Primary small-cell carcinoma of the breast.

Early diagnosis of rare breast cancers is expected to occur more frequently as screening compliance improves and diagnostic modalities become more sensitive. Well-defined treatment algorithms exist for the management of ductal and lobular carcinomas; however, less information is available to guide the treatment of atypical breast cancers. This case report describes a 38-year-old African American woman with primary small cell carcinoma of the breast and her treatment.

Diagnosis of sarcoidosis from a biopsy of a dilated mammary duct.

Sarcoidosis is an immunologic disease of unknown etiology that manifests most frequently within the lungs or associated lymph nodes. Sarcoidosis involving the breast is seen in <1% of cases and usually is diagnosed in patients with multisystem disease. The clinical and imaging presentations of sarcoidosis of the breast can be variable.

Myeloid sarcoma causing airway obstruction.

Myeloid sarcoma is an extramedullary collection of blasts of the myeloid series that partially or totally effaces the architecture of the tissue in which it is found. These tumors have been described in many sites of the body, but the skin, lymph nodes, gastrointestinal tract, bone, soft tissue, and testes are most common. They can arise in a patient following the diagnosis of acute myeloid leukemia, but they may also be precursors of leukemia and should be considered diagnostic for acute myeloid leukemia.

Plasma cell myeloma with lymphoplasmacytic morphology and cyclin D1 expression, an uncommon variant.

The genetic complexity of multiple myeloma is due in part to the accumulation of mutations, with primary and secondary events. One such secondary event is the development of a gene mutation that may result in overexpression of cyclin D1. The pathway involving cyclin D1 is intricately involved in cell cycle regulation from the G1 to S phase, and alterations may contribute to tumorigenesis.

A rare hemoglobin variant, Hb Belliard.

There are many documented variants of hemoglobin; however, other than a limited number (such as sickle cell disease), very few are known to have any clinical significance. As advances in detection and identification continue through gel electrophoresis, capillary electrophoresis, and DNA sequencing, more rare variants are identified. Without case reporting, the significance of these variants will remain unknown or continue to be thought of as insignificant.

Tularemia presenting as pulmonary nodules in an immunocompromised patient.

Tularemia is a zoonotic disease caused by that can be transmitted to humans when they handle rabbits, receive tick bites, consume contaminated water, or inhale aerosolized particles. We present the case of a 51-year-old white man with rheumatoid arthritis who was taking immunosuppressive medications and presented with tularemia. Our patient acquired the typhoidal form of tularemia, which is a severe systemic illness that manifests with fevers, headaches, myalgias, vomiting, diarrhea, and neurological symptoms, due to his immunocompromised state.

Systemic infection and splenic abscess.

Splenic abscess is a rare complication of systemic infection, sometimes associated with infective endocarditis. Due to its rarity and nonspecific symptoms, diagnosis is difficult. Antibiotic therapy alone is usually unsuccessful, and definitive treatment requires splenectomy, although percutaneous ultrasound-guided drainage has been successful in some patients.

Relation of left ventricular free wall rupture and/or aneurysm with acute myocardial infarction in patients with aortic stenosis.

This minireview describes 6 previously reported patients with left ventricular free wall rupture and/or aneurysm complicating acute myocardial infarction (AMI) in patients with aortic stenosis. The findings suggest that left ventricular rupture and/or aneurysm is more frequent in patients with AMI associated with aortic stenosis than in patients with AMI unassociated with aortic stenosis, presumably because of retained elevation of the left ventricular peak systolic pressure after the appearance of the AMI.

Influence of Aging on Microvascular Supply of the Gluteus Medius Tendon: A Cadaveric and Histologic Study.

Purpose: The purpose of this cadaveric study was to assess the relation between age and microvascular supply of 3 areas of the gluteus medius tendon using a previously validated CD31 immunohistochemistry staining technique.

Methods: Twenty-four fresh-frozen gluteus medius specimens were obtained through a posterolateral approach to the hip. Specimens aged 18 years or older, of either sex, and of any race were considered for this study.

White Paper AGA: Drug Development for Eosinophilic Esophagitis.

Since first characterized in 2 small case series in the early 1990s, eosinophilic esophagitis (EoE) has emerged as a commonly identified cause of esophageal symptoms in children and adults. Although several highly effectively dietary, pharmacologic, and endoscopic therapies have been reported, none is currently approved by either the US Food and Drug Administration (FDA) or European regulatory authorities. Evolving diagnostic criteria have challenged drug development, in particular the recognition of complex interactions with the most prevalent esophageal disorder, gastroesophageal reflux disease (GERD).

Combination therapy with rituximab, low-dose cyclophosphamide, and prednisone for idiopathic membranous nephropathy: a case series.

Background: Membranous nephropathy is a common cause of the nephrotic syndrome. Treatment with standard regimens fails to induce complete remission in most patients. We evaluated the efficacy of combination therapy with rituximab, low-dose, oral cyclophosphamide, and an accelerated prednisone taper (RCP) for the treatment of idiopathic membranous nephropathy.

Electromyogram-evoked focal myositis.

Focal myositis is a rarely reported inflammatory disease of skeletal muscle, particularly of an extremity. It is often misinterpreted as an infectious syndrome, leading to prolonged antibiotic use and a delay in immunosuppressive therapy. Without a confirmed etiology to date, we present a case of recurrent focal myositis following an electromyogram.

