Implementation of a Hepatocellular Carcinoma Surveillance Program in a Community-Based Integrated Health System in Patients With Hepatitis C Cirrhosis.

INTRODUCTION: Underutilization of hepatocellular cancer (HCC) surveillance has been reported, although data evaluating interventions to improve surveillance are sparse. We assessed the effect of a population-based HCC surveillance program on HCC surveillance utilization and outcomes. METHODS: In this retrospective cohort study, we assessed preinclusion and postinclusion HCC surveillance patterns among 597 patients with hepatitis C virus cirrhosis enrolled in a program at an integrated health system between 2013 and 2020. Adequate surveillance was defined as at least 5 surveillance studies within 36 months pre-enrollment and postenrollment; a secondary outcome was proportion of time covered by surveillance over 36 months. Tumor size, stage, and receipt of curative therapy were compared between HCC detected on the first imaging examination (prevalent HCC) and surveillance-detected HCC (incident HCC). We performed Kaplan-Meier analysis and multivariable competing risk analysis to characterize the association between surveillance and mortality. RESULTS: The surveillance program significantly improved surveillance completion (77.6% vs 5.0%, P < 0.001) and proportion time covered (80.9% vs 15.8%, P < 0.001). Compared with prevalent HCC, surveillance-detected cases were more likely unifocal (77.8% vs 44.8%, P < 0.001), early-stage (85.2% vs 44.8%, P < 0.001), with smaller maximum diameter (median 2.3 vs 3.2 cm), and more likely to undergo curative therapy (92.5% vs 72.4% P = 0.010). Survival was improved compared with prevalent cases hazard ratio (HR) 0.23 (0.11-0.51) after adjusting for age and Model for End Stage Liver Disease score. DISCUSSION: Implementation of a population-based program resulted in significant improvement in HCC surveillance use and clinical outcomes among patients with hepatitis C virus cirrhosis. These findings may inform similar interventions by other healthcare systems.

Influence of CrossFit and Deep End Fitness training on mental health and coping in athletes.

Physical exercise is known to improve mental health. Athletes can experience unique physical and emotional stressors, which can deteriorate mental health and cognitive function. Training apathy can lead to cognitive dissonance and further degrade performance by promoting maladaptive, avoidance coping strategies. Introduction of psychosocial and training variables, such as those used in CrossFit (CF) and other community-based fitness programs with strong peer support have been shown to help reduce training apathy and negative affect. Here, we explored whether addition of psychophysiological variation, experienced as "hunger for air" during underwater breath-hold exercises, could provide unique mental health benefits for athletes. We studied the influence of CF and Deep End Fitness (DEF), a community-based underwater fitness program, on several outcome measures of mental health and emotional well-being in volunteer athletes. We observed a significant reduction in stress scores of both the control CF training group and the experimental DEF group. We found that DEF produced a significant improvement in positive affect while CF training did not. Further supportive of our hypothesis that the psychological and biological stressors experienced in underwater, breath-hold training cause positive adaptive changes and benefits, DEF training uniquely increased problem-based coping. While our observations demonstrate both CF and DEF training can improve mental health in athletes, DEF produced additional, unique benefits to positive coping and attitudes of athletes. Future studies should further evaluate the broader benefits of community-based, underwater training programs on psychological and physiological health in athletes and the public.

Dyspnea Postpulmonary Embolism From Physiological Dead Space Proportion and Stroke Volume Defects During Exercise.

BACKGROUND: Many patients with pulmonary embolism (PE) report dyspnea on exertion following long-term treatment. Increased physiological dead space proportion (VD/VT) and decreased cardiac stroke volume reserve may distinguish persistent effects of PE itself from symptoms reflecting comorbid conditions or deconditioning. METHODS: This retrospective study analyzed a consecutive series of incremental symptom-limited cardiopulmonary exercise tests that had been ordered to evaluate persistent dyspnea on exertion following long-term treatment for acute PE. Physiological VD/VT was determined at anaerobic threshold from exhaled CO2 and transcutaneous Pco2 (validated against Paco2 measurements). Cardiac stroke volume reserve was estimated at rest and at anaerobic threshold by using oxygen consumption/pulse and previously validated estimates of the arteriovenous oxygen content difference. RESULTS: Cardiopulmonary exercise tests were performed on 40 patients with post-PE dyspnea. In 65.0% (95% CI, 50.2-79.8), VD/VT at anaerobic threshold was abnormally elevated, stroke volume reserve was decreased, or both defects occurred. VD/VT at anaerobic threshold was abnormally elevated (≥ 0.27) in 35.0% (95% CI, 20.2-49.8). VD/VT at anaerobic threshold significantly correlated with the extent of unmatched perfusion defects on subsequent ventilation-perfusion scans (P = .0085). In 55.0% (95% CI, 39.6-70.4), stroke volume reserve at anaerobic threshold was abnormally decreased (≤ 128% of the resting value). Both defects were present in 25.0% (95% CI, 11.6-38.4). CONCLUSIONS: Increased VD/VT at anaerobic threshold and decreased stroke volume reserve during exercise are common among patients with dyspnea on exertion after long-term treatment of PE. The defects can be disclosed noninvasively by using cardiopulmonary exercise testing.

