Osteochondral defect or osteochondritis dissecans (OCD) of the knee usually affects young, active populations. It is a challenging diagnosis as patients typically present with poorly localised activity-related pain, which is non-specific and covers many differentials. We present an active 11-year-old girl with bilateral osteochondral defects of the patellae: a rare clinical disorder which was affecting her sporting activities. She had a 12-month history of bilateral anterior knee pain before the diagnosis was achieved with appropriate imaging. Her pain significantly improved with activity modification and physiotherapy. Follow-up will require outpatient clinic assessment and imaging to determine if non-operative management continues to be successful or surgery may be required. This case report emphasises the importance of appropriate high index of suspicion when managing patients with non-specific knee pain. It also demonstrates the importance of judicious use of imaging to avoid a missed or delayed diagnosis.
RESUMENEste artículo analiza el Prólogo del Evangelio de Juan en relación con los estudios más recientes, como base para la interpretación de todo el Evangelio. En estos títulos entresacados del prólogo 1 de San Juan (1,1-18) queda resumido el artículo de fe cristológico central de la revelación cristiana: "El Verbo que estaba junto al Padre desde toda la eternidad, y era Dios 2 , como el Padre, es la inteligibilidad misma por esencia, es creador y fundamento de toda inteligibilidad creada 3 . No solo creó el mundo (1,3), sino que se hizo carne (1,14ab), y él, hecho hombre, por ser el Unigénito del Padre, reveló su gloria divina (= dov xan [= dóxan] cf. 1,14cd), o sea, el Espíritu Santo. Aunque no se le nombre explícitamente en el prólogo, el Espíritu Santo no está ausente de él; aquí lo encontramos implícitamente por lo menos en la palabra "gloria" (= dov xan: 1,14cd) 4 . El prólogo de San Juan no es solo uno de los textos más importantes del NT (= Nuevo Testamento), sino que no se encuentra un texto semejante en ninguna otra religión, sobre todo, por lo que se refiere a la afirmación neta y exclusivamente cristiana: "Y el Verbo se hizo carne" (1,14a): "Como muy bien sabe la escuela joánica, es el pensamiento de la Encarnación la auténtica novedad cristiana -quizás incluso
Aims
Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment and social and domestic activities. Management of BTRE is complex due to the higher incidence of pharmacoresistance and the potential for interaction between anti-cancer therapy and anti-epileptic drugs (AEDs). Neurologists, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current evidence to adapt current NICE guidelines for Epilepsy and to outline specific recommendations for the optimal treatment of BTRE, encompassing both primary and metastatic brain tumours.
Method
A comprehensive search of the literature from the past 20 years on BTRE was carried out in three databases: Embase, Medline and EMCARE. A broad search strategy was used and the evidence was evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence.
Results
All patients with BTRE should be treated with AEDs. There is no proven benefit for the use of prophylactic AEDs, although there are no randomised trials testing newer agents. Seizure frequency varies between 10-40% (Class 2a evidence) in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) (Class 2a evidence) in patients with Primary Brain Tumours (PBT). In patients with BM, risk factors include number of BM and melanoma histology (Class 2b evidence). In patients with PBT, risk factors include frontal and temporal location, oligodendroglial histology, IDH mutation and cortical infiltration (Class 2b evidence). There is a low incidence of seizures (13%) after stereotactic radiosurgery for BM (Class 2b evidence). Non-enzyme inducing AEDs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant (Class 2b evidence).
Conclusion
The review has highlighted the relative dearth of high quality evidence for the management of BTRE, and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for AEDs.
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