Bone Cancer: Diagnosis and Treatment Principles.

Primary bone cancers include osteosarcoma, Ewing sarcoma, and chondrosarcoma. They account for less than 1% of diagnosed cancers each year and are associated with significant morbidity and mortality. Timely diagnosis is challenging because of late patient presentation, nonspecific symptoms that mimic common musculoskeletal injuries, and low suspicion by physicians. Plain radiography is the preferred diagnostic test. Radiographic suspicion of a bone malignancy should prompt quick referral to a cancer center for multidisciplinary care. Osteosarcoma, the most common bone cancer, most often occurs in children and adolescents. It typically develops in the metaphysis of long bones, specifically the distal femur, proximal tibia, and proximal humerus. Metastasis to the lungs is common. Use of neoadjuvant and adjuvant chemotherapy, in combination with surgery, has improved survival rates to nearly 80% for patients with localized disease, and 90% to 95% of patients do not require limb amputation. Ewing sarcoma is the second most common bone cancer and is similar to osteosarcoma in terms of presenting symptoms, age at occurrence, and treatment. Prognosis for osteosarcoma and Ewing sarcoma depends on the presence of metastasis, which lowers the five-year survival rate to 20% to 30%. Chondrosarcoma is the rarest bone cancer, primarily affecting adults older than 40 years. Survival rates are higher because most of these tumors are low-grade lesions.

NATO Special Operations Forces Medical Engagements and Partnering Course: Initial Curriculum Recommendations from the NSHQ SOFMEP Committee.

Military partnering operations and military engagements with host nation civil infrastructure are fundamental missions for NATO Special Operations Forces (SOF) conducting military assistance operations. Unit medical advisors are frequently called upon to support partnering operations and execute medical engagements with host nation health systems. As a primary point of NATO SOF medical capability development and coordination, the NATO Special Operations Headquarters (NSHQ) sought to create a practical training opportunity in which medical advisors are taught how to prepare for, plan, and execute these complex military assistance operations. An international committee of SOF medical advisors, planners and teachers was assembled to research and develop the curriculum for the first NSHQ SOF Medical Engagement and Partnering (SOFMEP) course. The committee found no other venues offering the necessary training. Furthermore, a lack of a common operating language and inadequate outcome metrics were identified as sources of knowledge deficits that create confusion and inhibit process improvement. These findings provided the foundation of this committee?s curricular recommendations. The committee constructed operational definitions to improve understanding and promote dialogue between medical advisors and commanders. Active learning principles were used to construct a curriculum that engages learners and enhances retention of new material. This article presents the initial curriculum recommendations for the SOFMEP course, which is currently scheduled for October 2012.

Portal vein thrombosis: an unexpected finding in a 28-year-old male with abdominal pain.

BACKGROUND: Abdominal pain is a common primary care complaint. Portal vein thrombosis (PVT) is a rare cause of abdominal pain, typically associated with cirrhosis or thrombophilia. The following describes the presentation of PVT in a young male, the search for risk factors and underlying etiology, and the debate of anticoagulation therapy. CASE: A 28-year-old male presented with periumbilical pain, post-prandial nausea, and sporadic hematemesis for 3 weeks. The diagnosis was confirmed with a triphasic liver computerized tomography after obtaining an abnormal right upper quadrant ultrasound. This unexpected finding prompted investigation for intrinsic hepatic disease and potential hypercoagulable disorders. Laboratory analysis revealed a heterozygous genotype for the prothrombin 20210G/A mutation, an identified risk factor for venous thrombosis. DISCUSSION: Recommendations concerning anticoagulation for PVT in the absence of cirrhosis are not clearly defined. Current literature describes the following factors as indications for anticoagulation: acute thrombus, lack of cavernous transformation, absence of esophageal varices, and mesenteric venous thrombosis. This patient had clinical indications both for and against anticoagulation. Weighing this individual's clinical circumstances, we concluded the risk of thrombus in the setting of a hypercoagulable disorder outweighed the risk of variceal bleeding. A minimum of 6 months of anticoagulation was initiated. CONCLUSION: PVT is an uncommon cause of abdominal pain, and the absence of hepatic disease should raise the index of suspicion for an underlying thrombophilia. Specific recommendations for anticoagulation are not well defined, demonstrating the importance of weighing the individual risks and benefits in treatment with anticoagulation for young persons with thrombophilia.