The role of splenectomy in management of splenic B-cell lymphomas.

INTRODUCTION: Splenic B-cell lymphomas are rare and understudied entities. Splenectomy is frequently required for specific pathological diagnosis in patients with splenic B-cell lymphomas other than classical hairy cell leukemia (cHCL), and can be effective and durable therapy. Our study investigated the diagnostic and therapeutic role of splenectomy for non-cHCL indolent splenic B-cell lymphomas. METHODS: Observational study of patients with non-cHCL splenic B-cell lymphoma undergoing splenectomy between 1 August 2011 and 1 August 2021 at the University of Rochester Medical Center. The comparison cohort was patients categorized as having non-cHCL splenic B-cell lymphoma who did not undergo splenectomy. RESULTS: Forty-nine patients (median age 68 years) had splenectomy (SMZL n = 33, HCLv n = 9, SDRPL n = 7) with median follow up of 3.9 years post splenectomy. One patient had fatal post-operative complications. Post-operative hospitalization was ≤ 4 days for 61% and ≤ 10 days for 94% of patients. Splenectomy was initial therapy for 30 patients. Of the 19 patients who had previous medical therapy, splenectomy changed their lymphoma diagnosis in 5 (26%). Twenty-one patients without splenectomy were clinically categorized as having non-cHCL splenic B-cell lymphoma. Nine required medical treatment for progressive lymphoma and of these 3 (33%) required re-treatment for lymphoma progression compared to 16% of patients following first line splenectomy. CONCLUSION: Splenectomy is useful for the diagnosis of non-cHCL splenic B-cell lymphomas with comparable risk/benefit profile and remission duration to medical therapy. Patients with suspected non-cHCL splenic lymphomas should be considered for referral to a high-volume center with experience in performing splenectomies for definitive diagnosis and treatment.

Pre-Ramadan Consultation: Does a Physician's Religious Belief and Specialty Matter?

Background A pre-Ramadan consultation is a practical approach to optimize the care of patients with chronic conditions before the month-long fast. The present study aims to assess healthcare professionals' knowledge, attitude, and practice (KAP) toward pre-Ramadan counseling in Arab countries and assess the effects of physicians' specialty and religious beliefs on their KAP. Method An online cross-sectional survey was conducted to assess physicians' KAP toward pre-Ramadan consultation and management of patients with pre-existing health issues before Ramadan. Each participant got three scores: (1) knowledge score, (2) attitude score, and (3) practice score. A one-way ANOVA and post hoc tests were performed to detect the differences in physicians' KAP toward pre-Ramadan consultation with their specialties and religious backgrounds. Result Most of the participants did not use pre-Ramadan consultation timely (Only two of the 200 subjects did). The mean values of the physicians' scores were as follows: the knowledge score was 7.8 out of 17, the attitude score was 2.28 out of 4, and the practice score was 4.33 out of 11. However, post hoc tests showed that family physicians were more knowledgeable regarding pre-Ramadan consultation than other specialties. Moreover, Muslim participants achieved better attitude and practice scores than non-Muslim participants. Conclusion Most of the participants did not offer pre-Ramadan consultation timely. The attitudes and practices toward pre-Ramadan consultation were statistically different between Muslim and non-Muslim doctors. The findings of this study suggest that improving physicians' pre-Ramadan consultation knowledge is imperative to optimize the care of patients before Ramadan. Moreover, improving the attitude and practice of non-Muslim physicians is required to enrich the patient-centered approach. This study was limitedby the absence of earlier literature discussing pre-Ramadan consultation, so further work is needed to cover the literature gap.

An Elusive Case of Mycosis Fungoides: Case Report and Review of the Literature.

Erythroderma refers to a spectrum of skin diseases resulting in diffuse erythema and scaling encompassing ≥ 90% of the body surface area. The differential diagnosis ranges from primary dermatologic diseases such as atopic dermatitis and psoriasis to potentially deadly causes such as staphylococcal toxic shock syndrome, toxic epidermal necrolysis, and malignancy. Cutaneous T cell lymphoma (CTCL) is an uncommon but highly morbid cause of erythroderma. This non-Hodgkin lymphoma remains a diagnostic challenge due to its variable clinical presentation and varied histologic features. Mycosis fungoides (MF) is the most common form of CTCL. Making a timely diagnosis is challenging as it may mimic inflammatory diseases of the skin including eczema, psoriasis, lichen planus, and cutaneous lupus. We present a case of a 58-year-old man who presented with 5 years of cutaneous symptoms and several months of fevers and night sweats, ultimately diagnosed as MF. Owing to diffuse CD30 positivity, he was a candidate for brentuximab vedotin, an antibody-drug conjugate medication that selectively targets the CD30 antigen. This resulted in an excellent therapeutic response.

