Transcatheter aortic valve replacement with the repositionable Portico valve provides satisfactory short- and medium-term haemodynamic and clinical results.
Summary Social workers practicing in small rural towns regularly encounter overlapping or dual relationships with clients. This can lead to boundary crossing and conflicts of interest that require an ethical decision. Previous research on how rural social workers approach ethical decision-making in these situations has suggested that while they might draw on ethical codes, many rely on intuitive or personal viewpoints rather than systematic decision-making processes. Although social workers are often trained to engage in self-reflection when faced with the complexities of practice and the possibilities of personal biases, the role of systematic self-reflection in personal decision-making about dual relationships has not been sufficiently documented in the literature. Using qualitative inquiry, this study explored the lived experiences with dual relationships reported by 44 practitioners working in small towns in rural Canada. Findings The findings confirm that practitioners were frequently guided in their decisions by an intuitive or emotional understanding of dual relationships rather than by external codes, and while self-reflection was seen to play a role, a formal or systematic approach to personal self-reflection was not reported. Applications The findings suggest that educational or professional development on more intentional use of self-reflection in practice would aid in safeguarding the client and the worker when dealing with dual relationships, while providing an ethical process congruent with a rural and remote community identity. Explicit decision-making would also make the process more defensible and justifiable, not only to themselves, but also to colleagues, supervisors, and to their professional association.
Histoplasmosis is an endemic mycosis commonly found in the Ohio River valley and presents with various clinical presentations ranging from asymptomatic to disseminated disease. Most patients present with pulmonary symptoms, while the immunocompromised subset can have multiple organ involvement with varying symptomology. An increasing number of patients are being treated with tumor necrosis factor (TNF)-alpha inhibitors, which dampens immune response and puts these patients at risk of opportunistic infections. We report a rare presentation of disseminated peritoneal histoplasmosis initially mimicking peritoneal carcinomatosis in a patient with rheumatoid arthritis on a TNF-alpha inhibitor. Case Description/Methods: A 43-year-old female with known history of rheumatoid arthritis (RA) on leflunomide, infliximab, and recent steroid course presented to the ED for abdominal pain and shortness of breath. On admission, the patient was febrile, tachycardic, and required supplemental oxygen. CT chest/abdomen/pelvis demonstrated right-sided pleural effusion, diffuse mesenteric nodules along the anterior abdominal wall concerning for malignancy, and moderate ascites (Figure A). Tumor marker CA 125 was elevated at 341 U/mL and surgical oncology was consulted for diagnostic laparoscopy with drainage of ascites, which was initially concerning for peritoneal carcinomatosis. Surprisingly, the biopsy revealed chronic inflammation, granulomas, and fungal yeast cells with morphological features consistent with histoplasmosis. She underwent thoracentesis, and pleural studies were consistent with exudative effusion with lymphocyte predominance, and cultures confirmed histoplasmosis. Initial broad antibiotic therapy for sepsis of unknown origin was transitioned to itraconazole and she was eventually discharged. More than a year after hospitalization, she remains on itraconazole due to persistent histoplasmosis. Her RA treatment was switched to upadacitinib, with some control of her symptoms. Discussion: Diagnosis of histoplasmosis can be challenging because of its heterogeneous presentation. Disseminated histoplasmosis with peritoneal implants is exceeding rare, and most cases have been reported in ESRD patients on continuous peritoneal dialysis. Other cases of peritoneal histoplasmosis have been reported in immunosuppressed patients, which mimicked pathologies such as malignancy and IBD. It is essential to be vigilant of uncommon presentations of common disease, especially in immunocompromised patients.[3392] Figure 1. Diffuse nodularity to the mesentery most prevalent along anterior abdominal wall right paracolic gutter regions concerning for metastatic disease to the mesentery (Arrow). Mild bowel wall thickening seen involving descending colon.
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