been managed surgically. More aggressive therapies reported for ECD were trialled for this patient, such as radiotherapy and interferon-α, with no response. This case demonstrates a relatively good prognosis in ECD that has been managed conservatively.

Abstract 19675: Testing Strategies and Poor Outcomes of Syncope among Medicare Beneficiaries

Background: Syncope is a common problem among older patients in the United States and national guidelines recommend a variety of tests to determine the etiology. However, few data are available regarding how tests are used nationwide and outcomes of patients presenting with syncope. Methods: Using the nationally representative 5% sample of Medicare beneficiaries 65 years or older, we identified patients who had at least 1 inpatient or 2 outpatient claims for syncope between 2001 and 2010. We excluded beneficiaries with a pacemaker or implantable cardioverter defibrillator in situ prior to the incident syncope encounter that required no prior claim of syncope in the prior 365 days. Results: The overall incidence of syncope in 2001 was 11.8 per 1000 person years and remained stable over time ranging from 10.3 to 14.6 per 1000 person years. The average age of beneficiaries with syncope was 79, with the majority being women (63.3%) and white (87.5%). Hypertension was the most common comorbid condition (84%) followed by coronary heart disease (46.5%). When considering the tests ordered within 90 days of the incident encounter, the most frequently ordered tests were CT head (57%) and echocardiogram (50%). Holter monitors were ordered for 18% of beneficiaries, implantable loop recorders for 0.2%, tilt table testing for 4% and electrophysiology study for 2.7% of beneficiaries. From 2001 to 2010, the frequency of these tests did not significantly vary. Mortality at one year was 13% overall (17% for inpatients and 6% for outpatients). All cause readmission at one year was 44% with readmissions for syncope 9% (figure). Conclusion: Syncope is a common condition and is associated with a high mortality and hospitalization within 1 year of initial presentation. Guideline recommended diagnostic tests are ordered infrequently and represent an opportunity to improve care by developing a structured approach for the evaluation of syncope.

Plasmablastic lymphoma of bone in a human immunodeficiency virus positive child – A rare extra-oral presentation

Abstract Plasmablastic lymphoma (PBL) is an aggressive variant of diffuse large B-cell lymphoma seen in patients infected with human immunodeficiency virus. Though PBL was initially recognized as oral lesions in HIV infected individuals, various extra-oral sites of affection have been described. In general, PBL has a dismal prognosis with most patients dying within 2 years of initial presentation. We report the case of a ten year old girl presenting with multiple bone lesions and hepatosplenomegaly. Histopathology and immunophenotyping was suggestive of PBL. ELISA for HIV 1 was reactive. Despite her advanced stage at presentation, she responded well to Highly Active Anti Retroviral Therapy (HAART) and six cycles of chemotherapy (CHOP). She is continued on HAART and is on follow-up for 38 months.

English

Fibroadenomas are benign solid tumor associated with aberration of normal lobular development. Giant fibroadenoma is usually single and >5 cm in size /or >500 gms in weight. Their rapid growth, associated with skin congestion and ulceration, and tendency to recur, gives rise to a suspicion of malignancy.(1,2). Important differential diagnoses are: phyllodes tumor and juvenile gigantomastia. These tumours are almost always benign and should be treated with breast conserving surgery. We present a case of 40year old female who presented with a large lump in the right breast. The diagnosis was made on fine needle aspiration cytology, mammography and ultrasonography. Simple excision of the lump was done. The diagnosis was confirmed on histopathology. Patient again presented twice with similar complaints with no evidence of malignancy of histopathology. CASE REPORT: A 40 year old female presented to surgical opd with complaints of large lump in the right breast since 2months.It was insidious in onset and rapidly progressive in nature, pt also complained of associated pain since 15 days, dragging type nonradiating type. No history of discharge or ulcer over the skin. No history of fever, weight loss loss of appetite. On examination there was a large mass measuring 8*10cm occupying all the four quadrants of the right breast. Surface was bosselated. Dilated veins were noted over the lump. The lump was tender to palpate and margins were irregular. Lump was mobile .Skin was pinchable. Axillary nodes were not enlarged. Left breast and axilla was normal. All routine blood investigations and urine examinations were within normal limits. Fine needle aspiration cytology revealed -features suggestive of benign lesion, s/o giant fibroadenoma. USG of the right breast showed a solid mass with features suggestive of fibroadenoma. Patient was posted for surgery and simple excision of the lump was done. Post operative histopathology revealed it as a benign lesion of right breast. After 3 years patient presented with similar complaints again on the right breast. On examination, there was large lump occupying all the four quadrants of the right breast measuring 8*8cm. Surface was bosselated and dilated veins were noted .The lump was tender to palpate with variable consistency. Skin was pinchable and lymph nodes were not palpable in the right axilla. Left breast and axilla were normal. FNAC and ultrasonography showed features suggestive of fibroadenoma which had recurred. Mammography also revealed features suggestive of fibroadenoma Patient was operated again and simple excision of the lump was done. Histopathology of the specimen showed pericanalicular and intracanalicular type of fibroadenoma. No features suggestive of malignancy. Patient presented again with similar complaints after 5 years of initial presentation. The lump was excised for the third time and the histopathological specimen showed no evidence of malignancy.

Publication rates of presentations at the Irish Orthopaedic Association annual meeting

Presentation of scientific research at national and international meetings is an important forum for the dissemination of knowledge. Subsequent publication of a full-text paper in a peer-reviewed journal is the expected outcome of such presentations. The publication rate from these meetings is highly variable. To determine the publication rate of abstracts presented at the Irish Orthopaedic Association's Annual Conference and to determine which factors are associated with progression to full-text publication. We reviewed the proceedings from the Irish Orthopaedic Association's National Meeting over a 4 year period. We searched the Pubmed database using author names, institution names, and keywords from each abstract's title, to determine how many presented articles progressed to full-text publication. Sixty-six of 203 were published, 97 % within 5 years of presentation. Laboratory based studies presenting novel or innovative findings were more likely to be published than clinical studies. Clinical studies were more likely to be published if they were prospective and had a longer period of follow-up. Retrospective audits were less likely to be published, even with a large cohort size. Changes in authorship of presented papers were related to a longer delay in time to full-text publication. Thorough planning of research studies is essential to ensure a timely progression to full-text publication in a peer-reviewed journal. Most studies will be published within 5 years of initial presentation.

A large thigh mass: a blood clot or a rare skeletal muscle metastasis from renal cell carcinoma

BackgroundRenal cell carcinoma (RCC) is a tumor known for its unusual presentations and high rate of metastasis. Metastasis to lung, liver, bone and brain are common, but to skeletal muscle(SM) is very rare. Because only 11% of the RCC metastases to SM present after 10 years of initial presentation, there is no general consensus for its annual surveillance.MethodsWe report a case of a 58 year old male with a history of RCC, initially diagnosed 11 years ago, who presented with a large SM mass. A large mass measuring more than 25 cm was located in left posterior thigh and was present for more than a year. It initially was diagnosed as a large blood clot and was treated with warfarin for more than 6 months. Clinical work up including FDG-PET/CT and MRI raised the possibility of a tumor, but a negative biopsy made the diagnosis uncertain. Because of high suspicion for a tumor, patient underwent a complete resection of the mass.ResultsThe resected mass measuring 28 × 18 × 7 cm was detailed as the largest skeletal muscle metastasis from RCC ever reported.ConclusionThis case emphasizes the importance of maintaining a high suspicion for metastasis even in less common metastatic sites mainly in patients with a history of RCC. It also highlights the importance of annual surveillance for metastasis in patients with RCC even after 10 years of initial presentation using FDG-PET/CT.