Too Hot to Handle: A Case of Fever of Unknown Origin.

Fever of unknown origin (FUO) is defined as a fever higher than 38.3ºC for at least three weeks. It remains a difficult diagnostic challenge and it carries well over 200 differential diagnoses, including infectious, rheumatologic and malignant etiologies. A methodological approach with clinical deductive reasoning and value-based investigative work-up can establish the diagnosis. This case is about a 76-year-old male with a past medical history of atrial fibrillation, bladder cancer treated with chemotherapy (now in remission) and hydronephrosis with recent ureteropelvic junction stent placement. He presented to the emergency department (ED) for worsening shortness of breath (SOB), weakness, and fevers. His initial workup was notable for a urinary tract infection which was treated with ceftriaxone. However, there was only a limited improvement in the fever. Diagnostic imaging was negative on initial review. He was evaluated by consultants of different specialities including infectious disease, rheumatology, and hematology. Ultimately, the decision was made to discharge the patient home on steroids with further outpatient workup. He returned four weeks later with worsening fever and was found to have new-onset mediastinal lymphadenopathy. A biopsy of an inguinal lymph node was obtained which showed high grade-B cell lymphoma. The patient was continued on prednisone and started on chemotherapeutic agents which included vincristine, rituximab and cyclophosphamide. Shortly after starting treatment, the patient and family elected for hospice. This case demonstrates the importance of continuously questioning the diagnosis at hand and of keeping an open mind when evaluating a patient with FUO.

Complication Rates Following Septoplasty With Inferior Turbinate Reduction.

Background: Septoplasty with submucous resection of the inferior turbinate (SMRT) is a common correctional surgery performed in patients with deviated nasal septum resulting in nasal obstruction. Although complications are infrequent, studies examining long-term complications following septoplasty with SMRT are rare. Methods: We conducted a retrospective review of patients electing to undergo septoplasty with SMRT at a tertiary rhinology clinic from January 2007 to December 2015. Demographic data, intraoperative findings, duration of follow-up, and short-term and long-term complications were collected. Exclusion criteria included patients who underwent either septoplasty or turbinate reduction or any other nasal surgery, patients lost to follow-up within 1 year, and patients with incomplete medical records. Results: A total of 359 patients met inclusion criteria. The majority were males (66.6%), and the average age of the cohort was 36.8 ± 12.3 years. The mean follow-up time was 23.3 months. Short-term complications were postoperative infection (n=12, 3.3%) and epistaxis that required intervention (n=16, 4.5%). Long-term complications occurred in 10 patients (2.8%): revision septoplasty (n=9, 2.5%) and hyposmia (n=1, 0.3%). No instances of synechiae, septal perforation, or saddle nose deformity occurred. Conclusion: Long-term complications following septoplasty with SMRT are infrequent. The most common long-term complication in this cohort was revision septoplasty.

Structure based drug design: development of potent and selective factor IXa (FIXa) inhibitors.

On the basis of our understanding on the binding interactions of the benzothiophene template within the FIXa active site by X-ray crystallography and molecular modeling studies, we developed our SAR strategy by targeting the 4-position of the template to access the S1 beta and S2-S4 sites. A number of highly selective and potent factor Xa (FXa) and FIXa inhibitors were identified by simple switch of functional groups with conformational changes toward the S2-S4 sites.