Interventions to improve adherence to surveillance guidelines in survivors of childhood cancer: a systematic review.

PURPOSE: Many survivors of childhood cancer are at high risk of late effects of their cancer therapy, including cardiac toxicity and subsequent malignant neoplasms (SMN). Current North American guidelines recommend periodic surveillance for these late effects. We conducted a systematic review of the literature to estimate rates of adherence to recommended surveillance and summarize studies evaluating interventions intended to increase adherence. METHODS: We searched MEDLINE, Embase, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and September 2018 that reported adherence to surveillance for cardiac toxicity and SMN (breast and colorectal cancer) and interventions implemented to improve completion of recommended testing. Risk of bias was assessed using relevant Cochrane checklists. Due to heterogeneity and overlapping study populations, we used narrative synthesis to summarize the findings. This review was registered in PROSPERO: CRD42018098878. RESULTS: Thirteen studies met our inclusion criteria for assessing adherence to surveillance, while five assessed interventions to improve rates of surveillance. No studies met criteria for low risk of bias. Completion of recommended surveillance was lowest for colorectal cancer screening (11.5-30.0%) followed by cardiomyopathy (22.3-48.1%) and breast cancer (37.0-56.5%). Factors such as patient-provider communication, engagement with the health care system, and receipt of information were consistently reported to be associated with higher rates of surveillance. Of five randomized controlled trials aimed at improving surveillance, only two significantly increase completion of recommended testing-one for echocardiography and one for mammography. Both involved telephone outreach to encourage and facilitate these tests. CONCLUSION: The majority of childhood cancer survivors at high risk of cardiac toxicity or SMN do not receive evidence-based surveillance. There is paucity of rigorous studies evaluating interventions to increase surveillance in this population. IMPLICATIONS FOR CANCER SURVIVORS: Robust trials are needed to assess whether tailored interventions, designed based on unique characteristics and needs of each survivor population, could improve adherence.

A case of late-onset capsular block syndrome and its surgical treatment / Um caso de síndrome de bloqueio capsular tardio e uma abordagem cirúrgica

ABSTRACT - Capsular block syndrome is a rare complication of phacoemulsification surgery with continuous curvilinear capsulorhexis and intraocular lens implantation. Here, we report a case of very late-onset capsular block syndrome that developed 13 years after cataract extraction and present the surgical approach used for its successful treatment.

RESUMO - Síndrome do bloqueio capsular é uma complicação incomum da cirurgia de facoemulsificação com capsulorrexis curvilínea contínua e implante de lente intraocular. Nós relatamos um caso de síndrome de bloqueio capsular de início tardio que se desenvolveu após 13 anos da extração da catarata e apresenta a abordagem cirúrgica utilizada para o sucesso do tratamento.

A case of late-onset capsular block syndrome and its surgical treatment.

Capsular block syndrome is a rare complication of phacoemulsification surgery with continuous curvilinear capsulorhexis and intraocular lens implantation. Here, we report a case of very late-onset capsular block syndrome that developed 13 years after cataract extraction and present the surgical approach used for its successful treatment.

[Twenty years later A story of intra-thoracic textiloma]. / Vingt ans après Histoire d'un textilome intra-thoracique.

INTRODUCTION: Intrathoracic textiloma is a rare complication possibly leading to misdiagnosis. It could present as haemoptysis, lung abscess, pseudo-tumour or a chronic cough. CASE REPORT: A 65-year-old patient with a history of multiple cardiac problems and needing long-term anticoagulation, complained since 2007 of recurrent haemoptysis of increasing abundance, the etiological investigation of which was negative. A thoracic CT-scan revealed a lesion in the lingula in contact with the pericardial plates of an implanted automatic defibrillator dating from 1989. In 2016, after two failures of arterial embolization, a diagnostic and therapeutic surgical exploration was undertaken on this patient who was a high operative risk. A segmental resection revealed an intra-pulmonary textiloma on pathological examination. CONCLUSION: The diagnosis of intrathoracic textiloma remains rare and its late presentation is non specific. Radiological imaging with a CT-scan and/or MRI could lead to the diagnosis. Surgery remains the reference treatment for the diagnosis and cure of intrathoracic textiloma with pathological examination, essential for confirmation. A means of prevention has to be developed because swab count is not totally reliable.

Inflammation in older subjects with early- and late-onset depression in the NESDO study: a cross-sectional and longitudinal case-only design.

