[A rapidly growing skin lesion on the sternum]. / Een snelgroeiende huidafwijking op het borstbeen.

This case involves a man with a medical history of multiple myeloma and osseous metastasis of prostate carcinoma. He presented with a progressively growing red tumor on his chest for the past three weeks. Histopathological examination revealed many atypical CD0138-positive plasmablastic cells, which matches a cutaneous manifestation of multiple myeloma.

Relationship between Body Mass Index and Physical Activity among Children from Low-Income Communities in Gqeberha, South Africa: A Cross-Sectional Study.

This study aimed to establish the prevalence of underweight, overweight and obesity, the level of moderate-to-vigorous physical activity (MVPA) and the association thereof among vulnerable children from low-income communities in South Africa. Cross-sectional data were collected from 916 children (467 boys and 449 girls) aged 8-13 years (x̄ = 10.4 ± 1.2 years) attending eight low-income schools in Gqeberha, South Africa. Measured outcomes included accelerometery-measured physical activity (PA), weight, height and body mass index (BMI). Analysis of variance was used to determine the mean difference of total MVPA stratified by sex and BMI classification. Overall, 13% of the cohort were underweight, 19% were overweight/obese and 64% engaged in 60 min of MVPA per day. Girls presented nearly twice the odds of being overweight or obese than boys (95% CI: 1.40-2.77). Underweight to normal-weight children (boys: OR = 3.89, 95% CI: 2.18-6.93; girls: OR = 1.78, 95% CI: 1.13-2.80) were more likely to engage in 60 min/day of MVPA than overweight to obese children. There is an inverse association between BMI categories and theduration of MVPA achieved per day. Special attention should be aimed at increasing awareness of healthy nutrition and promoting a variety of PA, especially among girls and children with excess weight.

Clustered cardiovascular disease risk among children aged 8-13 years from lower socioeconomic schools in Gqeberha, South Africa.

Objectives: To determine the prevalence of individual cardiovascular disease (CVD) risk factors and clustered CVD risk among children attending schools in periurban areas of Gqeberha and to investigate the independent association between clustered CVD risk, moderate to vigorous physical activity (MVPA) and cardiorespiratory fitness (CRF). Methods: Baseline data were collected in a cross-sectional analysis of 975 children aged 8-13 years. We measured the height, weight, waist circumference, blood pressure, fasting glucose, full lipid panel, 20 m shuttle run performance and accelerometry. The prevalence of individual risk factors was determined, and a clustered risk score (CRS) was constructed using principal component analysis. Children with an elevated CRS of 1 SD above the average CRS were considered 'at-risk'. Results: We found 424 children (43.3%) having at least one elevated CVD risk factor: 27.7% elevated triglycerides, 20.7% depressed high-density lipoprotein cholesterol and 15.9% elevated total cholesterol. An elevated clustered risk was identified in 17% (n=104) of the sample; girls exhibited a significantly higher CRS >1 SD than boys (p=0.036). The estimated odds of an elevated clustered risk are doubled every 2 mL/kg/min decrease in VO2max (95% CI 1.66 to 3.12) or every 49 min reduction in MVPA (95% CI 27 to 224). Conclusion: A relatively high prevalence of elevated individual and clustered CVD risk was identified. Our results have also confirmed the independent inverse association of the clustered CVD risk with physical activity and CRF. These indicate that increased levels of CRF or MVPA may aid in the prevention and reduction of elevated clustered CVD risk.

Practice Change Needed for the Identification of Pediatric Hypertension in Marginalized Populations: An Example From South Africa.

