Bilateral Adrenal and testicular Tumours; When a Simple Diagnosis Becomes Complicated.

A 78-year-old man with a BMI 28.7, a moon face and a medical history of diabetes mellitus, hypothyroidism, undefined adrenal insufficiency and history of cardiac ablation, had been in urological follow up for both prostate and bladder cancer. PSA remained low after radiation and adjuvant ADT. Cystoscopy revealed no recurrence after transurethral resection of bladder tumour and instillation of BCG. A routine CT scan as indicated by EAU guideline, showed bilateral enlargement of the adrenal glands as the only abnormality de novo. Patient had no other symptoms than already long-existing fatigue. Considering patient's medical history, subsequently a FDG PET scan was performed which showed intense FDG uptake not only bilaterally in the adrenal glands, but also in both testes. An ultrasound of the testes demonstrated hypodense lesions with increased flow. US imaging raised the suspicion of testicular adrenal rest tumours. Differential diagnoses were primary testis tumour, metastatic disease, BCG-itis, lymphoma or rare endocrine disorders. The combination of bilateral adrenal gland hyperplasia and testicular masses reminded us of seeking the rare diagnosis of ectopic adrenal remnant in both testis and a Cushing-like feature. Endocrinological evaluation could not establish an all-encompassing diagnosis to explain all of the clinical findings. Bilateral orchidectomy was performed. Histological examination showed localization of diffuse large B cell lymphoma (DLBCL) in both testes. Patient was referred to the haematologist and started with chemotherapy, R-CHOP. The diagnostic process in this case was challenging and misleading.

Is Satisfaction with the Acute-Care Experience Higher amongst Consumers Treated in the Private Sector? A Survey of Public and Private Sector Arthroplasty Recipients.

BACKGROUND: Consumer satisfaction with the acute-care experience could reasonably be expected to be higher amongst those treated in the private sector compared to those treated in the public sector given the former relies on high-level satisfaction of its consumers and their subsequent recommendations to thrive. The primary aims of this study were to determine, in a knee or hip arthroplasty cohort, if surgery in the private sector predicts greater overall satisfaction with the acute-care experience and greater likelihood to recommend the same hospital. A secondary aim was to determine whether satisfaction across a range of service domains is also higher in the private sector. METHODS: A telephone survey was conducted 35 days post-surgery. The hospital cohort comprised eight public and seven private high-volume arthroplasty providers. Consumers rated overall satisfaction with care out of 100 and likeliness to recommend their hospital on a 5-point Likert scale. Additional Likert-style questions were asked covering specific service domains. Generalized estimating equation models were used to analyse overall satisfaction (dichotomised as ≥ 90 or < 90) and future recommendations for care (dichotomised as 'definitely recommend' or 'other'), whilst controlling for covariates. The proportions of consumers in each sector reporting the best Likert response for each individual domain were compared using non-parametric tests. RESULTS: 457 survey respondents (n = 210 private) were included. Less patient-reported joint impairment pre-surgery [OR 1.03 (95% CI 1.01-1.05)] and absence of an acute complication (OR 2.13 95% CI 1.41-3.23) significantly predicted higher overall satisfaction. Hip arthroplasty [OR 1.84 (1.1-2.96)] and an absence of an acute complication [OR 2.31 (1.28-4.17] significantly predicted greater likelihood for recommending the hospital. The only care domains where the private out-performed the public sector were hospitality (46.7 vs 35.6%, p <0.01) and frequency of surgeon visitation (76.4 vs 65.8%, p = 0.03). CONCLUSIONS: Arthroplasty consumers treated in the private sector are not more satisfied with their acute-care experience nor are they more likely to recommend their hospital provider. Rather, avoidance of complications in either sector appears to result in improved satisfaction as well as a greater likelihood that patients would recommend their hospital provider.