An Unexpected Presentation of a Maxillary Non-Hodgkin Lymphoma in an Elderly Hispanic Patient.

Extranodal NK/T-cell lymphoma (ENKTL), nasal type and aggressive NK cell leukemia are rare in Western World been less than 1% in USA to 8% in Asia among Non-Hodgkin's lymphomas. It is aggressive, with poor outcome and optimal treatment is unclear. A combination therapy that includes Peg-Asparaginase (SMILE) has been employed in young patients. An 85-year-old Puerto Rican male presented with anorexia, epistaxis, vertigo and involuntary facial movements. He was treated with injectable Onabotulinum toxin A due to suspicion of a hemifacial spasm. However, a CT scan demonstrated a left maxillary sinus lesion extending into the left middle turbinate with biopsy consistent with ENKTL. We adjusted therapy to patient's age and performance receiving Gemcitabine-Oxaliplatin (Gemox) with radiation obtaining a complete response with persistent negative Epstein Barr DNA titers. ENKTL is a rare disease initially misdiagnosed in our elderly patient, who demonstrated adequate response with a modified therapeutic regime.

Cutaneous leiomyosarcoma: a retrospective review of 45 cases.

Primary cutaneous leiomyosarcoma (LMS) is a rare soft tissue tumour type with two subtypes, dermal and subcutaneous. As deeper tumours confer a worse prognosis, they require a more aggressive approach. Conversely, a more conservative surgical approach for dermal LMS has been suggested. Few studies have comprehensively reported both clinical surgical and histological excision margins. Therefore, we sought to provide margin recommendations based on our experience and review of the existing literature. We undertook a retrospective case-note review (1998-2019) of cutaneous LMS management to establish histological/surgical margins using pathology/electronic patient records. The diagnosis was made and classified by an experienced dermatopathologist according to the World Health Organization classification. In the dermal LMS cohort (n = 35), mean peripheral and deep histological margins were 5.4 mm (range 0.5-20) and 5.6 mm (range 0.1-14.5), respectively. The incomplete excision rate was 31% (11 of 35). There were no recurrences. In the subcutaneous LMS cohort (n = 10), mean peripheral and deep histological margins were 5.7 mm (range 0.2-14) and 1.1 mm (range 0.2-1.7), respectively. The incomplete excision rate was 40% (4 of 10). The recurrence rate was 20% (2 of 10) despite achieving histological clearance after 1 year. One lung metastasis occurred 1 year following an adequately excised primary scalp LMS. Thus, for dermal LMS we propose a clinical margin of 5-10 mm (depending on lesion size) at the initial excision or at scar re-excision following involved/close histological peripheral and/or deep margins (i.e. < 1 mm). For subcutaneous LMS, we suggest a clinical margin of 15-20 mm (depending on lesion size) to achieve a peripheral histological clearance of 10 mm and negative deep margin (i.e. > 1 mm), down to the periosteum/fascia/muscle according to anatomical site. If this is not achieved, a re-excision would be recommended. However, prospective studies are needed for optimal guidance.

From the Nares to the Bone Marrow: A Role for Transarterial Embolization in an Aberrant Life-Threatening Cause of Epistaxis.

Identifying underlying bleeding diathesis that is amenable to medical therapy must be determined to provide timely treatment and minimize morbidity. Nasal bleeding is viewed as an annoyance by most who suffer from its episodes. However, it can at times be a baleful ailment that can compromise a patient's airway, breathing, and circulation, which can result in death. A 75-year-old Hispanic man presented with life-threatening epistaxis and was ultimately diagnosed with multiple myeloma (MM). The patient suffered profuse bleeding and hemodynamic compromise, requiring endoscopic nasal packing, red cell transfusions, platelet transfusions, and right external carotid artery angiogram with maxillary arteries embolization prior to chemotherapy. Embolization of maxillary arteries helped to stabilize the patient to diagnose MM and start definitive management with chemotherapy. On data review, we could not find another case with severe epistaxis secondary to MM, which was controlled with endovascular embolization. This case highlights the difficulties in managing a rare condition and the importance of a multidisciplinary approach in patients who present with life-threatening epistaxis secondary to plasma cell dyscrasia.

Endophthalmitis diagnosis supported by bedside ultrasound.

