Late presentation and suboptimal treatment of breast cancer among Syrian refugees: a retrospective study

ObjectivesThe crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management of Syrian patients with breast cancer treated at our institution.MethodsWe retrospectively collected data on Syrian refugees treated for breast cancer over the past 10 years at our center. Management was compared against our approved clinical practice guidelines.ResultsA total of 113 patients were eligible and included. The median age (range) at diagnosis was 47 (21–84) years and most women presented with locally advanced or metastatic disease (n = 74, 65.5%). Breast-conserving surgery and breast reconstruction were performed in 27 (33.8%) and 11 (35.4%) patients, respectively. Only a few patients received targeted (35.5%) or advanced endocrine therapy (30.0%). In total, 37 (32.7%) patients had considerable deviations from our institutional treatment guidelines and had worse outcomes.ConclusionsSyrian refugees with breast cancer present late, have more advanced-stage disease, and are more likely to receive delayed and suboptimal therapy. An international systematic approach for cancer care among such vulnerable populations is urgently needed.     

Mesenteric venous thrombosis presenting as gastrointestinal bleeding,a challenging diagnosis

Acute mesenteric venous thrombosis (MVT) is an uncommon cause of intestinal ischemia and is associated with high morbidity and mortality. Patients with acute MVT often present with gastrointestinal (GI) bleeding and other unspecific findings making the diagnosis challenging. This condition requires emergent treatment. The high rates of misdiagnosis of these patients and subsequently the delay in proper and quick management put patients at increased risk of having a negative outcome. Physicians should suspect acute MVT in patients with GI bleed while also considering other factors such as, a past medical history of pro-thrombotic conditions, past surgical history of splenectomy, symptoms of nausea, vomiting, abdominal pain, physical exam findings of abdominal tenderness and abdominal distention and a laboratory workup indicating leukocytosis and an increased plasma lactic acid level. An increase in the yield of accurate diagnosis of acute MVT is possible if physicians in the ED accurately interpret all these findings. The authors herein present a case of acute MVT in a patient whose initial complaint was GI bleeding and provide a thorough review of the literature of cases of acute MVT presenting with GI bleed.     

Atypical presentation of gangrenous cholecystitis: A case series

Gangrenous cholecystitis (GC) is a serious complication of acute cholecystitis that has been associated with increased morbidity. Patient with GC can present with a wide variety of non-specific clinical, laboratory, and imaging characteristics, making the diagnosis challenging. This disease requires emergent treatment, which is why a quick and reliable diagnosis is essential for the wellbeing of the patient. The authors herein present a case of GC in a patient whose initial complaint was intractable hiccups, and provide a thorough review of the literature of cases of GC with atypical presentations.     

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients.     

Ageing changes the cellular basis of the "fight-or-flight" response in human adrenal chromaffin cells.

Stress-induced increases in plasma epinephrine in man have been reported to decrease with age. To investigate the possible cellular basis for this decline we determined the characteristics of calcium currents and their relationship to catecholamine secretion in isolated human adrenal chromaffin (AC) cells. Cells derived from young individuals displayed prominent prepulse facilitation of L-type Ca channels but this property was absent in cells from older subjects. Robust quantal secretion in young cells as determined by amperometry was strongly coupled to the activation of these channels with an average delay of only approximately 3 msec. N- and P-type Ca channels also contributed to secretion but were more weakly coupled to catecholamine release sites. Cells from older subjects secreted much less efficiently and showed only weak coupling between Ca channels and secretion. These studies suggest that the magnitude and timing of adrenal secretion changes with age and that the facilitation Ca channel is key to rapid activation of the fight-or-flight response in young individuals.     

Clinical spectrum of neurofibromatosis type 1 among children in a tertiary care center

Objectives:To identify the clinical and neuroradiological features of neurofibromatosis type 1 and the risk of malignancy in a pediatric age group.Methods:This observational retrospective cohort study was conducted at King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia, for the patients with neurofibromatosis type 1 who were seen and had follow up from January 2000 to January 2019.Results:A total of 50 children were included. Approximately 90% of patients presented with café-au-lait macules, and 34% had skin-fold freckling. Moreover, 42% of the participants had a first-degree relative with neurofibromatosis type 1, and about a quarter presented with associated epilepsy. About 90% of the neuroradiological features were consistent with those of neurofibromatosis type 1. About 52% of the patients had one or multiple types of tumors, and 34% presented with optic pathway glioma.Conclusion:This study described clinical spectrum of neurofibromatosis type 1 among children. It showed also a higher percentage of tumors than previous studies.

Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous disorder, that affects 1 in 3500 people worldwide.1 The NF1 is a complex disorder involving multiple body systems, such as the integumentary, visual, skeletal, and central nervous system (CNS); hence, it has different clinical manifestations. This condition is mainly characterized by cutaneous pigmented spots referred to as cafe-au-lait macules.2 The diagnosis of NF1 is mainly based on the criteria established by the National Institutes of Health (NIH) in 1988.3 Based on these criteria, patients are diagnosed with NF1 if they meet ≥2 of the following criteria: 6 or more cafe-au-lait macules with a diameter measuring >5 mm in prepubertal individuals and >15 mm in postpubertal individuals, 2 or more neurofibromas of any type or one plexiform neurofibroma, axillary or inguinal freckling (Crowe’s sign), optic pathway glioma (OPG), 2 or more Lisch nodules, dysplasia of the sphenoid wing or thinning of the long bone cortex (-/+ pseudarthrosis), and a first-degree relative with NF1 fulfilling the above mentioned criteria. The diagnostic criteria were revised in 1997 and were continuously used without modifications.4 Moreover, patients with NF1 have a higher risk of malignancies than individuals in the general population, with an estimated prevalence of 5%, and these malignancies are usually detected during childhood.1There are no available data on the radiologic features and the signs and symptoms at the time of clinical presentation, which are essential for the clinical knowledge of physicians in identifying patients with such condition. In addition, there is a lack of information about clinical outcomes, including the risk of malignancy, among patients with NF1. Therefore, the current study aimed to evaluate the different clinical manifestations and the radiological features of NF1 among pediatric patients. Moreover, the outcomes, which are essential for urgent interventions that can improve life expectancy, were assessed.