Exophthalmos is typically associated with Graves' ophthalmopathy. Although originally described by Harvey Cushing, exophthalmos is an underappreciated sign of Cushing's syndrome. We present a case of a 38-year-old female who presented with severe bilateral proptosis and was subsequently diagnosed with Cushings disease. We discuss the possible mechanisms causing exophthalmos in patients with either endogenous or exogenous hypercortisolemia.
Clostridium difficile infection (CDI) is one of the leading causes of hospital-acquired infections in recent times. Hematopoietic stem cell transplantation (HSCT) confers increased risk for CDI because of prolonged hospital stay, immunosuppression, the need to use broad-spectrum antibiotics and a complex interplay of preparative regimen and GvHD-induced gut mucosal damage. Our study evaluated risk factors (RF) for recurrent CDI in HSCT recipients given the ubiquity of traditional RF for CDI in this population. Of the 499 allogeneic HSCT recipients transplanted between 2005 and 2012, 61 (12%) developed CDI within 6 months before transplant or 2 years after transplant and were included in the analysis. Recurrent CDI occurred in 20 (33%) patients. One year incidence of CDI recurrence was 31%. Multivariable analyses identified the number of antecedent antibiotics other than those used to treat CDI as the only significant RF for recurrence (hazard ratio 1.96, 95% confidence interval 1.09-3.52, P = 0.025). Most recurrences occurred within 6 months of the first CDI, and the recurrence of CDI was associated with a trend for increased risk of mortality. This prompts the need for further investigation into secondary prophylaxis to prevent recurrent CDI.
INTRODUCTIONClostridium difficile (C. diff) infection (CDI) is one of the leading causes of hospital-acquired infections in recent times. Allogeneic hematopoietic stem cell transplantation (HSCT) confers increased risk for CDI because of prolonged hospital stay, immunosuppression, the need to use broad-spectrum antibiotics and a complex interplay of chemo-preparative regimen and GvHD-induced gut mucosal damage. The incidence of CDI following autologous and allogeneic HSCT ranges from 5 to 20% 1-8 and recurrence rate has been~20%; 1 consistent with the general population. There are numerous studies describing the epidemiology and risk factors (RFs) of recurrent CDI in the general population, namely receipt of antibiotics, age 460 years, length of hospital stay and concomitant receipt of antacid medications. 9-12 Allogeneic HSCT recipients are a unique patient population, given the ubiquity of traditional risk factors and gut involvement with GvHD, with three studies showing an increased risk of CDI in patients with GvHD, 1,3,7 and there is a need to understand the risk of recurrence in this highly vulnerable group of immunosuppressed patients. Identifying these RFs will enable us to establish preventive measures for CDI by modifying our infection prevention and antibiotic utilization policies.
Background: Primary care physicians (PCPs) may face barriers to caring for hematologic malignancy and hematopoietic cell transplantation (HCT) survivors.
Methods:A web-based survey consisting of 40 questions and 2 case scenarios was administered to 302 PCPs at two large integrated healthcare systems. The questionnaire assessed perceived barriers to delivery of care to hematologic malignancy/HCT survivors, resources available to care for cancer survivors, practices for care coordination with hematologist-oncologists, and preferred models of care delivery.Results: Overall response rate was 30% (N=86). PCPs reported several barriers such as lack of resources to facilitate care (69%), lack of awareness of screening/prevention guidelines (55%) and psychosocial needs of survivors (65%), inadequate time (65%), and patient preference to follow up with their oncologists (66%). They expressed confidence in caring for general medical issues (84%) and general cancer screening (73%), but preferred oncologists manage cancer related medical issues (42%), screen for cancer recurrence (52%) and secondary cancers (55%). In multivariable analysis, PCPs who had previously cared for larger number of hematologic malignancy/HCT survivors and those further out since graduation from medical school had greater confidence in managing cancer related medical issues.Conclusions: PCPs report several barriers in providing care to hematologic malignancy/HCT survivors. Clinical experience with this patient population is associated with greater confidence in providing survivorship care. Several barriers identified by PCPs in providing survivorship care to
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