Neoadjuvant Chemotherapy Approach to Pineal Germinoma: A Case Report

Intracranial germ cell tumors (GCTs) are rare malignant tumors with a peak incidence around puberty. The pineal region is the most commonly involved area of all intracranial GCTs. Due to the heterogeneous tumor origin, subtypes, and presentation, diagnosis and management are challenging. Complicated pineal germinomas are rarely reported in the literature. Here, we report a rare case of pineal germinoma with hydrocephalus and discuss the potential treatment approach. A 20-year-old boy presented to the hospital with vomiting and a decreased level of consciousness. The brain magnetic resonance imaging (MRI) revealed a pineal tumor. A ventriculoperitoneal shunt was placed to relieve the increased intracranial pressure. The patient underwent a suboccipital craniotomy with excisional biopsy of the pineal region tumor due to its critical location, as imaging studies alone may not be sufficient to establish a definitive diagnosis. Although there has been a rise in reported cases of germinoma tumors, there is currently no standardized therapeutic approach for treating them. Therefore, more randomized controlled cohort studies are necessary to evaluate potential treatments and develop a therapeutic approach.

Factors associated with emergency department avoidance during the COVID-19 pandemic and alternatives sought: a cross-sectional, telephone-based survey of frequent emergency department users in Beirut, Lebanon

OBJECTIVES

To explore avoidant behaviour of frequent emergency department (ED) users, reasons behind ED avoidance and healthcare-seeking behaviours in avoiders during the COVID-19 pandemic.

DESIGN AND SETTING

Cross-sectional, telephone-based survey administered between March and August 2021 at a tertiary care centre in Beirut, Lebanon.

PARTICIPANTS

Frequent ED users (defined as patients who visited the ED at least four times during the year prior to the first COVID-19 case in Lebanon).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was ED avoidance among frequent ED users. Secondary outcomes included reasons behind ED avoidance and healthcare-seeking behaviours in avoiders.

RESULTS

The study response rate was 62.6% and 286 adult patients were included in the final analysis. Within this sample, 45% (128/286) of the patients reported avoidant behaviour. Male patients were less likely to avoid ED visits than female patients (adjusted OR (aOR), 0.53; 95% CI 0.312 to 0.887). Other independent variables associated with ED avoidance included university education (aOR, 1.76; 95% CI 1.004 to 3.084), concern about contracting COVID-19 during an ED visit (aOR, 1.31; 95% CI 1.199 to 1.435) and underlying lung disease (aOR, 3.39; 95% CI 1.134 to 10.122). The majority of the patients who experienced acute complaints and avoided the ED completely (n=56) cited fear of contracting COVID-19 as the main reason (89.3% (50/56)). Most of the ED avoiders (83.9% (47/56)) adopted alternatives for seeking acute medical care, including messaging/calling a doctor (46.4% (26/56)), visiting a clinic (25.0% (14/56)), or arranging for a home visit (17.9% (10/56)). Of the avoiders, 64.3% (36/56) believed that the alternatives did not impact the quality of care, while 30.4% (17/56) reported worse quality of care.

CONCLUSIONS

Among frequent ED users, ED avoidance during COVID-19 was common, especially among women, those with lung disease, those with university-level education and those who reported fear of contracting COVID-19 in the ED. While some patients resorted to alternative care routes, telemedicine was still underused in our setting. Developing strategies to reduce ED avoidance, especially in at-risk groups, may be warranted during pandemics.

Predictors for hospital admission in emergency department patients with benign paroxysmal positional vertigo: A retrospective review

OBJECTIVE

This study aims to assess the incidence of Emergency Department (ED) visits for benign paroxysmal positional vertigo (BPPV), describe patient characteristics, management practices and predictors of inpatient admission of BPPV patients.

METHODS

This was a retrospective chart review of patients presenting with BPPV to a single ED between November 2018 and August 2020. Patients' characteristics, ED management, discharge medications, disposition and unscheduled return visits were determined.

RESULTS

In total, 557 patients were included. Average age was 49 years, 54.2% were females and 12.4% required hospital admission. In the ED, 51.1% received intravenous hydration, 33.8% received anti-emetics, 10.1% received benzodiazepines, 31.8% underwent canalith repositioning maneuvers (CRMs) and 56.7% were discharged on acetyl-leucine. Of discharged patients, 2.5% had unscheduled return visits. A higher likelihood of admission was associated with age above 54 years (aOR = 4.86, p<0.001, 95% CI [2.67, 8.86]), home use of proton pump inhibitors (PPIs) (aOR = 2.44, p = 0.03, 95% CI [1.08, 5.53]), use of anti-emetics and benzodiazepines in the ED (aOR = 2.34, p = 0.003, 95% CI [1.34, 4.07]) and (aOR = 2.18, p = 0.04, 95% CI [1.03, 4.64]), respectively.

CONCLUSION

While BPPV is a benign diagnosis, a significant number of patients presenting to the ED require admission. Predictors of admission include older age, PPIs use and ED treatment with anti-emetics and benzodiazepines. Although CRMs are the gold standard for management, CRMs usage did not emerge as protective from admission, and our overall usage was low.