OBJECTIVE: Different biological mechanisms may underlie depression beginning in early life (early-onset) and depression beginning later in life (late-onset). Although the relation between inflammation and depression has been studied extensively, the distinct role of inflammation in early and late-onset depression in older patients has not been addressed before. In the cross-sectional part of this study, we explored differences in levels of circulating inflammatory markers and cytokine levels in lipopolysaccharide (LPS) stimulated whole blood between older subjects with a late-life onset depression (≥60 years) and older subjects with an early-onset depression (<60 years). Secondly, in a 2-year follow-up study, we examined if circulating and stimulated inflammatory markers influenced the change in Inventory of Depressive Symptomatology (IDS) scores, and if this relation was different for early- and late-onset depression. METHODS: The study was part of the Netherlands Study of Depression in Older Persons (NESDO). We included 350 patients, all aged 60 and older, with a depressive episode in the previous 6 months: 119 with a late-onset depression and 231 with an early-onset depression. Blood samples were collected and CRP, IL-6, NGAL, GDF15, and, LPS plasma levels were determined and whole blood was LPS stimulated and cytokine levels IL-1ß, IL-6, TNFα, IFNγ, IL-10, and IL-1 receptor antagonist (IL-1ra) were determined. RESULTS: After adjustment for demographics, health indicators, and medication use, increased plasma CRP levels were more strongly associated with late-onset depression than early-onset depression (OR [95% CI]: 1.43 [1.05-1.94]). In the longitudinal analyses, higher circulating IL-6 levels were associated with a significantly slower decline in IDS scores in the crude and the adjusted models (p ≤ 0.027). This relation was not different between late- and early-onset depression. Other circulating and stimulated inflammatory markers were not associated with late- and/or early-onset depression. CONCLUSIONS: This study provides preliminary evidence that low-grade inflammation is more strongly associated with late-onset than early-onset depression in older adults, suggesting a distinct inflammatory etiology for late-onset depression. Cytokine production capacity did not distinguish between early- and late-onset depression.

Late onset adrenal insufficiency after adrenalectomy due to latent nonclassical 21-hydroxylase deficiency: A case report.

RATIONALE: Adrenal incidentaloma is sometimes complicated with 21-hydroxylase deficiency (21-OHD). Latent nonclassical 21-OHD in incidentaloma is difficult to diagnose. Although adrenalectomy in 21-OHD has been conducted when malignancy could not be excluded, adrenal insufficiency sometimes occurs, and it might not be observed immediately after operation. Here, we report a case of a 71-year-old man who experienced adrenal insufficiency over 2 decades postadrenalectomy, leading to a diagnosis of latent nonclassical 21-OHD. PATIENT CONCERNS: A 71-year-old man was admitted to the hospital due to difficulty in movements and a sodium level of 119 mEq/L. His medical history revealed precocious puberty and left adrenalectomy because of an incidentaloma at 49 years of age, diagnosed pathologically as an adenoma. He did not attend follow-up visits because he did not have any symptoms. In 2017, 3 months before hospitalization, he experienced general fatigue. A few days before admittance, he complained of difficulty in moving and visual hallucination of small animals. DIAGNOSES: Laboratory evaluations revealed a high level of adrenocorticotropic hormone (ACTH) and low cortisol level. ACTH-stimulating test revealed a low basal level and low response for cortisol, and a high basal level and low response for 17-hydroxyprogesterone. We analyzed large gene deletion or conversion and the 9 most common micro mutations in the CYP21A2 gene by polymerase chain reaction; micro mutation of I172N and heterozygous large gene deletion or conversion were detected leading to the diagnosis of nonclassical 21-OHD. INTERVENTIONS: Immediately, 100 mg hydrocortisone was administered, followed by daily hydrocortisone and saline. The symptoms and hyponatremia improved in a few days. He was discharged from the hospital on day 34 with a daily dose of 15 mg hydrocortisone. LESSONS: Clinicians should be aware of late onset of adrenal insufficiency after adrenalectomy. In such cases, clinicians should not overlook the latent nonclassical 21-OHD.

Anemia at older age: etiologies, clinical implications, and management.