Endophthalmitis is a bacterial or fungal infection in the deep spaces of the eye. The diagnosis of endophthalmitis has traditionally been made by vitreous humor culture and is commonly missed on initial presentation. In this case report, we emphasize the role of ocular point-of-care ultrasound (POCUS) in revealing endophthalmitis as a primary differential diagnosis for a patient presenting with unilateral eye pain and significant swelling that limited physical examination of the eye. Here, the patient's initial clinical examination was more suggestive of an alternative diagnosis, orbital cellulitis, which could have delayed the highly morbid and time-sensitive diagnosis of endophthalmitis. Although POCUS is traditionally enlisted for other posterior ophthalmic pathologies, including retinal detachment, vitreous detachment, vitreous hemorrhage, and papilledema, this rare case of endophthalmitis secondary to hepatic abscess demonstrates the utility of bedside ocular ultrasound as a tool to distinguish endophthalmitis from mimicking differentials when physical examination is unable to do so.

Application of biochar for minewater remediation: Effect of scaling up production on performance under laboratory and field conditions.

Metals discharged from abandoned mines are a major source of pollution in many parts of the world. As a result, there is a growing need for suitable low-cost remediation methods. While a large literature base exists demonstrating the efficacy of biochar to remove metals from solution, most studies are confined to the laboratory. This study examines the effects on the biochar quality when scaling up production from laboratory to pilot scale. Pilot scale biochars were produced using a 600 kg batch pyrolysis reactor, these chars were then deployed in the field using a series of 100 mm × 1200 mm cylindrical treatment cells installed at the point of discharge from an abandoned mine site. Most biochars produced at a pilot removed more zinc under laboratory conditions, however all of the biochars showed a reduced performance when tested in the field, this ranged from a 14% to an 85% reduction depending on the biochar.

Leukemia Cutis As the Initial Manifestation of Chronic Lymphocytic Leukemia Progression.

Chronic lymphocytic leukemia (CLL) is a malignant proliferation of monoclonal mature B-cells in peripheral blood. Leukemia cells can commonly spread from the blood to other sites such as the lymph nodes, liver, and spleen. However, contrary to T-cell lymphomas that can involve the skin, CLL metastasis to the skin is unusual and is rarely the first manifestation of systemic disease. When leukemia cells invade the skin, it is termed leukemia cutis. Furthermore, multiple skin morphologies can be present in leukemia cutis making diagnosis challenging. Likewise, it can be mistaken for other common etiologies such as drug or substance allergy, infection, and scabies, among others. We herein present a case of CLL with leukemia cutis as the initial manifestation of systemic disease. The initial punch biopsy results were non-specific for inflammatory changes, but a subsequent biopsy revealed findings confirming leukemia cutis. This case not only demonstrates that identifying malignant skin manifestations in a timely manner and treating them is essential, as it improves the quality of life and survival, but also demonstrates that leukemia cutis can be a dynamic disease where multiple biopsies may be needed to confirm the diagnosis, as histopathology can change over time.

Metal distribution, bioavailability and isotope variations in polluted soils from Lower Swansea Valley, UK.

Soils in the Lower Swansea Valley, (United Kingdom) contain elevated level of metals, enough to cause direct or indirect effects on human health. This study assesses the severity of soil pollution and bioavailability of Cu and other metals (Ni, Zn, Co, Pb and Cr) in soils with various distances from a Ni refinery. We compare Cu concentrations in operationally defined soil fractions (bioavailable, bound to Fe/Mn oxide and incorporated in organic matter) with other metals (Ni, Zn, Pb, Co, Cr) usually occurring in ores used in metallurgic processes and report their pollution and geoaccumulation indices (PI and Igeo). Further, we use Cu stable isotope ratios (δ65Cu) to trace the fate and mobility of Cu in soils. Our data suggest a point source of contamination for some of the heavy metals including Ni (Igeo = 1.9), Zn (Igeo = 0.28) and Cu (Igeo = 3.6) near the Ni refinery. However, Co (Igeo = 0.15) and Pb (Igeo = 3.3) contaminations are likely to be linked to different sources. No elevated Cr levels (Igeo= -0.07) occur in any of the studied soils. All soil metals are predominantly associated with organic matter (>50%) which  reduces their bioavailibility and thus their risk for ecological and human health. The Cu isotope data show that Cu in soil organic matter is enriched in 65Cu, while the lighter isotopes (63Cu) remain in the dissolved bioavailable Cu fraction (Δ65Cuorganic-bioavailable is +0.12 ± 0.13‰). This suggests the preferential complexation of 65Cu with soil organic matter after dissolution of Cu deposited to the soil. Thus, Cu isotope data can effectively indicate pathways of metal migration in polluted soils.

Gastric MALT Lymphoma with Biclonal Gammopathy and Bone Marrow Involvement Mimicking Multiple Myeloma.

