Seek and ye shall find: Hodgkin's lymphoma presenting as paraneoplastic cerebellar degeneration

Paraneoplastic neurological syndromes (PNS) are rare complications of cancer and may be the presenting sign of an occult malignancy. Diagnosis of PNS is often challenging and treatment of the underlying tumour remains the best therapeutic option for preventing further neurological damage. We report on a patient who developed a rapidly progressive cerebellar ataxia and underwent extensive investigations before a paraneoplastic aetiology was confirmed by detection of an underlying malignancy.     

Stable isotopes as valid components for identification of drugs in biological specimens

Selected ion monitoring in mass spectrometric methods (SIM-MS) is generally used to confirm the presence of a drug in biological samples. Criteria for identification of a compound by MS are based on some specific guidelines. However, some disparities exist between the guidelines as to how many and what type of ions to monitor. Although European guidelines allow the monitoring of isotopic ions, such monitoring is not valid by SOFT/AAFS guidelines. The feasibility of monitoring a stable isotopic ion as an alternate to the fragment ion was examined in our study. Area ratios of stable isotopic ion m/z 275 and its parent ion m/z 274 of optical isomers of methamphetamine as (R)-(-)-alpha-methoxy-alpha-(trifluoromethyl)phenylacetyl derivative were found to be within +/- 4% of theoretical value (14.969) calculated from fragment formula C(13)H(15)F(3)NO(2) and isotopic abundances (C(13) = 1.1%, H(2) = 0.015%, F = 0%, N(15) = 0.37%, and O(17) = 0.037%). In another example, the area ratios of a stable isotopic ion m/z 283 and the parent ion m/z 282 of 6-pentafluoropropionyl codeine was also within +/- 4% of theoretical value (20.542) calculated from fragment formula C(18)H(20)NO(2). This relationship between the isotopic abundance and fragment composition was also useful in assigning structures to many fragment ions of methamphetamine, LSD, morphine, and 6-acetylmorphine derivatives, whereas structural assignment to the ions based on mass alone was difficult. The predictability of the relative abundance of the examined isotopic ions has proven reliable in our studies. The use of an isotope was found to be an important additional tool for compound identification by MS.     

Outcomes of surgically managed primary lung sarcomas: a National Cancer Database analysis

BackgroundPrimary lung sarcoma (PLS) represents a rare form of lung cancer with outcomes that are poorly defined by small datasets. We sought to characterize clinical and pathological characteristics and associated survival within the surgically managed subgroup of these unusual pulmonary malignancies.MethodsWe performed a retrospective analysis of the National Cancer Database (NCDB), which was queried for cases of surgically managed PLS diagnosed between 2004–2014. Adjusted mortality was evaluated in a multivariable Cox proportional hazards model and compared to surgically manage non-small cell lung cancer (NSCLC) patients from the same time period.ResultsA total of 695 patients with surgically managed PLS were identified with 37 different histologic subtypes. The mean age of diagnosis was 57.7 years (range, 18–90 years). A majority of patients underwent surgical resection alone (64.3%) with an estimated 5-year overall survival (OS) of 51%. The multivariable Cox model identified increasing age, Charlson-Deyo score ≥2, high tumor grade, tumor size >5 cm, positive margins, and positive lymph nodes to be associated with higher risk for mortality (P<0.05). Compared to 101,428 surgically managed patients with adenocarcinoma, PLS patients were younger with fewer comorbidities but had larger tumors, higher grade tumors, and were more likely node negative (P<0.001). Surgery with adjuvant chemotherapy was associated with worse survival than surgery alone (HR 1.41, 95% CI: 1.05–1.88). The extent of parenchymal resection (lobar vs. sublobar) was not predictive for survival. Five-year OS was lower for patients with PLS (44%) than adenocarcinoma (53.6%, P<0.001).ConclusionsThe survival of surgically managed PLS is reasonable and impacted by tumor attributes and the completeness of surgical resection. Further study to define the role of multimodal therapy is indicated.     

Physical and psychological aspects of whiplash: Important considerations for primary care assessment

Whiplash is a heterogenous and in many, a complex condition involving both physical and psychological factors. Primary care practitioners are often the first healthcare contact for individuals with a whiplash injury and as such play an important role in gauging prognosis as well as providing appropriate management for whiplash injured patients. It is imperative that factors associated with poor outcome are recognized and managed in the primary care environment at the crucial early acute stage post injury. This paper outlines the heterogeneity of the whiplash condition in terms of both physical (particularly the sensory presentation) and psychological characteristics and the relationships between these features. The clinical assessment of these factors will be explored as well as direction for appropriate early interventions. An early co-ordinated inter-professional management approach, particularly in patients with a complex clinical presentation involving central hyperexcitability and symptoms of posttraumatic stress will be required.     

The "gastric fluid" sign: an unrecognized false-positive finding during focused assessment for trauma examinations

The FAST exam has become the current standard for free intraperitoneal fluid determination in most emergency departments. Knowledge of false negative and false positive findings is imperative to improve accuracy. We detail a case in which an important false positive findings previously not discussed in the medical literature was noted. The ability of the physician to recognize the "gastric fluid" sign and make the adjustments accordingly could improve the specificity of the FAST exam, preventing non-therapeutic laparotomies.     

Hybridizing behavioral models: A possible solution to some problems in neurophenotyping research?

The use of batteries of single-domain tests for neurophenotyping research is a common strategy to achieve higher data density and explore different behavioral domains. This approach, however, is accompanied by several methodological challenges, briefly discussed here. As an alternative, this paper advocates the wider use of extensive "hybrid" protocols that assess multiple domains in parallel, or logically/logistically combine experimental paradigms, in a way that disproportionately maximizes the number of tested phenotypes per experimental manipulation. Several examples of this approach are given in this paper, demonstrating the potential to reduce time, cost and subject requirements for the experiments. Offering behavioral analyses that are lacking in the standard single-domain tests, such "hybrid" models enable innovative modeling of neuropsychiatric disorders by more thorough and broader investigation of complex phenotypical characteristics.     

Therapist Attitudes and Beliefs Relevant to Client Dropout Revisited

This study replicates a survey conducted in the 1980s that examined therapist attitudes and beliefs relevant to client dropout. A revamped questionnaire modelled on the original was completed by 92% of therapists employed in the outpatient counselling arm of an alcohol and other drug treatment service. This questionnaire sought therapist perceptions of treatment length and client dropout as well as their preferred length of treatment engagement. Responses were then contrasted with known service attendance norms. As with the previous study, the results suggest therapists typically expect and prefer treatment of a considerably longer duration than the service mean and underestimate the rate of client dropout.