Diffuse idiopathic skeletal hyperostosis (DISH) is rarely symptomatic. However, it can present with dyspnea, hoarseness, dysphagia, and stridor. An 80-year-old chronic smoker male presented with 6-month history of sore throat and progressive dysphagia. Computed tomography of the neck revealed bulky anterior bridging syndesmophytes along the anterior aspect of the cervical spine and facet effusion involving four contiguous vertebrae consistent with DISH. Dysphagia secondary to DISH was diagnosed. Fiberoptic laryngoscopy showed bilateral vocal cord paralysis. Patient's airway became compromised requiring tracheostomy tube placement. After discussion of therapeutic options, patient agreed on a percutaneous endoscopic gastrostomy tube insertion for nutritional support. Osteophytectomy was left to be discussed further.
Healthcare providers use antinuclear antibodies (ANAs) to screen and diagnose patients with autoimmune diseases. In the recent years, commercial multiplex ANA kits have emerged as a convenient and fast diagnostic method. Diagnostic testing should follow sequenced algorithms: initial screen followed by specific antibody analysis. Second-level testing as an initial screen for autoimmune disease is inappropriate. We reviewed 68 patients with ANA comprehensive panels over a 6-month period from May 2015 to October 2015. We assessed appropriateness and estimated incurred losses from inappropriate testing. We found 92.6% (63 out of 68) of the ANA comprehensive panel results to be negative. Incurred losses from inappropriate ANA comprehensive panel testing were $66,000. Physicians should become familiar with ANA-sequenced diagnostic algorithms to avoid unnecessary higher level testing.
OBJECTIVE A physician-nurse shadow program was established to improve interdisciplinary collaboration. BACKGROUND Ineffective communication between physicians and nurses leads to poor outcomes in patient satisfaction, safety, and associate engagement. Physician unfamiliarity of the nursing process is identified as a root cause. METHODS First-year resident physicians shadowed nurses for a 4-hour shift. Residents did not function as a physician during the shadowing experience but participated in nursing workflow and tasks. Participants completed a Likert-scale rating and qualitative survey before and after the shift. RESULTS The survey measured confidence in communication and perception of workflow. Confidence levels increased in all areas by 29% for residents and 34% for nurses. Data demonstrated improved physician understanding of nursing workflow and inspired recommendations to enhance communication. CONCLUSIONS First-year resident physicians practiced direct communication skills and experienced hands-on nursing care during the shadow program. The initiative provided an environment for mutual learning and interdisciplinary relationship-building.
Non-Hodgkin lymphoma (NHL) is a type of blood cancer and 25% of NHL patients present with a primary extranodal tumor. Primary NHL of the vagina is extremely rare with only a few cases reported. We present the case of a 79-year-old, grand multipara, Peruvian woman with an eleven-month history of symptoms of pelvic and vaginal pain and vaginal bleeding. Vaginal examination revealed an exophytic tumor that involved the labia, right vaginal wall, cervix, parametrium, and pelvic bone. A computed tomography (CT) image showed a 10 x 10 x 9-cm solid tumor in the pelvic cavity with irregular edges in the pelvic floor, parametrium, and the perineal soft tissues. Bilateral pelvic and inguinal adenomegalies were found. No signs of metastases were found. Marrow and bone biopsy studies were negative. The diagnosis was NHL type diffuse large B-cell lymphoma (DLBCL) of vagina stage one. The patient was treated with six courses of CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab). She showed a complete response and remained in remission in follow-up control visits. NHL of the female genital tract is rare. CHOP-R is the first line of treatment for this type of cancer. However, less is known about the follow-up protocol and relapse management. Vaginal lymphoma has an extremely low prevalence, and collaborative studies are required to study the same.
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