The Curious Case of a Painful Leg Ulcer.

Sickle cell disease is a condition that can involve numerous organ systems secondary to vascular occlusion. Herein, we present a case of a 21-year-old male with sickle cell disease requiring long-term hydroxyurea therapy. Upon migrating to the United States from Yemen, the patient developed a rapidly progressive, exquisitely painful ulcer on his right lower extremity. Given his country of origin, a broad differential, including select infectious diseases, was essential. Moreover, establishing the unequivocally correct diagnosis was crucial to determine proper and safe therapy. Ultimately, a lesional biopsy demonstrated numerous sickled red blood cells occluding blood vessels, leading to the diagnosis of sickle cell disease-related leg ulceration.

Spiradenoma With Adenoid Cystic Carcinoma-Like Features.

Spiradenoma is a benign cutaneous adnexal neoplasm that characteristically presents as a painful dermal nodule, often on the head or trunk. It has a distinct histologic phenotype and management involves surgical excision with low risk of recurrence. In comparison, adenoid cystic carcinoma (ACC) is a low-grade malignancy manifesting as an often painless subcutaneous mass with potential for local invasion, perineural extension, and high rates of recurrence after excision. We report the case of a 63-year-old male patient with a recurrent, painful hematoma-like cyst overlying the left lower extremity tibial tuberosity. A firm nodule was located at the base of the cyst, which was histologically consistent with spiradenoma. Interestingly, the lesion contained multifocal ACC-like components composed of epithelial basaloid cells surrounding pseudocystic structures filled with mucinous material. The ACC-like components did not demonstrate infiltration or perineural invasion. To the best of our knowledge, this is the second publication in the English literature regarding spiradenoma with an ACC-like pattern. Although a benign entity, knowledge of this morphological variant of spiradenoma is essential for diagnostic accuracy in these cases. If a limited biopsy captures only the ACC-like component of a spiradenoma, the lesion may be incorrectly diagnosed as ACC.

Group cognitive-behavioral treatment for internalized weight stigma: a pilot study.

OBJECTIVE: This study tested a novel group-based, cognitive-behavioral intervention designed to reduce internalized weight stigma among individuals with obesity. METHODS: A total of eight men and women with obesity who had experienced weight stigma and reported high levels of internalized weight stigma attended the Weight Bias Internalization and Stigma (BIAS) Program. The program provided eight weekly sessions of cognitive-behavioral treatment to cope with weight stigma. Participants completed questionnaires pre- and post-intervention, including the Weight Bias Internalization Scale (WBIS), Fat Phobia Scale, Weight Efficacy Life-Style Questionnaire (WEL), and Beck Depression Inventory-II (BDI-II). Six additional participants were included in a quasi-control group that received no intervention until after completing all study measures. RESULTS: Participants in the Weight BIAS Program reported significantly greater decreases in WBIS and Fat Phobia scores, and greater increases in WEL scores than participants in the quasi-control group (ps < .04). Changes in BDI-II scores did not differ between groups. Treatment-acceptability ratings were high among participants who received the intervention. CONCLUSION: Including cognitive-behavioral strategies to address weight stigma in weight management programs could potentially reduce internalized weight stigma and enhance treatment outcomes.

Binge-eating disorder and the outcome of bariatric surgery in a prospective, observational study: Two-year results.

OBJECTIVE: A previous study reported that preoperative binge-eating disorder (BED) did not attenuate weight loss at 12 months after bariatric surgery. This report extends the authors' prior study by examining weight loss at 24 months. METHODS: A modified intention-to-treat population was used to compare 24-month changes in weight among 59 participants treated with bariatric surgery, determined preoperatively to be free of a current eating disorder, with changes in 33 surgically treated participants with BED. Changes were also compared with 49 individuals with obesity and BED who sought lifestyle modification for weight loss. Analyses included all available data points and were adjusted for covariates. RESULTS: At month 24, surgically treated patients with BED preoperatively lost 18.6% of initial weight, compared with 23.9% for those without BED (P = 0.049). (Mean losses at month 12 had been 21.5% and 24.2%, respectively; P = 0.23.) Participants with BED who received lifestyle modification lost 5.6% at 24 months, significantly less than both groups of surgically treated patients (P < 0.001). CONCLUSIONS: These results suggest that preoperative BED attenuates long-term weight loss after bariatric surgery. We recommend that patients with this condition, as well as other eating disturbances, receive adjunctive behavioral support, the timing of which remains to be determined.

Osteoporosis management in older patients who experienced a fracture.