Histiocyte-rich pleomorphic mastocytoma: an uncommon variant mimicking juvenile xanthogranuloma and Langerhans cell histiocytosis.

An 11-year old Caucasian female with a remote history of urticaria pigmentosa presented with a neck mass. A biopsy demonstrated a large intradermal nodule composed of unusually large epithelioid mast cells, including a prominent subset with bi-lobed and multi-lobed nuclei. By immunohistochemistry, the cells expressed CD117 (C-Kit), mast cell tryptase, CD68, and CD25, and were negative for CD163, CD1a, and S-100, confirming the diagnosis of mastocytoma. Equally prominent was an admixed infiltrate of CD68 and CD163-positive xanthomatous histiocytes that included Touton-type giant cells. Eosinophils were abundant. At 7 months follow-up, there was no recurrence of the lesion following complete excision. However, given the unusual cytologic features, close clinical observation is warranted, as the long-term biologic potential of mastocytoma with this degree of cytologic atypia is uncertain. Awareness of this unusual morphologic variant is also important as the histologic features may mimic such childhood neoplasms as juvenile xanthogranuloma and Langerhans cell histiocytosis.

An infiltrative variant of non-neural granular cell tumor: a case report.

Dermal non-neural granular cell tumors are rare tumors of indeterminate lineage that typically present as well-circumscribed tumors with nuclear pleomorphism and mitotic activity. We describe a dermal non-neural granular cell tumor with a distinctive growth pattern with granular cells interspersed between collagen bundles. This asymptomatic papule arose on the scapula of a 46-year-old woman and consisted of a mixture of epithelioid and spindled granular cells. The immunohistochemical characteristics were similar to those of previously reported dermal non-neural granular cell tumors. Despite mild nuclear pleomorphism and dispersion of lesional cells among collagen bundles, mitoses were not present and Ki-67 staining indicated a low proliferative rate. In addition to being S-100 protein negative and NKI/C3 positive, our case was positive for PGP9.5 and weakly positive for neuron-specific enolase, a staining pattern similar to what has been observed for cellular neurothekeomas. Our case could represent a dermal non-neural granular cell tumor with unique architecture, a granular cellular neurothekeoma or a granular cell dermatofibroma. As both dermal non-neural granular cell tumor and cellular neurothekeoma are of indeterminate lineage, our case with features characteristic of both entities may suggest a common precursor or lineage for dermal non-neural granular cell tumor and cellular neurothekeoma.

Reported immigration and medical coercion among immigrants referred to a cultural consultation service.

Members of visible minorities are commonly targets of social coercion related to immigration and medical measures. Social coercion is associated with poor mental health outcomes and mistrust of medical services. This study will determine if Afro-Canadian immigrants referred to a Cultural Consultation Service (CCS) in Montreal report more or less medical and immigration coercion compared with other ethnic minorities. We reviewed the charts of 729 referrals to the CCS and gathered data on the 401 patients included in the study. Chi-square statistics examined the relation between minority group and self-reported coercion. Binary logistic regression models controlled for standard sociodemographic variables in addition to ethnicity, language barrier, length of stay in Canada since immigration, refugee claimant status, referral source, presence of psychosis in the main diagnosis, and presence of legal history. Patients were diverse and included 105 Afro-Canadians, 40 Latin Americans, 73 Arab and West Asians, 149 South Asians, and 34 East and Southeast Asians. Being Afro-Canadian was significantly and positively associated with medical coercion (p = .02, 95% CI = 1.15-4.57), while being South Asian was negatively and significantly associated with immigration coercion (p = .03, 95% CI = .29-.93). Members of visible minority communities are not equal in their reported experience of social coercion after arriving to Canada. Future research clarifying pathways to mental health care for immigrants and the experience of new Canadians in immigration and health care settings would give needed context to the findings of this study.

An 'eruptive' variant of juvenile xanthogranuloma associated with langerhans cell histiocytosis.