Mucosa-associated lymphoid tissue (MALT) lymphomas are B-cell neoplasms that commonly affect the gastrointestinal (GI) tract, usually the stomach. In most cases, extranodal marginal zone lymphoma (ENMZL) is an indolent disease. Bone marrow involvement is common with MALT lymphoma accompanied by paraproteinemia; such involvement impels disease progression. Here, we present the case of an 82-year-old Hispanic patient with long-standing ENMZL in whom the gastric site responded to antibiotic treatment and Helicobacter pylori eradication, but the disease progressed over the years, with a biclonal gammopathy and bone marrow involvement with marked plasmacytic differentiation. In view of this, we suggest the routine evaluation of paraprotein in patients with ENMZL.

Seasonal blooms of neutrophilic Betaproteobacterial Fe(II) oxidizers and Chlorobi in iron-rich coal mine drainage sediments.

Waters draining from flooded and abandoned coal mines in the South Wales Coalfield (SWC) are substantial sources of pollution to the environment characterized by circumneutral pH and elevated dissolved iron concentrations (>1 mg L-1). The discharged Fe precipitates to form Fe(III) (oxyhydr)oxides which sustain microbial communities. However, while several studies have investigated the geochemistry of mine drainage in the SWC, less is known about the microbial ecology of the sites presenting a gap in our understanding of biogeochemical cycling and pollutant turnover. This study investigated the biogeochemistry of the Ynysarwed mine adit in the SWC. Samples were collected from nine locations within sediment at the mine entrance from the upper and lower layers three times over one year for geochemical and bacterial 16S rRNA gene sequence analysis. During winter, members of the Betaproteobacteria bloomed in relative abundance (>40%) including the microaerophilic Fe(II)-oxidizing genus Gallionella. A concomitant decrease in Chlorobi-associated bacteria occurred, although by summer the community composition resembled that observed in the previous autumn. Here, we provide the first insights into the microbial ecology and seasonal dynamics of bacterial communities of Fe(III)-rich deposits in the SWC and demonstrate that neutrophilic Fe(II)-oxidizing bacteria are important and dynamic members of these communities.

Reassessing the impact of intraoperative electrocorticography on postoperative outcome of patients undergoing standard temporal lobectomy for MRI-negative temporal lobe epilepsy.

OBJECTIVE: Almost 30% of the patients with suspected temporal lobe epilepsy (TLE) have normal results on MRI. Success rates for resection of MRI-negative TLE are less favorable, ranging from 36% to 76%. Herein the authors describe the impact of intraoperative electrocorticography (ECoG) augmented by opioid activation and its effect on postoperative seizure outcome. METHODS: Adult and pediatric patients with medically resistant MRI-negative TLE who underwent standardized ECoG at the time of their elective anterior temporal lobectomy (ATL) with amygdalohippocampectomy between 1990 and 2016 were included in this study. Seizure recurrence comprised the primary outcome of interest and was assessed using Kaplan-Meier and multivariable Cox regression analysis plots based on distribution of interictal epileptiform discharges (IEDs) recorded on scalp electroencephalography, baseline and opioid-induced IEDs on ECoG, and extent of resection. RESULTS: Of the 1144 ATLs performed at the authors' institution between 1990 and 2016, 127 (11.1%) patients (81 females) with MRI-negative TLE were eligible for this study. Patients with complete resection of tissue generating IED recorded on intraoperative ECoG were less likely to have seizure recurrence compared to those with incomplete resection on univariate analysis (p < 0.05). No difference was found in seizure recurrence between patients with bilateral independent IEDs and unilateral IEDs (p = 0.15), presence or absence of opioid-induced epileptiform activation (p = 0.61), or completeness of resection of tissue with opioid-induced IEDs on intraoperative ECoG (p = 0.41). CONCLUSIONS: The authors found that incomplete resection of IED-generating tissue on intraoperative ECoG was associated with an increased chance of seizure recurrence. However, they found that induction of epileptiform activity with intraoperative opioid activation did not provide useful intraoperative data predictive of improving operative results for temporal lobectomy in MRI-negative epilepsy.

Urgent Repositioning After Venous Air Embolism During Intracranial Surgery in the Seated Position: A Case Series.

