Introduction. The diagnosis of B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma (DLBCL) and classical Hodgkin’s lymphoma (cHL), also referred to as grey zone lymphoma (GZL), is a challenging diagnosis. There are no standardized guidelines; however, evidence strongly suggests that DLBCL-based regimens are effective in the treatment of GZL. Brentuximab vedotin (BV) is an anti-CD30 antibody drug conjugate that has established efficacy in relapsed/refractory Hodgkin and some T-cell lymphomas. There is some evidence that BV has a positive response in non-Hodgkin lymphoma (NHL) with a wide range of CD30 expressions—including GZL.Case. We present a case of a patient initially diagnosed with cHL who underwent repeat biopsy which was revealed to be GZL. Based on PET scanning and immunohistochemical studies, she was classified as a stage IIIA CD20+/CD30+ GZL patient. Given her strong CD30 expression, she underwent 6 cycles of R-BV-CHP (rituximab, brentuximab vedotin, cyclophosphamide, doxorubicin, and prednisone) chemotherapy and achieved complete response (CR) both clinically and radiographically.Discussion. Given the rarity of GZL, this case illustrates the immense challenges in making the diagnosis, discusses the current treatment options, and suggests that BV may be a viable therapeutic candidate in the treatment of GZL.
and, therefore, one of the most misused and underused modalities. Unfortunately, the majority of the time that ultrasound is used, it is used by someone with little knowledge of the device or its use. At times, some healthcare professionals rarely read the literature concerning ultrasound. Instead they depend on being trained by their co-workers. If wrong parameters and inadequate dosimetry are used on the patient, there may be negligible or even adverse outcomes. 1 The purpose of this article is two-fold. First, it aims to compare traditional ultrasound with wearable ultrasound. Second, this review provides corrections for mistakes clinicians often make when applying (and prescribing) ultrasound for treatment.Myth 1. Warm whirlpools, paraffin baths, and silicate-gel heating packs all produce therapeutic heat. Thus, there is no reason to employ ultrasound.
Admissions for diabetic foot osteomyelitis (DFO) are associated with increased length of stay due to several modifiable barriers and one of which includes setting up intravenous (IV) antibiotics upon discharge. The aim of this study was to reduce the length of stay (LOS) by at least 10% for all DFO patients who underwent surgical amputation and required IV antibiotics upon discharge. Using a quality improvement approach, the patient journey was mapped out using Lean principles and areas of waste were identified. An innovative electronic order was created and implemented to facilitate placement of a PICC (peripherally inserted central catheter) line to be placed immediately after podiatry surgery to reduce the length of time between surgery and PICC line placement. Pre-intervention and post-intervention LOS was compared using Mann-Whitney test to analyze the nonparametric distribution of the data. The post-intervention group had a mean LOS of 7 days (pre-intervention group: 10 days, p-value=0.027), and the length of time between podiatry surgery to placement of the PICC line was a mean of 2 days (pre-intervention: 5.29 days; p-value=0.008). This study used Lean methodology to identify areas of waste, facilitate discharge and subsequently reduce the LOS for DFO surgical patients.
Barriers to early discharges include poor communication among the healthcare team and families, pending laboratory test results, delays in discharge orders, medical reconciliation list, and patient transport. The baseline data at our hospital in October 2017 (N = 1,021) showed that 5% of patients were discharged before 11 a.m., with the mean discharge processing time being 145 minutes. The goal of this study was to assess the effectiveness of using an electronic predischarge order to discharge more than 40% of patients before 11 a.m. A predischarge order set was created in the electronic record, which notified the nurses, pharmacists, and case and social workers to complete all tasks related to discharge (medication reconciliation, complete laboratory test results and imaging, and arrange transport with family and nursing homes). The resident teaching service group (N = 381) from November 2017 to September 2018 discharged 22% of their patients before 11 a.m. (baseline: 5%, p value = 3.38638E-22), and the mean total discharge time was 77 minutes (baseline: 145 minutes; p value = 1.12013E-19). Our inability to discharge more than 40% of patients from the resident teaching service group before 11 a.m. was attributed to 3 limitations. We propose three viable recommendations to meet our goal in a future intervention.
Superior mesenteric artery (SMA) syndrome is defined as an upper gastrointestinal mechanical obstruction caused by compression of the 3rd part of the duodenum between the SMA anteriorly and the aorta posteriorly that has an incidence of 0.1-0.3%. This is due to loss of the intervening mesenteric fat pad and classically seen in young females in anorexic or hyper-emetic states with rapid weight loss and progressively worsening postprandial epigastric pain, hiccups, abdominal fullness and vomiting.
An 83-year-old male with a history of hypertension and coronary artery disease presented to the ED with complaints of persistent hiccups for 1-week duration associated with drooling, decreased appetite, inability to lie flat, and significant weight loss over several months. He was hemodynamically stable and afebrile but noted to have diffuse abdominal tenderness with distension, firmness on palpation and hypoactive bowel sounds. Significant lab values were Cr 3.5 mg/dL, BUN 63 mg/dL, lactate 9.2 U/L, 11,500 white blood cells/UL and abdominal X-ray revealed mildly dilated air-filled loop of bowel in the right side of the abdomen. He was started on IV fluids and nasogastric tube was placed for suction and decompression. Given lactic acidosis in the setting of bowel obstruction and acute kidney injury, a CT abdomen and pelvis without IV contrast was done which revealed significant gastroduodenal distention to the level of the SMA at the 3rd portion of the duodenum (Figures 1 and 2). An EGD was done to rule out endoluminal causes of duodenal obstruction. However, endoscopy showed gastroesophageal reflux disease with esophagitis and extrinsic compression of the 3rd part of the duodenum, thus confirming a diagnosis of SMA syndrome (Figure 3).
While SMA syndrome is typically treated with adequate nutrition, nasogastric decompression, and proper positioning of the patient after eating, this was not an option for this patient. Given the severe gastroduodenal distension, progressive weight loss, poor gastric motility and extensive fluid collection in the stomach, the patient underwent a gastrojejunostomy for gastric fluid drainage. There were no complications and he has remained asymptomatic for the past year. This unique case stresses the importance of keeping a high clinical suspicion of SMA syndrome in the setting of severe weight loss with gastroduodenal distension and hiccups, as well as the prompt use of CT and endoscopy to diagnosis and assess the surgical approach.
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