A 53-year-old man presented after noting bright red blood from his rectum. On examination, he was found to have a mass 1 cm above the anal sphincter complex. He had a BMI of 40 kg/m 2 and was otherwise healthy. MRI revealed a T2/early T3 lesion with extramural venous invasion and suspicious perirectal lymph nodes. Low rectal cancer was diagnosed. He underwent long-course neoadjuvant chemoradiation with good but not complete clinical response. Given his obesity and the low nature of his rectal cancer, a transanal total mesorectal excision (taTME) was planned.
CLINICAL QUESTIONSEarn Continuing Education (CME) credit online at cme.lww.com. This activity has been approved for AMA PRA Category I credit. TM Funding/Support: None reported.
In Canada, meningitis is a rare manifestation of Mycobacterium tuberculosis infection. Additionally, a microbiological diagnosis can be difficult because of low sensitivity of mycobacterial tests of cerebrospinal fluid specimens. The typical presentation of meningitis is in the form of subacute meningitis, which is life threatening in the absence of appropriate treatment. Therefore, a high index of suspicion must be maintained. We report a case of tuberculous meningitis highlighting the presentation, workup, and treatment of this serious infection. This report highlights the challenges in identifying cases and establishing a timely diagnosis. Close monitoring of the patient and collecting multiple cerebrospinal fluid samples can improve sensitivity.
At the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, 2,400-2,800 new outpatient referrals for hematology consultation are received annually and approximately 10% of these referrals are specifically for isolated anemia. In recent years, such referrals have been sent from hematology to general internal medicine (GIM) for assessment and management. A retrospective chart review was conducted of a cohort of 99 patients from 2013 to describe the demographics, assessment, management and outcome of these patients, as well as to inform whether this practice should continue. The median age of patients was 60.3 years (min 19.4, max 97.6) and 62% were female. The median hemoglobin level was 109.0 g/L (min 66, max 137) at the time of referral and the median wait time was 53 days (min 8 days, max 171 days). Pearson's correlation analysis revealed that those with lower hemoglobin levels were seen more quickly. The patients had an additional 2.8 comorbidities on average, and were significantly more likely to receive non-anemia related adjustment to care with increasing number of comorbidities. A small proportion of patients (n = 5, 5.1%) were referred from GIM back to hematology, whereas 21% were referred to gastroenterology. A small number of patients (n = 5, 5.1%) underwent a bone marrow aspirate and biopsy. The most common diagnoses identified in the initial clinic letters were iron deficiency anemia (n = 59, 59.6%) and anemia of chronic disease (n = 8, 8.1%). 26.3% did not have a diagnosis identified. These findings support our practice to have patients with an isolated anemia evaluated by a general internist rather than a hematologist. Most of these patients had iron deficiency anemia or the anemia of chronic disease and received additional care for their comorbid conditions in the GIM clinic. Further work will help to define how such patients can be most effectively assessed and treated.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.