Introduction: Hypertension in children has increased globally over the past 20 years; yet, little is known about this issue among disadvantaged communities from low- and middle-income countries. Age-, sex-, and height-adjusted normative tables are the "gold" standard for the diagnosis and estimation of pediatric hypertension worldwide, but it is unclear whether the use of international standards is appropriate for all contexts. The purpose of this study was to evaluate and compare different international references to identify hypertension among South African school-aged children from disadvantaged communities. Methods: Blood pressure, weight, and height were measured in a cohort of 897 children aged 8-16 years from eight peri-urban schools in the Eastern Cape of South Africa. Cross-sectional prevalence of hypertension was calculated according to American, German, and global normative tables, as well as pseudo-normative data from the own study population. Isolated systolic hypertension and body mass index (BMI) were considered markers for cardiovascular disease. Multinomial logistic regression was used to compare the likelihood of blood pressure categorization with increasing BMI levels. Results: Hypertension prevalence ranged from 11.4% with the pseudo-normative study tables to 28.8% based on the German reference. Global guidelines showed the highest agreement both among international standards (92.5% with American guidelines) and with the study reference (72.5%). While the global and the American references presented higher systolic over diastolic hypertension rates (23.6 vs. 10.6% and 24.2 vs. 14.7%, respectively), the American guidelines predicted the highest increased risk for hypertension stage 2 [odds ratio, 1.72 (95% confidence interval: 1.43-2.07)] with raising levels of BMI. Conclusion: Our results support the heterogeneity of blood pressure estimates found in the South African literature, and highlight the underrepresentation of African children in international guidelines. We call for caution in the use of international standards in different contexts and advocate for the development of normative tables that are representative of the South African pediatric population necessary to ensure an accurate identification of hypertension both from the clinical and epidemiological perspective.

Delayed diagnosis of lymphogranuloma venereum in a hospital setting - a retrospective observational study.

OBJECTIVE: The incidence of lymphogranuloma venereum (LGV) in Europe is increasing. However, diagnosing LGV in a hospital setting is rare. We analysed the diagnostic process and clinical characteristics of patients with LGV in a hospital setting. DESIGN AND SETTING: A retrospective observational study conducted in a teaching hospital in Amsterdam, The Netherlands. All adult patients with LGV between November 2010 and February 2019 were included. Clinical data were retrieved from electronic patient records. RESULTS: 40 patients were included. 90% of patients were men who have sex with men (MSM) and 62,5% were HIV positive. The most common presenting symptoms were rectal bleeding (47,5%), anal symptoms (30%) and change in bowel habits (25%). The mean time from first consultation to diagnosis was 28 days (range: 0 to 332, median 16,5 days). Diagnostic delay was increased by clinical presentation (ie anogenital syndrome) and the number of specialists involved. Diagnostic procedures not leading to the diagnosis were performed in 98% of cases. CONCLUSION: To prevent late complications, unnecessary diagnostic procedures and further transmission, early testing for LGV should be incorporated in the work-up of every patient reporting MSM-activity presenting with anorectal symptoms or inguinal lymphadenopathy.

[A 79-year-old patient with pancytopenia and Kaposi sarcoma]. / Een 79-jarige man met pancytopenie en huidafwijkingen.

We report the case of a 79-year-old patient with pancytopenia and blue-purple cutaneous lesions on his legs, arms and in the oral cavity. These lesions had been present for several months. Based on a positive HIV test result we made a presumptive diagnosis of cutaneous Kaposi sarcoma. Histological examination confirmed the diagnosis of AIDS-related Kaposi sarcoma.

Imatinib-induced agranulocytosis in patients with gastrointestinal stromal tumors.

Agranulocytosis is a rare but serious side effect of imatinib in gastrointestinal stromal tumor (GIST) patients. Imatinib is an inhibitor of the proto-oncogene tyrosine kinase (c-kit) and the first-line agent in patients with locally advanced and metastatic GIST. Little evidence is available on the management of this adverse event, and consensus-based guidelines are lacking. In this article, we describe 4 patients with agranulocytosis after starting imatinib. In addition, an overview of the available literature concerning the underlying mechanisms is given, and therapeutic strategies for overcoming this adverse event are discussed. In our experience it appears safe to restart imatinib after normalization of neutrophil count. In case of relapse of agranulocytosis, reintroduction combined with prednisolone, with treatment with granulocyte colony-stimulating factor or dose reduction can be considered.

Severe isolated sciatic neuropathy due to a modified lotus position.

