Foramen magnum meningioma: Dysphagia of atypical etiology.

INTRODUCTION: We present a case of a foramen magnum meningioma that highlights the importance of the neurologic exam when evaluating a patient with dysphagia. A 58-year-old woman presented with an 18-month history of progressive dysphagia, chronic cough and 30-pound weight loss. Prior gastroenterologic and laryngologic workup was unrevealing. RESULTS: Her neurologic examination revealed an absent gag reflex, decreased sensation to light touch on bilateral distal extremities, hyperreflexia, and tandem gait instability. Repeat esophagogastroduodenoscopy was normal, whereas laryngoscopy and video fluoroscopy revealed marked hypopharyngeal dysfunction. Brain magnetic resonance imaging demonstrated a 3.1 x 2.7 x 2.9 cm foramen magnum mass consistent with meningioma. The patient underwent neurosurgical resection of her mass with near complete resolution of her neurologic symptoms. Pathology confirmed diagnosis of a WHO grade I meningothelial meningioma. CONCLUSION: CNS pathology is an uncommon but impressive cause of dysphagia. Our case demonstrates the importance of a thorough neurologic survey when evaluating such a patient.

Even patients with changing moles face long dermatology appointment wait-times: a study of simulated patient calls to dermatologists.

BACKGROUND: Previous studies have shown long wait-times for general dermatology patients seeking routine appointments. No evidence has been gathered on wait-times for patients with urgent problems or on the impact of physician extenders on access to dermatologic care. OBJECTIVE AND METHODS: To evaluate access for patients with an urgent problem, we performed scripted patient telephone calls to 851 dermatologists to assess wait-times for both patients with Medicare and those paying out-of-pocket complaining of a changing mole. RESULTS: Mean wait-times were similarly long for patients paying out-of-pocket (38.2 days) and those on Medicare (38.9 days; P = .85). Acceptance rates and wait-times varied greatly by geographic area (range of mean wait-times, 19.7-73.4 days). Many dermatologists (23.3%) employed a physician extender, and the wait-times for these extenders (27.9 days) were significantly shorter than those for the physicians supervising them (45.8 days; P < .001). LIMITATIONS: The metropolitan areas sampled represented about one tenth of practicing dermatologists in the United States, and no remote or highly rural communities were included. CONCLUSIONS: Patients with a changing pigmented lesion, a possible indicator of malignancy, face wait-times just as long as those previously published for patients with routine complaints. Medicare patients did not experience any greater barriers to access. Although the use of physician extenders remains controversial, these practitioners were able to schedule patients more quickly than their supervising physicians.

The role of dermatopathology in conjunction with teledermatology in resource-limited settings: lessons from the African Teledermatology Project.

BACKGROUND: Access to dermatology and dermatopathology services is scarce in sub-Saharan Africa. Teledermatology provides consultations for healthcare providers in resource-limited settings where specialty medical services are difficult to obtain, and the African Teledermatology Project has helped to bridge the gap in dermatological care in Africa. This program also allows for biopsy specimens to be sent to the USA for processing in cases where the clinical diagnosis is difficult and definitive diagnosis has implications for patient management. This study characterizes conditions diagnosed through clinicopathological correlation in conjunction with photos and tissue submitted to the African Teledermatology Project. MATERIALS AND METHODS: Retrospective case review of tissue specimens submitted over three years. RESULTS: Fifty-five biopsy specimens met inclusion criteria and represent cases of malignancy (35%), infection (7%), suspected infection (15%), lichenoid tissue reaction (5%), dermatitis (15%), and other various conditions (18%). Three biopsy specimens were non-diagnostic (5%). Clinicopathological concordance between submitting clinician and biopsy results occurred in 32 out of 55 cases (58%). Clinical and pathological diagnoses differed in 21 out of 55 cases (38%). Kaposi sarcoma (KS) represents the clinical diagnosis most often suspected in the evaluated biopsy specimens (42%) and was correctly recognized clinically in 13 out of 23 cases (57%). CONCLUSION: Clinical images may not provide sufficient information to definitively diagnose certain infectious and malignant dermatological conditions submitted through telemedicine consultation. Microscopic examination of skin biopsy specimens is an important adjunct for accurate diagnosis of disease and determination of appropriate treatment strategies.