The development of juvenile xanthogranuloma (JXG) as a sequel to langerhans cell histiocytosis (LCH) treated with chemotherapy is rare and the hypothesis is intriguing. This is a case of a 19-year-old woman who presented with progressive development of tan-red papules on the axilla and eyelids over a 1.5-year time span. A biopsy of an axillary lesion showed a prominent dermal infiltrate of foamy histiocytoid cells with occasional Touton-type multinucleate giant cells, consistent with JXG. Three years later, the patient presented with additional similar papules on the axilla and vulva as well as a painful mass in the pelvic bone and diabetes insipidus with an associated pituitary mass. An iliac crest bone biopsy showed an eosinophil-rich infiltrate admixed with histiocytoid cells with reniform nuclei, which expressed S100 and CD1a, consistent with a diagnosis of LCH. Nonetheless, an additional axillary papule was once again consistent with JXG, with negative reaction for S100 and CD1a with no Birbeck granules by electron microscopy. This case is unique by the co-existing presentation of multiple cutaneous JXG lesions and internally confined LCH lesions without an apparently associated chemotherapy, corroborating the concept that JXG and LCH may share a common histogenesis.

A comparison between ultrasound-guided infraclavicular block using the "double bubble" sign and neurostimulation-guided axillary block.

BACKGROUND: Ultrasound-guided infraclavicular block can be performed using the double bubble sign. Previously described, the double bubble sign consists superiorly of the axillary artery (in short axis) superimposed on an inferior bubble created by local anesthetic injection. In this study, we compared this new method of brachial plexus anesthesia to the traditional triple-nerve stimulation axillary block. METHODS: Seventy patients were randomized to receive a single-injection, ultrasound-guided infraclavicular block using the double bubble sign or a triple-stimulation axillary block. RESULTS: Both methods produced similar success rates (89%-91%). However, infraclavicular blocks were associated with a shorter performance time (3.90 +/- 2.27 vs 8.03 +/- 3.92 min; P < 0.001) and lower block-related pain scores (2.70 +/- 2.02 vs 4.17 +/- 2.57 on a 0-10 scale; P = 0.01). CONCLUSION: Compared to triple-stimulation axillary block, ultrasound-guided infraclavicular block using the double bubble sign provided a similar efficacy, a shorter performance time and lower procedural pain scores.

First Manic Episode in an 11 Year-old Girl.

OBJECTIVE: We present the case of an 11 year-old girl admitted to the Centre hospitalier universitaire de Sherbrooke for a first manic episode. METHOD: Differential diagnoses of adjustment disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder were considered but eliminated. RESULTS: No organic etiology was detected. Her condition rapidly remitted with aripiprazole 3mg. After her discharge, she suffered a relapse due to instability of her living conditions and was rehospitalized. CONCLUSION: Mania is a difficult diagnosis in youths due to its nonspecific symptoms, rare prepubertal occurrence, and diagnostic complexity. Despite ongoing research, there is little conclusive information on the impact of psychosocial stressors on the evolution of early-onset bipolar disorder.

OBJECTIF: Nous présentons le cas d'une fillette de 11 ans hospitalisée au Centre hospitalier universitaire de Sherbrooke pour un premier épisode de manie. MÉTHODE: Les diagnostics différentiels du trouble d'adaptation, du trouble de déficit de l'attention avec hyperactivité, du trouble oppositionnel avec provocation et du trouble des conduites ont été envisagés mais rejetés. RÉSULTATS: Aucune étiologie organique n'a été détectée. La rémission de son affection a été rapide avec 3 mg d'aripiprazole. Après son congé, elle a souffert d'une rechute attribuable à l'instabilité de ses conditions de vie et a été réhospitalisée. CONCLUSION: La manie est un diagnostic difficile chez les adolescents en raison de ses symptômes non spécifiques, d'une rare occurrence pré-pubère, et de la complexité diagnostique. Malgré la recherche en cours, il y a peu d'information concluante sur l'effet des stresseurs psychologiques sur l'évolution du trouble bipolaire d'apparition précoce.

Granulomatous dermatitis with pseudoxanthoma elasticum-like changes: report of a case in a patient with cystic fibrosis.

BACKGROUND: There is scant literature that documents pseudoxanthoma elasticum (PXE)-like histologic changes in the setting of inflammatory skin diseases. This article documents granulomatous dermatitis with PXE-like changes in a patient with cystic fibrosis. This is the first report of its kind, to our knowledge. OBSERVATIONS: A 33-year-old woman with cystic fibrosis developed a papular eruption on the flexural surfaces of the upper and lower extremities, which was initially treated with prednisone. A punch biopsy showed granulomatous inflammation and associated PXE-like changes. The combined histologic and clinical findings were most consistent with granuloma annulare. There was no family history of PXE or clinical manifestations of PXE. The rash gradually resolved itself over the next several months. CONCLUSIONS: There are few publications that document PXE-like changes in association with various inflammatory skin conditions. Thus, the clinical significance of this finding remains uncertain. This case and previous reports are discussed in the context of current molecular and genetic knowledge. It is hoped that greater awareness of this phenomenon will promote further investigation and elucidation of the clinical and biologic significance of PXE-like changes observed in biopsies of inflammatory skin disorders.