BACKGROUND: Venous air embolism (VAE) is a well-described complication of neurosurgical procedures performed in the seated position. Although most often clinically insignificant, VAE may result in hemodynamic or neurological compromise resulting in urgent change to a level position. The incidence, intraoperative course, and outcome in such patients are provided in this large retrospective study. METHODS: Patients undergoing a neurosurgical procedure in the seated position at a single institution between January 2000 and October 2013 were identified. Corresponding medical records, neurosurgical operative reports, and computerized anesthetic records were searched for intraoperative VAE diagnosis. Extreme VAE was defined as a case in which urgent seated to level position change was performed for patient safety. Detailed examples of extreme VAE cases are described, including their intraoperative course, VAE management, and postoperative outcomes. RESULTS: There were 8 extreme VAE (0.47% incidence), 6 during suboccipital craniotomy (1.5%) and 2 during deep brain stimulator implantation (0.6%). VAE-associated end-expired CO2 and mean arterial pressure reductions rapidly normalized following position change. No new neurological deficits or cardiac events associated with extreme VAE were observed. In 5 of 8, surgery was completed. Central venous catheter placement and aspiration during VAE played no demonstrable role in patient outcome. CONCLUSIONS: Extreme VAE during seated intracranial neurosurgical procedures is infrequent. Extreme VAE-associated CO2 exchange and hemodynamic consequences from VAE were transient, recovering quickly back to baseline without significant neurological or cardiopulmonary morbidity.

Case Report of IgM Multiple Myeloma: Diagnosing a Rare Hematologic Entity.

IgM multiple myeloma is an exceedingly rare hematologic entity comprising only less than 0.5% of multiple myeloma cases. Given the rarity of this disorder, it makes it a challenge to differentiate from other more prevalent hematologic disorders like Waldenstrom macroglobulinemia. These 2 diseases have the common finding of an IgM monoclonal gammopathy and distinguishing between these 2 diagnoses is of great importance given that therapy and prognosis differ significantly. This report illustrates the case of a 64-year-old man who presented with IgM lambda monoclonal gammopathy in whom signs, symptoms, laboratories, and imaging were initially thought to be consistent with Waldenstrom macroglobulinemia. Upon further analysis, which included bone marrow biopsy, flow cytometry, immunohistochemistry, fluorescence in situ hybridization, and MYD88 (L265P) gene mutation analysis, the rare diagnosis of IgM multiple myeloma was confirmed. As highlighted by this patient's case, reaching the diagnosis of IgM multiple myeloma can be a difficult task which requires a high index of suspicion and accurate diagnostic methods. By using the approach detailed in this report, more cases of IgM multiple myeloma can be diagnosed early, which in turn may lead to earlier treatment and better outcomes.

The Examination of Patient-Reported Outcomes and Postural Control Measures in Patients With and Without a History of ACL Reconstruction: A Case Control Study.

CONTEXT: There is a lack of literature to support the diagnostic accuracy and cut-off scores of commonly used patient-reported outcome measures (PROMs) and clinician-oriented outcomes such as postural-control assessments (PCAs) when treating post-ACL reconstruction (ACLR) patients. These scores could help tailor treatments, enhance patient-centered care and may identify individuals in need of additional rehabilitation. OBJECTIVE: To determine if differences in 4-PROMs and 3-PCAs exist between post-ACLR and healthy participants, and to determine the diagnostic accuracy and cut-off scores of these outcomes. DESIGN: Case control. SETTING: Laboratory. PARTICIPANTS: A total of 20 post-ACLR and 40 healthy control participants. MAIN OUTCOME MEASURES: The participants completed 4-PROMs (the Disablement in the Physically Active Scale [DPA], The Fear-Avoidance Belief Questionnaire [FABQ], the Knee Osteoarthritis Outcomes Score [KOOS] subscales, and the Tampa Scale of Kinesiophobia [TSK-11]) and 3-PCAs (the Balance Error Scoring System [BESS], the modified Star Excursion Balance Test [SEBT], and static balance on an instrumented force plate). Mann-Whitney U tests examined differences between groups. Receiver operating characteristic (ROC) curves were employed to determine sensitivity and specificity. The Area Under the Curve (AUC) was calculated to determine the diagnostic accuracy of each instrument. The Youdin Index was used to determine cut-off scores. Alpha was set a priori at P < 0.05. RESULTS: There were significant differences between groups for all PROMs (P < 0.05). There were no differences in PCAs between groups. The cut-off scores should be interpreted with caution for some instruments, as the scores may not be clinically applicable. CONCLUSIONS: Post-ACLR participants have decreased self-reported function and health-related quality of life. The PROMs are capable of discriminating between groups. Clinicians should consider using the cut-off scores in clinical practice. Further use of the instruments to examine detriments after completion of standard rehabilitation may be warranted.