A 51-year-old man presented to our hospital with progressive pain and weakness in his right leg. Neurological examination revealed atrophy of all muscles of the right leg, unilateral foot drop and paralysis of the anterior tibial and gastrocnemicus muscles. Electromyography confirmed a severe isolated sciatic neuropathy in the thigh. For unclear reasons, our patient habitually used to sit in a modified lotus position. We concluded that this position, in literature known as "lotus neuropathy" had resulted in the sciatic neuropathy. After more than a year our patient was referred again to our outpatient clinic. At that time there was only minimal improvement, now with an achilles tendon contracture and pes equinus due to immobility.

[Recurrent isolated angioedema as a result of acquired C1 inhibitor deficiency]. / Geïsoleerd angio-oedeem door verworven C1-esteraseremmerdeficiëntie.

Isolated angioedema may be the presenting symptom of acquired C1 inhibitor (C1-INH) deficiency. C1-INH deficiency is associated with lymphoproliferative disorders. Treatment of the underlying disease can result in a complete reversal of clinical and complement abnormalities. We describe a 41-year-old woman who was referred to our emergency department with recurrent episodes of isolated angioedema. Initially, her angioedema was linked to the use of angiotensin receptor blockers. However, after discontinuation of this drug angioedema recurred. Additional investigations revealed the presence of acquired C1-INH deficiency caused by an indolent non-Hodgkin's lymphoma. Treatment with rituximab resulted in complete clinical and biochemical remission of the acquired angioedema.

[Patients with superior vena cava syndrome: pitfalls in recognition]. / Patiënten met het vena-cava-superiorsyndroom: valkuilen bij de herkenning.

Superior vena cava syndrome (SVCS) may be the presenting sign of malignancy. SVCS may be difficult to recognize due to its usual slow development or possible temporary regression. We discuss the pitfalls in recognizing SVCS by presenting two cases. In a 45-year-old man, facial swelling diminished after he was administered intraarticular steroids to treat brachialgia. During the same period, collateral veins appeared on his chest wall. Only a few weeks later he was diagnosed with SVCS due to lung cancer. A 31-year-old man with a swollen face was treated with glucocorticoids, allegedly for an allergic reaction. When symptoms recurred after one week, it was discovered that SVCS was caused by lymphoma. These cases illustrate that the first manifestations of SVCS may be subtle and that development of collaterals or the use of glucocorticoids may relieve symptoms. Importantly, late diagnosis of SVCS results in delay of treatment of the underlying cause, which is often malignant.

Reduction of biofilm formation with trisodium citrate in haemodialysis catheters: a randomized controlled trial.

BACKGROUND: Formation of an intraluminal microbial biofilm is noted to play a significant role in the development of catheter-related infections (CRIs). Recently, it has been demonstrated that trisodium citrate (TSC) has superior antimicrobial effects over heparin for catheter locking. In this randomized controlled trial, we compared the influence of catheter locking with heparin and TSC on the in vivo intraluminal biofilm formation in haemodialysis catheters. METHODS: Six patients were studied from the time of catheter insertion for haemodialysis treatment. They were randomly assigned to TSC 30% or heparin 5000 U/ml for catheter locking for the duration of 1 month. After elective guidewire exchange of the catheter, the locking solution was also changed. After removal, catheters were dissected in three segments and examined by standardized scanning electron microscopy (SEM) to assess quantitative biofilm formation. Furthermore, standardized cultures of all segments were performed to identify any microorganisms. RESULTS: In catheters filled with TSC, the average coverage by biofilm was 16% versus 63% in the heparin group (P < 0.001). A total of eight subsegments were associated with local catheter infection in the patients who were randomized to heparin locking versus three subsegments who were assigned to TSC (P < 0.05). CONCLUSIONS: Our study demonstrates that using TSC 30% for catheter locking reduces the formation of microbial biofilm in haemodialysis catheters and culture-positive colonization. It is likely that this is the explanation for the observed prevention of CRIs by TSC locking.