Ruptured ectopic pregnancy with a negative urine pregnancy test.

Ectopic pregnancy is commonly seen as a differential diagnosis of first-trimester vaginal bleeding. Often the diagnosis is made based on a combination of exam findings, transvaginal ultrasound, and a positive pregnancy test. Our case describes a patient with a history of ectopic pregnancy treated with methotrexate and serial human chorionic gonadotropin measurements that were decreasing appropriately.

Right atrial thrombus and its causes, complications, and therapy.

A 70-year-old man who presented with dyspnea and intermittent chest pain was found to have a large free-floating right atrial thrombus on two-dimensional echocardiogram. Atriotomy was performed, and an 18-cm-long thrombus was removed from the right atrium and inferior vena cava. Postoperatively, the patient developed cardiogenic shock treated by intravenous vasopressor agents and extracorporeal membrane oxygenation.

Endovascular therapy using flow diversion for giant internal carotid artery pseudoaneurysm arising in the setting of an invasive pituitary macroadenoma.

This report illustrates the unusual occurrence of a pseudoaneurysm arising in the setting of a skull base mass and describes the first reported use of endovascular flow diversion therapy in such a setting. A 63-year-old man with occasional headaches during the preceding month presented with the acute onset of severe left retroorbital headache and oculomotor nerve palsy. Computed tomography (CT) and CT angiogram revealed a destructive skull base mass with an associated giant probable pseudoaneurysm of the cavernous segment of the left internal carotid artery.

Optimizing laboratory test utilization in long-term acute care hospitals.

Laboratory tests can be considered inappropriate if overused or when repeated, unnecessary "routine" testing occurs. For chronically critically ill patients treated in long-term acute care hospitals (LTACHs), inappropriate testing may result in unnecessary blood draws that could potentially harm patients or increase infections. A quality improvement initiative was designed to increase physician awareness of their patterns of lab utilization in the LTACH environment.

Relation between proprotein convertase subtilisin/kexin type 9 and directly measured low-density lipoprotein cholesterol.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a regulator of low-density lipoprotein cholesterol (LDL-C) receptor (LDL-R) recycling and, thus, is a determinant of plasma LDL-C concentration. We sought to determine the relation between serum concentrations of PCSK9 and LDL-C while considering a variety of influential variables, including treatment for dyslipidemia. Using a prospective lipid clinic registry, we evaluated clinical variables, the results of advanced lipid testing, and PCSK9 concentrations determined by immunoassay.

Learning Curve Associated With an Automated Laparoscopic Suturing Device Compared With Laparoscopic Suturing.

Background: Laparoscopic suturing has proved to be a challenging skill to master which may prevent surgical procedures from being started, or completed, in a minimally invasive fashion. The aim of this study is to compare the learning curves between traditional laparoscopic techniques with a novel suturing device.

Methods: In this prospective single blinded nonrandomized controlled crossover study, we recruited 19 general surgery residents ranging from beginner (PGY1-2, n = 12) to advanced beginner (PGY3-5, n = 7).

Metastatic Prostate Cancer Diagnosed by Bone Marrow Aspiration in an Elderly Man Not Undergoing PSA Screening.

Prostate cancer screening by PSA testing remains controversial, particularly in the elderly. Practice guidelines from most clinical societies suggest discontinuing PSA screening at age 70 while the USPSTF recommends against screening at any age. Recent reports have demonstrated an increased incidence of metastatic prostate cancer, with men aged 75 or older accounting for roughly half of those newly diagnosed at an incurable stage.

Case report: whole exome sequencing of primary cardiac angiosarcoma highlights potential for targeted therapies.

Background: Primary cardiac angiosarcomas are rare, but they are the most aggressive type of primary cardiac neoplasms. When patients do present, it is with advanced pulmonary and/or cardiac symptoms. Therefore, many times the correct diagnosis is not made at the time of initial presentation.

Effect of Continuous B Cell Depletion With Rituximab on Pathogenic Autoantibodies and Total IgG Levels in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.

Objective: To evaluate the effect of rituximab on pathogenic autoantibodies and total Ig levels, and to identify serious adverse events in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) treated with continuous B cell depletion.

Methods: We conducted a retrospective analysis of 239 patients with AAV treated with rituximab-induced continuous B cell depletion. Two treatment cohorts were analyzed: an induction group (n = 52) and a maintenance group (n = 237).

Laparoscopic resection of rectal cancer in the elderly.

Recent published trials have failed to demonstrate that laparoscopic resection is not inferior to open resection of rectal cancer in terms of pathologic outcomes. However, there have been numerous studies showing the benefit of laparoscopic resection in terms of short-term complications and quality of life. Fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population.

Adding an advanced practice provider to a neurology practice: Introduction to outpatient and inpatient models.

Advanced practice providers (APPs) are qualified medically licensed health care providers, including nurse practitioners (NPs), physician assistants (PAs), nurse anesthetists, certified nurse-midwives, and clinical nurse specialists, who can function either independently or alongside a physician in population-centered care models, disease management integration, care coordination, or in the provision of direct patient care. They also can improve revenue and reduce physician burnout. The use of APPs in the practice of neurology is still in its infancy, and many neurologists are not sure how to integrate an APP in their practice.