Primary Adrenal Angiosarcoma: A Rare and Potentially Misdiagnosed Tumor.

A man aged 69 years presented with acute right flank pain secondary to a hemorrhagic large adrenal tumor. En bloc resection was performed to repair the inferior vena cava. Immunoperoxidase levels in the tumor were positive for factor VIII and CD31 and negative for S100, protein Melan-A, CD34, synaptophysin, chromogranin, desmin, muscle specific actin, ETFA (EMA), KRT20 (CK20), CDX2, TTF1, LNPEP (PLAP), inhibin, ?-fetoprotein, CD30, hepatocyte paraffin, and aberrant expression of cytokeratin 7 and pankeratin. The pathological diagnosis was consistent with adrenal angiosarcoma. Obtaining appropriate immunoperoxidase stains and multidisciplinary evaluation helped make the diagnosis of this rare adrenal tumor and determine its management. The patient had an uneventful postoperative course and completed 4 cycles of adjuvant chemotherapy with doxorubicin/ifosfamide and adequately tolerated the treatment. However, positive surgical margins were found, so he was referred to radiation oncology specialists for possible adjuvant radiotherapy to the surgical bed. Weeks after the first initiation of therapy, the patient presented to the emergency department complaining of shortness of breath, fatigue, and generalized weakness for 3 days. He was admitted and found to have new-onset anemia and a new-onset, large, right pleural effusion. Thoracentesis performed showed sanguinolent fluid that, after microscopic evaluation, was suggestive of recurrent malignancy. Thoracic aortography performed with subselective catheterization to several arteries (right bronchial, right phrenic, and right renal arteries) did not show any active bleeding. However, the right inferior intercostal and adrenal arteries were presumed to be the reason for the bleeding event, so they were embolized until stasis. The patient remained hemodynamically unstable but eventually experienced multiorgan failure. In spite of aggressive measures, he died 10 days after admission to the hospital.

Somatosensory deficits in post-ACL reconstruction patients: A case-control study.

INTRODUCTION: Diminished cutaneous detection thresholds have been identified in patients with multiple orthopedic conditions, and these phenomena may occur in postanterior cruciate ligament reconstructed (ACLR) patients. The purpose of this study was to determine if differences in lower extremity cutaneous detection thresholds exist in post-ACLR patients when compared with healthy controls. METHODS: Fifteen individuals who were post-ACLR and 15 individuals who had no history of knee injury participated. Light touch cutaneous detection thresholds were assessed at 4 locations on the foot and ankle (first metatarsal, fifth metatarsal, medial malleolus, and lateral malleolus). Nonparametric statistics examined group differences between the sites. RESULTS: ACLR subjects had decreased cutaneous sensation at the first metatarsal and medial malleolus compared with healthy controls. CONCLUSIONS: Somatosensory deficits are present in post-ACLR patients. Future research should investigate these phenomena longitudinally in post-ACLR individuals along with somatosensory targeted interventions. Muscle Nerve 55: 5-8, 2017.

Surgery Versus 5% Imiquimod for Nodular and Superficial Basal Cell Carcinoma: 5-Year Results of the SINS Randomized Controlled Trial.

We previously reported modest clinical 3-year benefit for topical imiquimod compared with surgery for superficial or nodular basal cell carcinoma at low-risk sites in our noninferiority randomized controlled SINS trial. Here we report 5-year data. Participants were randomized to imiquimod 5% cream once daily (superficial basal cell carcinoma, 6 weeks; nodular basal cell carcinoma, 12 weeks) or excisional surgery (4-mm margin). The primary outcome was clinical absence of initial failure or signs of recurrence at the 3-year dermatology review. Five-year success was defined as 3-year success plus absence of recurrences identified through hospital, histopathology, and general practitioner records. Of 501 participants randomized, 401 contributed to the modified intention-to-treat analyses at year 3 (primary outcome), 383 (96%) of whom had data at year 5. Five-year success rates for imiquimod were 82.5% (170/206) compared with 97.7% (173/177) for surgery (relative risk of imiquimod success = 0.84, 95% confidence interval = 0.77-0.91, P < 0.001). These were comparable to year 3 success rates of 83.6% (178/213) and 98.4% (185/188) for imiquimod and surgery, respectively. Most imiquimod treatment failures occurred in year 1. Although surgery is clearly superior to imiquimod, this study shows sustained benefit for lesions that respond early to topical imiquimod.

Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position.

OBJECTIVE Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series. METHODS The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure. RESULTS In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2-70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12-0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4-39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09-5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery. CONCLUSIONS In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.