Anemia is quite frequently diagnosed in older individuals and is a key indicator of various reactive and clonal conditions. Many underlying diseases, like myelodysplastic syndrome (MDS), develop preferentially in elderly individuals. The prevalence of anemia at older age is increasing, and this is mainly attributable to more frequently applied diagnostics and demographic changes in our societies. The etiology of anemia at older age is complex and ranges from bone marrow failure syndromes to chronic kidney disease, and from nutritional deficiencies to inflammatory processes including inflammaging in immunosenescence. In a smaller number of cases, no clear-cut etiology is identified. These patients are referred to as unexplained anemia or idiopathic cytopenia of unknown significance. In others, somatic mutations in leukocytes are found, but diagnostic criteria for MDS or other hematologic diseases are not fulfilled, a condition termed clonal cytopenia of undetermined significance. Management of anemias at older age depends on (1) the severity of the anemia, (2) underlying condition(s), and (3) patient-related factors, including comorbidities. Even a mild anemia may substantially affect physical and cognitive capacities and quality of life. An underestimated aspect is that because of age-related changes, organ function such as erythropoietin production in the kidney may become suboptimal. Management and treatment of anemia in older patients often require a multidisciplinary approach and detailed investigations of organ function. In this article, we review current concepts around anemias at older age, with special emphasis on etiologies, clinical implications, and innovative concepts in the management of these patients.

Acquired erythropoietic uroporphyria secondary to myelodysplastic syndrome with chromosome 3 alterations: a case report.

Congenital erythropoietic porphyria is a rare autosomal recessive disease caused by a deficiency of uroporphyrinogen III synthase, owing to mutations in UROS in chromosome 10. Occasionally, patients show a mild, late-onset disease, without germline UROS mutations, associated with haematological malignancies. We report a 65-year-old patient with photosensitivity, overexcretion of porphyrins and thrombocytopenia. Bone marrow analysis gave a diagnosis of myelodysplastic syndrome (MDS) with the presence of a derivative chromosome 3, possibly due to an inversion including 3q21 and 3q26 break points. After allogeneic stem-cell transplantation, complete remission of MDS and uroporphyria was achieved. To our knowledge, this is the first reported case of acquired erythropoietic uroporphyria associated with MDS, with chromosome 3 alterations.

Sialocutaneous fistula to the external auditory canal repaired with superficial parotidectomy and temporoparietal flap: A case report.

RATIONALE: Gustatory otorrhea can lead to cutaneous changes, recurrent infection, and social disruption. We present a case of a late, evolving sialocutaneous fistula to the external auditory canal, managed surgically after failing conservative therapies. This case is unique by late evolution, whereby the symptoms presented with significance 27 years after her operation and 19 years after mild symptoms initially arose. PATIENT CONCERNS: Gustatory, left-sided clear otorrhea with acutely increased volume over 8 months causing social disruption. DIAGNOSES: Sialocutaneous fistula to the external auditory canal. INTERVENTIONS: Superficial parotidectomy and temporoparietal flap for closure of fistula. OUTCOMES: No postoperative complications and resolution of gustatory otorrhea at one-year follow-up. LESSONS: This rare, but important, postoperative complication can present late with evolving symptoms, causing significant social disruption. It can be treated with conservative medical management and several surgical approaches.

Onset of psychosis at age 81? With regard to frontal lobe syndromes / Psicose inaugural aos 81 anos? A propósito das síndromes do lobo frontal

When the frontal lobe of the brain is affected important behavioral changes may occur mainly at the level of executive functioning, i.e., planning, decision-making, judgment and self-perception. However, the behavioral changes may be of different nature with marked indifference and apathy. We report a clinical case of an 81-year-old patient with sudden onset of behavioral changes that were initially interpreted as an acute confusional episode of infectious etiology, but actually they were due to an ischemic lesion in the frontal lobe.

O lobo frontal, quando afetado, pode provocar alterações importantes do comportamento, principalmente na função executiva: planejamento, tomada de decisões, juízo e autopercepção. Contudo, as alterações podem ser de outra natureza, caracterizando-se por marcada indiferença e apatia. É relatado aqui o caso de uma paciente de 81 anos, com alterações súbitas do comportamento, que foram interpretadas inicialmente como um quadro confusional agudo de natureza infecciosa, mas que se mostraram provocadas por uma lesão isquêmica na região frontal.

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi.

Kidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi

ABSTRACTKidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

Etiology and Long-Term Outcomes of Late-Onset Infantile Spasms.