BACKGROUND: Fractures in older patients are common, morbid, and associated with increased risk of subsequent fractures. Inpatient and outpatient management and treatment of fractures can be costly. With more emphasis placed on quality care for Medicare beneficiaries, we studied if patients were receiving proper screening for osteoporosis and treatment after diagnosis of fracture. This study aims to determine if adequate screening and treatment for osteoporosis occurs in the postfracture period. METHODS: A retrospective analysis of Medicare beneficiaries aged 67 years or older was gathered from a single institution in both inpatient and outpatient visits. Based on International Classification of Diseases ninth revision codes, primary diagnosis of fractures of neck and trunk, upper limb, and lower limb were obtained in addition to current procedural terminology codes for fracture procedures. We studied patients who had been screened for osteoporosis with a bone mineral study or received osteoporosis treatment after their fracture. RESULTS: Medicare beneficiaries totaling 1,375 patients were determined to have an inclusion fracture between June 1, 2013 and November 30, 2014. At the time of our analysis on December 1, 2014, 1,219 patients were living and included in the analysis. Of these patients, 256 (21.0%) either received osteoporosis testing with bone mineral density or received treatment for osteoporosis. On sex breakdown, 208/820 (25.4%) females received proper evaluation or treatment of osteoporosis in comparison to 48/399 (12.0%) males. This is in comparison to the Centers for Medicare and Medicaid Services' national average of 19.1% for osteoporosis management in females. CONCLUSION: A minority of studied patients received evaluation or treatment for osteoporosis after their fracture. Postfracture investigation and treatment for osteoporosis in Medicare beneficiaries is inadequate. If improved, Medicare costs could be reduced by prevention of future fractures. Future studies could determine how best to ensure this intervention occurs.

Extracellular matrix in obesity - cancer interactions.

Obesity or overweight is a risk factor for several health disorders such as type 2 diabetes, hypertension, and certain cancers. Furthermore, obesity affects almost all body systems including the extracellular matrix (ECM) by generating a pro-inflammatory environment, which are associated with abnormal secretions of several cytokines or hormonal substances, for example, insulin-like growth factors (IGFs), leptin, and sex hormones. These chemical mediators most likely have a great impact on the ECM. Accumulating evidence suggests that both obesity and ECM can influence tumor growth and progression through a number of chemical mediators. Conversely, cells in the connective tissue, namely fibroblasts and macrophages, support and aggravate the inflammatory situation in obesity by releasing several cytokines or growth factors such as vascular endothelial growth factor, epidermal growth factor, and transforming growth factor-beta (TGF-ß). A wide range of functions are performed by TGF-ß in normal health and pathological conditions including tumorigenesis. Breast cancer in postmenopausal women is a classic example of obesity-related cancer wherein several of these conditions, for example, higher levels of pro-inflammatory cytokines, impairment in the regulation of estrogen and growth factors, and dysregulation of different ECM components may favor the neoplastic process. Aberrant expressions of ECM components such as matrix metalloproteinases or matricellular proteins in both obesity and cancer have been reported by many studies. Nonstructural matricellular proteins, viz., thrombospondins, secreted protein acidic and rich in cysteine (SPARC), and Cyr61-CTGF-Nov (CCN), which function as modulators of cell-ECM interactions, exhibit protean behavior in cancer. Precise understanding of ECM biology can provide potential therapeutic targets to combat obesity-related pathologies.

A randomized clinical trial of an integrated behavioral self-management intervention Simultaneously Targeting Obesity and Pain: the STOP trial.

BACKGROUND: Obesity often occurs co-morbid with chronic, non-cancer pain. While behavioral treatments have proved effective for pain management and weight loss independently, integrated interventions are lacking. The study Simultaneously Targeting Obesity and Pain (STOP) is a prospective, pragmatic, randomized controlled trial that aims to determine whether overweight/obese individuals with chronic pain who are randomized to receive an integrated treatment Simultaneously Targeting Obesity and Pain (STOP) will show more weight loss and greater reduction in pain intensity over a 6-month period and greater maintenance at 12 months than those who receive standard care behavioral weight loss or standard care behavioral pain management. We hypothesize that individuals randomized to receive the STOP treatment will demonstrate improved weight loss, pain reduction, and maintenance compared to standard care treatment approaches. METHODS/DESIGN: Adults aged ≥ 18 with a body mass index ≥ 25 and who report persistent pain (≥4 out of 0-10 for > 6 months) will be recruited for treatment at the Health Behavior Research Lab at the University of the Sciences. After baseline assessments and goal setting, participants will be randomized to receive one of three treatments. Participants will receive eleven treatment sessions delivered during 1 hour, weekly individual meetings with a clinic therapist. Follow-up will occur at 3, 6 and 12-month time points; assessments will include measures of weight and pain intensity (primary outcomes). A mixed-method approach to evaluating study outcomes will include individual interviews with participants about their treatment experience. These interviews will be led by a research staffer who was not involved in study intervention or assessment using a semi-structured discussion guide. DISCUSSION: This study fills an important gap in intervention research, evaluating best-practices for behavioral management of a highly prevalent co-morbidity that has sub-optimal outcomes with currently-implemented approaches. STOP's pragmatic focus builds upon treatments already in use in clinical practice. Should STOP be found efficacious in achieving the dual outcomes of pain management and weight loss, such an approach could be integrated into practice with minimal additional cost or training. TRIAL REGISTRATION: Clinical Trials.gov NCT02100995 Date of Registration: March 2014.