96 A Rare Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare subtype of T-cell lymphoma that develops around breast implants and was first described in 1997. To date, the estimated risk of BIA-ALCL in UK is reported to be 1 in 24000, but as yet appears to have a substantial variation of incidence around the world. The aetiology of this recognised clinical entity remained widely unknown.

A 72-year-old woman in remission for systemic anaplastic lymphoma kinase (ALK)-positive ALCL of right axilla, presented with a discoloured lump at the medial mastectomy scar following a progressive enlargement of right breast, 20 years after silicone breast implant reconstruction. Imaging studies showed fluid collection and herniation of the affected breast implant. Subsequently, the discoloured lump burst and patient then had tissue biopsy and removal of her right breast implant in together with intravenous antibiotic. Histocytopathological examination confirmed the presence of BIA-ALCL without capsular invasion and the growth of Gram-negative bacteria were noted in fluid culture. Total capsulectomy was performed and patient continues to be in remission with no local or systemic therapy.

We reported a rare yet interesting case of the coexistence of BIA-ALCL and systemic ALK-positive ALCL in an elderly patient. This case has further strengthened the causal relationship of composition and/or textured implant, and the presence of a theoretical association of a select group of pathogens maybe a trigger and contributes to the pathogenesis of BIA-ALCL. Due to the rarity of this disease, diagnosis can be challenging and requires a multidisciplinary approach.

A bruise-like patch in a 4-year-old girl

Dermatofibrosarcoma protuberans (DFSP), a rare medium grade sarcoma, occasionally occurs in childhood and is even more rarely present at birth. In children, the clinical appearance may be mistaken for a vascular malformation and so delayed diagnosis is not uncommon. Dermatofibrosarcoma protuberans is locally invasive and notorious for its high recurrence rate even after attempted wide local excision owing to extensive subclinical and asymmetrical extensions. In adult DFSP, Mohs Micrographic Surgery (MMS) is the treatment of choice because it offers a higher clearance rate compared to wide local excision. However, MMS may result in extended operating times owing to tissue processing and multiple stages. In children, this means a prolonged period under general anesthetic, which may be undesirable. We describe an interesting case of a 4- year-old girl diagnosed with DFSP. She underwent a modified MMS procedure in which she had two short general anesthetics. The advantage of MMS technique in which the full peripheral and deep margin of the specimen was examined.

The efficacy of donepezil in the treatment of neuropsychiatric symptoms in Alzheimer disease

OBJECTIVE

To determine the efficacy of donepezil in the treatment of neuropsychiatric symptoms in patients with Alzheimer disease (AD) in a randomized withdrawal study.

METHOD

Patients with mild to moderate AD with marked neuropsychiatric symptoms at baseline (Neuropsychiatric Inventory [NPI] > 11 points) were treated openly with donepezil 5 mg daily for 6 weeks followed by 10 mg daily for a further 6 weeks. Patients were then randomized (60:40) to either placebo or 10 mg donepezil daily. All patients were assessed at 6 weeks and provided there was no marked cognitive deterioration their blinded treatment was continued for a further 6 weeks. NPI and carer distress were assessed at 6 weekly intervals throughout the study.

RESULTS

A total of 134 patients participated. Following randomization patients who continued on donepezil 10 mg for 12 weeks had improvements in NPI compared with the placebo group (mean change -2.9 vs 3.3 points; ITT-LOCF p = 0.02) and in NPI-Distress scores (median change -2.0 vs 1.0 points; ITT-LOCF p = 0.01). During the open-label phase the total NPI and NPI-Distress scores were lower after 12 weeks treatment with open label donepezil compared with baseline (total NPI 22 points vs13 points; ITT-LOCF p < 0.0001; NPI-Distress 13.5 vs 7.9 points; ITT-LOCF p < 0.0001). In the open-label phase all domains of the NPI (with the exception of elation) were improved (all p < 0.05 after Bonferroni correction).

CONCLUSIONS

Donepezil has significant efficacy in the treatment of neuropsychiatric symptoms in patients with mild to moderate AD.

Carpal tunnel syndrome: classic clinical symptoms and electrodiagnostic studies in poultry workers with hand, wrist, and forearm pain

Carpal tunnel syndrome (CTS) has been linked to repetitive motion only in the past 15 years or so. Often the studies supporting this proposed link have not used strict clinical criteria and have rarely had electrodiagnostic confirmation of the diagnosis. In order to better assess the actual incidence of CTS in patients in a repetitive-motion job who had pain, numbness, tingling, or all three in the hand, wrist, or forearm, we examined 112 consecutive charts of such patients referred to a consulting neurologist for a possible diagnosis of carpal tunnel syndrome. Thirty-five percent of those patients had either classic clinical symptoms or positive electrodiagnostic results, but only half of these (17% of the total) actually had both. It is thus suggested that the incidence of CTS in patients doing repetitive motion may have been overestimated in the literature, and very strict clinical and electrodiagnostic criteria should be used before a diagnosis of carpal tunnel syndrome is made or surgery is contemplated in these patients.

Irregular discharge against medical advice from the accident and emergency department--a cause for concern

An irregular discharge (ID) from the A&E department is an undesirable, but relatively common occurrence. A prospective study was undertaken to quantify the size of the problem and by arranging a subsequent review of the patient, to determine the clinical outcome. Over a 3-month period, 139 patients (0.73%) of attendances) took their own discharge against medical advice. A further 566 patients (3.03% of attendances) left prematurely prior to any medical assessment (DNW). Attenders irregularly discharged, often with serious untreated conditions. A high proportion were intoxicated with alcohol (65.5%). Attempted follow up proved difficult and incomplete. Patients with serious conditions appeared to return spontaneously for further care. Methods of minimizing the numbers of patients who take an ID or DNW are discussed. Taken together, the numbers of these attenders leaving prematurely, can be used as a valid performance indicator of the delivery of health care in the A/E department.

Median nerve latencies in poultry processing workers: an approach to resolving the role of industrial "cumulative trauma" in the development of carpal tunnel syndrome

Much attention has been paid recently to a claimed connection between stressful repetitive motion at the work site and the development of carpal tunnel syndrome. Little of this has made its way into the widely appreciated medical literature. To try to discover a reasonable basis for the presence or absence of such an association we measured median nerve motor and sensory latencies in a random sample of employees in a medium industry of the kind thought to be associated with the emergence of carpal tunnel syndrome. A control group made up of applicants for positions of this sort was used. No association between employment experience and the development of slowing of the median motor latency was encountered in any group. No association was discovered for sensory latencies for men or for the left hands of women. A small association was discovered for the sensory latency in right hands of long-term female employees. This was similar in magnitude to the increased risk of prolongation associated with aging. Our data provide very little evidence for the concept of cumulative trauma as a prominent cause of carpal tunnel syndrome in American industry. These results are discussed in light of the recent Australian false epidemic of repetition strain injury.