OBJECTIVES: The purpose of the study was to evaluate the etiology and long-term outcomes of late-onset epileptic spasms (LOS). METHODS: This is a retrospective analysis of all consecutive patients seen at our center with onset of clusters of epileptic spasms between 1 and 3 years of age in 1995 through 2005. RESULTS: Overall, 17 children with LOS were identified. Overall, 14 children (82%) had structural etiology. Six patients received resective surgical treatment. Five had focal cortical dysplasia type 1 (FCD1) histology (29% of all the patients). Overall, 16 children were followed for 2 to 18 years. At the latest follow-up, seizure freedom was observed in 67% of the operated and in 50% of the nonoperated patients. Normal cognition or only mild mental deficiency was observed in nine patients (56%), of whom eight were seizure-free. All patients with intractable spasms had a severe mental deficiency. CONCLUSION: The overall cognitive outcome of LOS was more favorable than in the previous reports and was associated with seizure freedom. FCD1 is a frequent etiology for LOS and the cognitive outcome of patients with FCD1 seemed to be favorable.

A mobile application to manage and minimise the risk of late effects caused by childhood cancer.

In their first 15 years of life, about 1 800 children are diagnosed with cancer each year in Germany. Their chances of survival, however, have improved significantly over the last 40 years. In Germany alone, over 30 000 survivors of childhood cancer are presently living. Therefore, the late effects caused by the therapy occur ever more frequently as chemotherapy and radiotherapy may leave traces even years later. In order to recognize and treat these late effects in survivors, structured and regular follow-up examinations are necessary from an early stage on. However, the compliance of former patients to participate in the recommended check-ups is not satisfying for multiple reasons. To enhance this compliance, an application for smartphones and tablets has been developed. The Aftercare App supplies a wide range of information regarding the aftercare and supports a reminder functionality to attend medical visits.

Long-term outcome and medical radiation exposure in patients hospitalized for cardiovascular disease.

BACKGROUND: Low radiation doses from diagnostic and therapeutic procedures may increase cancer incidence after decades in cardiac patients. The aim of the study was to evaluate the long-term outcome and the prognostic effect of radiological exposure. METHODS: A retrospective cohort study examined 16,311 Italian cardiac patients without cancer consecutively hospitalized between 1970 and 2009 and followed-up for a median of 10 years. Cumulative estimated effective dose was calculated for the imaging procedures. Main causes of death and primary cancer onset were the end points and their relation with radiation exposure was analyzed by Cox model. RESULTS: Over the years, there was an increasing trend of cancer, a decreasing trend of cardiovascular, with stability of other-causes death. Cumulative estimated effective radiation dose was higher in patients who died for cancer (20 ± 19 mSv) compared to cardiovascular (17 ± 17, P < 0.001) and other-causes deaths (15 ± 17, p < 0.001). The cumulative estimated effective dose adjusted HR was 1.004 (95% CI 1.000-1.009, p = 0.045) for cancer death and 1.008 (95% CI 1.005-1.011, p < 0.001) for (fatal and non-fatal) cancer onset. Radiation effective dose was not predictive of cardiovascular mortality (HR = 0.991), nor it was of other types of deaths (HR = 0.995). Smoking was a predictor for cardiovascular mortality, but it was not of other types of deaths. CONCLUSIONS: Non-cardiovascular causes of death are responsible for almost half of later deaths in cardiac patients. The radiological exposure from medical imaging procedures is predictive of cancer risk and cancer death.

Parkinson's disease and age: The obvious but largely unexplored link.

Parkinson's disease is a chronic, progressive neurodegenerative disorder with increased prevalence in the aging population. It is estimated that approximately 1.5 million individuals in the US alone suffer from Parkinson's disease and with the extension of life expectancy this number is expected to rise dramatically within the next twenty-five years. The majority of Parkinson's disease cases are sporadic. But mutations in genes such as α-synuclein, Parkin, PINK1, DJ-1 and LRRK2, have been conclusively associated with both early- and late-onset of the disease. Although the genetics of Parkinson's disease is starting to become unraveled, the interplay between genetic and environmental factors is largely unknown as are the underlying mechanisms that trigger the disease as the brain ages. The risk of Parkinson's disease increases dramatically in individuals over the age of 60 and it is estimated that more than 1% of all seniors have some form of the condition. In this review, we will highlight some of the central proteins associated with Parkinson's disease and how they may be linked to processes and factors associated with age.