Managing suspected myasthenia gravis and myositis induced by pembrolizumab in a Jehovah's Witness sarcoma patient.

INTRODUCTION: Immune checkpoint inhibitors (ICIs) can cause a spectrum of adverse events known as immune-related adverse events (irAEs) that resemble autoimmune responses. Immune-mediated myasthenia gravis (MG) is a rare and serious neurologic adverse event that has been associated with ICIs requiring prompt treatment. In the Jehovah's Witness population, typical management of these adverse events may not be options, and alternative treatment choices would be needed. CASE REPORT: 73-year-old Jehovah's Witness patient with high-grade undifferentiated pleiomorphic sarcoma who developed immune-mediated MG approximately 4 weeks after initiation of pembrolizumab. On the day of admission, the patient presented with a three-day history of worsening ptosis, right greater than left. He was later found to be seronegative for MG. MANAGEMENT AND OUTCOME: The patient required therapy with pyridostigmine, steroids, and agreed to plasma exchange (PLEX) prior to discharge. He achieved near resolution of his neurologic symptoms, and pembrolizumab was discontinued. He later underwent radical resection of the left thigh soft tissue sarcoma and superficial inguinal lymph node dissection. He is now on active surveillance. DISCUSSION: While neurologic adverse events typically present 6 weeks after initiation of ICIs, MG has been reported occurring as early as 4 weeks after initiation. This rare and serious adverse event requires prompt treatment, and clinicians need to be aware of the alternative treatment options in this unique patient population. Early conversations regarding blood products and factions must be had to develop a treatment plan in accordance with the patient's personal decisions.

Meta-analysis on the Effectiveness of ECG Screening for Conditions Related to Sudden Cardiac Death in Young Athletes.

Controversy exists over the use of electrocardiograms (ECGs) in sports pre-participation screening. We performed a meta-analysis comparing the effectiveness of history and physical examination (H&P) with ECG at detecting both cardiac disease and sudden cardiac death-associated conditions (SCD-AC). Pre-participation studies published from 2015 to 2020 with athletes 10 to 35 years old were included. This yielded 28 011 athletes screened and 124 cardiac diagnoses, 103 of which were SCD-AC. A meta-analysis of log odds ratios (ORs) was conducted using a random-effects model. The ORs for the association between H&P and detecting both cardiac disease and SCD-AC were not statistically significant (OR = 3.4, P = .076; OR = 2.9, P = .078). The ORs for the association between ECG and detecting both cardiac disease and SCD-AC were statistically significant (60, P < .001; 148, P < .0001). In conclusion, the odds of detecting both cardiac disease and conditions related to SCD with ECG are greater than with H&P during sports pre-participation screening.

Overactive bladder syndrome: Management and treatment options.

BACKGROUND: Overactive bladder (OAB) is a common syndrome in the community characterised by unstable bladder contractions, resulting in urinary urgency, frequency and nocturia in the absence of detectable disease. Large studies suggest that >10% of the general population is symptomatic. OBJECTIVE: The aim of this article is to summarise the stepwise treatment for OAB that seeks to improve patient quality of life and reduce patient and health system costs. DISCUSSION: OAB is a diagnosis of exclusion that begins with a targeted history and examination of the urogenital system with the aim of assessing the burden of disease on the patient. First-line treatment comprises conservative measures including weight reduction, a decrease in exposure to bladder stimulants, fluid optimisation and pelvic floor exercises. Pharmacological treatments for OAB include anticholinergic medications such as oxybutynin. If the patient is unresponsive to pharmacological treatment, a review by a urology specialist is appropriate. Recommendations may include minimally invasive procedures such as intravesical botulinum toxin A injections, reserving the invasive procedures for patients in specific circumstances.

Surgical correction of distal radius malunions using an anatomic radial locking plate.

BACKGROUND: Correction of a distal radius fracture malunion is challenging technically. These malunions most classically deform dorsally, but often the deformity involves three planes. METHODS: Using an anatomically designed radial plate that takes into consideration the three planes, correction of the deformity can be obtained. In this video we see a patient with a classic dinner fork deformity that is associated with a dorsal malunion involving the distal radius. Correction of a distal radius malunion can be performed using a radial approach and an anatomic radial plate. RESULTS: The authors have used this technique for difficult distal radius fracture malunions and have achieved superb correction, returning patients to early range of motion and an active lifestyle. CONCLUSIONS: Careful mobilization of the branches of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve is required. This technique affords the surgeon excellent access to three sides of the radius to help perform this complex surgery.