Foreign bodies: Is it feasible to develop tolerance for ambiguity among medical students through Equine-Facilitated learning?

Intolerance of ambiguity among medical students is associated with negative attitudes towards psychosocially complex patients. In this paper, the authors evaluated the feasibility of a 3.5-hour workshop aimed at fostering tolerance for ambiguity in medical students through semi-structured interactions with horses that functioned as experiential surrogates for ambiguity. Among 26 first-year medical students who participated in the feasibility assessment, an overwhelming majority rated the workshop as academically valuable and recommended that it be offered again in the future. After feasibility was established, an additional group of 7 first-year medical students and 5 fourth-year students completed Budner's Tolerance of Ambiguity scale before and after the workshop to provide preliminary data on its effectiveness. The post-workshop mean scores on the Budner scale were lower than pre-workshop mean scores, suggesting that students developed greater tolerance for ambiguity following the workshop. This difference was statistically significant among the first-year students, but not among the fourth-year students. Our findings demonstrate that the equine-facilitated workshop is feasible and can potentially help medical students develop greater tolerance for ambiguity.

Sticky Business: a syndrome of mucoid bacterial spread.

A 70-year-old man presented with acute wrist pain concerning for septic arthritis. Shortly thereafter, he developed acute monocular vision loss and was diagnosed with endogenous endophthalmitis. Subsequent imaging revealed numerous visceral abscesses and a mycotic abdominal aortic aneurysm. Cultures, in conjunction with the clinical syndrome, were strongly suggestive of hypervirulent Klebsiella pneumoniae syndrome (hvKP). hvKP syndrome may present with multiple sites of infection or subsequent metastatic spread may develop; the liver, lungs, central nervous system and eye are most commonly involved. Prompt source control and intravenous antibiotic therapy leads to a cure in the majority of patients. This case highlights the risk factors, presentation, management and prognosis of this disease as well as its increasing incidence in North America and Europe.

Readmissions With Dehydration After Ileostomy Creation: Rethinking Risk Factors.

BACKGROUND: Twenty-nine percent of postileostomy discharges are readmitted, most commonly because of dehydration. However, there is a lack of detailed data specifically evaluating factors associated with readmission with dehydration. In addition, patients with a history of an ileostomy have often been excluded from previous studies and therefore represent a group of understudied ileostomates. OBJECTIVE: This study aimed to evaluate factors available at discharge associated with 30-day readmission for dehydration, rather than all-cause readmissions. DESIGN: This was a retrospective cohort study. SETTING: Study patients received ileostomies at a tertiary academic medical center from 2014 to 2016. PATIENTS: Patients with a preexisting ileostomy that was not recreated per the operative note were excluded, whereas those who received a new ileostomy were included. MAIN OUTCOME MEASURE: The primary outcome measured was 30-day readmission for dehydration as defined by objective clinical criteria. RESULTS: A total of 262 patients underwent ileostomy creation and were discharged alive. Twenty-five percent were ≥65 years of age, 53% were men, 14% had a history of ileostomy, 18% had a creatinine >1.0 on discharge, and 26% had high ileostomy output at any time during the index admission. Among all ileostomates, the all-cause readmission rate was 30%. Mean days to readmission for any cause was 8.5, whereas for dehydration it was 11.6 days. Of the readmissions, 37% were readmitted with a diagnosis of dehydration, and dehydration was the sole reason in 26%. Among those with dehydration, the most common length of stay was 2 days. In multivariable logistic regression, 30-day readmission with dehydration was associated with older age, male sex, history of an ileostomy, high ileostomy output during index admission, and a discharge creatinine >1.0. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Ileostomy dehydration efforts have focused on new ileostomy patients; however, our data suggest that patients with a history of an ileostomy are actually at risk for readmission with dehydration. Further studies aimed at the reduction of readmission with dehydration after ileostomy are warranted and should include patients with a history of an ileostomy. See Video Abstract at http://links.lww.com/DCR/A643.