Nine treatments of 1000 mL therapeutic phlebotomy in a subject with polycythemia: A case report.

Large-volume therapeutic phlebotomy is the mainstay of hemochromatosis treatment and offers an opportunity to investigate the hemodynamic changes during acute hypovolemia. An otherwise healthy 64-year-old male with hemochromatosis participated. On nine separate visits, 1000 mL therapeutic phlebotomy was performed. On one occasion, pre- and post-phlebotomy orthostatic challenge with 27° reverse Trendelenburg position was administered. Mean arterial pressure, heart rate, and stroke volume were measured continuously during the procedures. The patient's tolerance to the interventions was continuously evaluated. The procedures were well tolerated by the patient. Mean arterial pressure was maintained during hemorrhage and following phlebotomy in both supine and reverse Trendelenburg positions, primarily through an increase in heart rate and systemic vascular resistance. The present study found that 1000 mL therapeutic phlebotomy in a patient with hemochromatosis may be acceptably and safely used to model hemorrhage. The approach demonstrates high clinical applicability and ethically robustness in comparison with volunteer studies.

Feasibility of effectiveness trials in pediatric anesthesia.

BACKGROUND: Effectiveness studies aim to investigate whether an intervention does more good than harm in normal clinical practice. DISCUSSION: Historically, research in pediatric anesthesia has appropriately concentrated on efficacy studies which even if of excellent design, tell us little about how generalizable or applicable the findings are to routine clinical practice. Simultaneously effectiveness and cost-effectiveness research has been limited due to systematic and cultural factors. To understand the challenges of effectiveness research in children, it is necessary to examine the overlapping relationship between efficacy, effectiveness, and cost-effectiveness studies. This can be illuminated with Cochrane´s hierarchy of investigation and the disease, illness, and sickness modelfrom the philosophy of science. Effectiveness (illness perspective) studies form the middle rung of Cochrane´s research hierarchy, between efficacy (disease perspective) and cost-effectiveness (sickness perspective) research. Effectiveness studies aim to be generalizable and determine whether interventions work in routine clinical practice. Since outcomes that reflect patient priorities offer the most generalizability these are encouraged in effectiveness studies. Due to developing consciousness and communication in young children, identifying and measuring patient-centered outcomes has challenges. These challenges are not insurmountable and with appropriate communication and research techniques the subjective nature of the experience of illness in the young may be elucidated and should direct research goals where possible. Sickness perspective research, in terms of cost-effectiveness, remains underdeveloped in pediatric anesthesia. SUMMARY: Pediatric anesthesia has a strong base in efficacy research, but the need to expand research to include effectiveness and eventually cost-effectiveness studies should not be ignored.

Colonic perforation following polypectomy of a gastrointestinal follicular lymphoma masquerading as a colon polyp.

INTRODUCTION: The gastrointestinal (GI) tract is the predominant site for primary extranodal non-Hodgkin lymphomas (NHL), accounting for 5-10% of all extranodal disease. CASE: A 74-year-old man underwent colonoscopy for a positive fecal occult blood test. Colonoscopy revealed a 3.5-cm polyp in the descending colon and was removed by snare cautery polypectomy. Post-polypectomy site showed a 0.3-0.5-cm mucosal defect. Five endoclips were applied to close the mucosal defect. The patient remained stable during subsequent intensive monitoring and never required surgical intervention. Pathology of the polyp revealed follicular lymphoma (FL) involving the lamina propria of the mucosa with extension into the submucosa. The patient had no systemic symptoms, and staging for NHL with contrast computerized tomography of the chest, abdomen, and pelvis revealed no evidence suggestive of lymphoma. DISCUSSION: Approximately 6-20% of all primary GI-NHL are in the colon. The frequency of GI-FL accounts for 1-3.6% of all GI-NHL. After a search of the current literature, there have been no cases of a follicular lymphoma presenting solely as an isolated colon polyp. Likewise, bowel perforation due to polypectomy of such polyps has never been cited. Retrospectively, the diagnosis and extent of the polyp could have been established using endoscopic end-to-end forceps biopsy and/or endoscopic ultrasound with a radial scanning catheter probe and fine-needle aspiration of the lesion. Such a diagnosis could have changed the strategy for endoscopic removal of the polyp. Our case is interesting because it is the first report of a follicular lymphoma presenting as a single isolated colon polyp involving all layers of the colonic mucosa.

Giant gastric hyperplastic polyp: not always a benign lesion.

Giant gastric hyperplastic polyps constitute of around 76% of all gastric polyps found. They are often found incidentally on upper GI endoscopy. They often present with occult GI bleeding causing iron deficiency anemia or partial gastric outlet obstruction. Although mostly benign, they do have potential for malignant transformation and hence must be excised endoscopically or surgically, whichever may be feasible. We hereby present a couple of cases of gastric hyperplastic polyps in an attempt to add to the current literature on this rather rare entity.