This Teachable Moment discusses providing patients with an opportunity to initiate dietary change before prescribing statin therapy for even severely high low-density lipoprotein cholesterol levels.

BACKGROUND: Evaluating isolated extremity discomfort can be challenging when initial imaging and exams provide limited information. Though subtle patient history hints often underlie occult pathologies, benign symptoms are frequently miscategorized as idiopathic.
METHODS: We present a case of retained glass obscuring as acute calcific periarthritis on imaging. A 48-year-old White male with vague fifth metacarpophalangeal joint pain had unrevealing exams, but radiographs showed periarticular calcification concerning inflammation. Surgical exploration unexpectedly revealed an encapsulated glass fragment eroding bone. Further history uncovered a forgotten glass laceration decade prior. The foreign body was removed, resolving symptoms.
CONCLUSIONS: This case reveals two imperative diagnostic principles for nonspecific extremity pain: (1) advanced imaging lacks specificity to differentiate inflammatory arthropathies from alternate intra-articular processes such as foreign bodies, and (2) obscure patient history questions unearth causal subtleties that direct accurate diagnosis. Though initial scans suggested acute calcific periarthritis, exhaustive revisiting of the patient\'s subtle decade-old glass cut proved pivotal in illuminating the underlying driver of symptoms.
CONCLUSIONS: Our findings underscore the critical limitations of imaging and the vital role that meticulous history-taking plays in clarifying ambiguous chronic limb presentations. They spotlight the imperative of probing even distant trauma when symptoms seem disconnected from causative events. This case reinforces the comprehensive evaluation of all subtle patient clues as key in illuminating elusive extremity pain etiologies.

Background: The association between medical history and primary progressive multiple sclerosis (PPMS) development has not been well documented in the pertinent literature. The possible association between 23 medical diseases and PPMS occurrence was assessed in the present study. Methods: In order to figure out the possible association between several medical histories and PPMS occurrence, the present population-based case-control study examined 143 PPMS cases in Tehran, Iran, from 2019 to 2020. Diagnosis of PPMS was confirmed by neurologists based on the 2017 McDonald criteria. Sex-matched healthy controls (n = 143) were selected using the random-digit dialing (RDD) technique. Face-to-face and telephone interviews were conducted for gathering the data. The conditional logistic regression model was used to calculate adjusted and unadjusted odds ratio (OR) at a 95% confidence interval (CI). Results: A significant association was found between PPMS development and diseases like depression (OR = 3.12, 95% CI: 1.49-6.53), migraine (OR = 0.19, 95% CI: 0.05-0.67), infectious mononucleosis (OR = 13.16, 95% CI: 2.74-63.17), hypothyroidism (OR = 3.20, 95% CI: 1.23-8.30), and kidney failure (OR = 3.76, 95% CI: 1.41-9.99). Conclusion: Lifetime history of depression, infectious mononucleosis, hypothyroidism, and kidney failure might increase the risk of PPMS development, while individuals with positive history of migraine disease are at lower risk for developing PPMS.

A 74-year-old woman was admitted with a dry cough and dyspnea that had persisted for 2 weeks at the beginning of winter. Chest computed tomography revealed bilateral diffuse non-segmental ground-glass opacities without centrilobular nodules. Bronchoalveolar lavage fluid revealed a marked increase in the lymphocyte ratio. Her condition and chest radiographic findings improved spontaneously after admission. An additional interview conducted after admission revealed that the patient had started using a contaminated humidifier approximately 2 weeks before the onset of symptoms. Thus, the diagnosis of humidifier lung was established. Humidifier lung is a rare phenotype of hypersensitive pneumonitis that often occurs during dry winter when the use of humidifiers increases. Humidifier lung is an important differential diagnosis of bilateral pneumonia during dry winter, and detailed history-taking regarding the use of humidifiers, assuming a humidifier lung, is crucial for its diagnosis.

UNASSIGNED: A middle-aged male with a history of bilateral inguinal hernia repair was admitted for acute abdominal pain. The patient reported that he took prescribed hydrocodone and a saw palmetto supplement prior to surgery. He denied any recent trauma after the procedure, and he was unable to schedule a follow-up appointment with the surgeon or the primary care physician.
UNASSIGNED: Diagnosis: The CT angiography of the abdomen/pelvis was indicative of new interval development of a large left retroperitoneal hematoma. Intervention: No emergent intervention was required following the evaluation by the surgery and interventional radiology (IR) departments. Outcome: There was no evidence of overt bleeding over the 3-day hospital course, and his hemoglobin was within normal limits. The patient was stable for discharge as the hematoma would slowly absorb over the next 2 months.
UNASSIGNED: A retroperitoneal hematoma (RPH) has a multi-factorial etiology, such as endovascular procedures and surgeries. Detection and presentation of an RPH serves as a guide in management. There are various modes of detection. However, a multi-detector computer tomography-angiography (MDCTA) provides greater information in regards to the anatomical etiology and extent of RPH. Despite the common risk factors associated with a RPH, there are understudied and underreported influences of medications and herbal supplements, such as saw palmetto, in the development of this outcome. A large portion of the population consume herbal and/or dietary supplements, which belong to the category of complementary and alternative medicine (CAM). The challenge for health care providers, especially in the primary-care setting, is the unregulated use of herbal supplements and the associated effects. It is imperative for primary-care physicians to recognize these unknown risks and attempt to inquire about supplement use. Future education should be aimed at integrating CAM into the medical curriculum to improve physician-patient interaction in addressing this topic.

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BACKGROUND: The accessory breast is composed of residual glandular mammary tissue that persists after normal embryonic development. The entity is so rare that it is easily neglected in the diagnosis of disease.
METHODS: We report a 24-year-old virgin Persian woman with a left-sided vulvar mass and no pain or discomfort until shortly before her presentation at our department. Ectopic breast tissue in the vulva was diagnosed. We performed wide local resection of the lesion. Pathological investigation of the lesion confirmed the presence of ectopic breast tissue with secretory changes. She had no specific developmental abnormalities and had no relevant family history. She was followed up for 10 months and had recovered fully by this time.
CONCLUSIONS: Accessory breast tissue should be considered as a diagnosis when a mass is seen along the embryonic milk line, especially if the clinical findings reveal changes in the mass accompanied by changes in sex hormones.

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BACKGROUND: Ectodermal Dysplasia is a diverse group of inherited disorders characterized by a congenital defect in two or more ectodermal structures. Due to a fairly low incidence, to the best of our knowledge there are few clues that can assist in making an effective prenatal ultrasound diagnosis. Currently, the prenatal diagnosis of ectodermal dysplasia depends on a fetal genetic test combined with the family history. In this case report, we present a fetal case of ectodermal dysplasia with a remarkable prenatal ultrasound image, genetic testing, family history, and relevant exams of the stillbirth.
METHODS: A multipara with a 22-week singleton male pregnancy undergoing a fetal ultrasound examination. The image showed a hypoplastic maxilla and mandible. Subsequently, the ectodermal dysplasia was defined using a family history and genetic testing. The skin pathology from the aborted fetus demonstrated a hypohidrotic type. The computed tomography (CT) reconstruction after induced labor confirmed the prenatal ultrasound findings of the maxilla and mandible.
CONCLUSIONS: This case suggested that prenatal ultrasound may provide a valuable clue of ectodermal dysplasia. The diagnosis can be established using further prenatal genetic testing and a family history.

OBJECTIVE: Risk factors for sporadic GEP-NENs are still not well defined. To identify the main clinical risk factors represents the aim of this study performed by three Italian referral centers for NENs.
METHODS: We performed a retrospective case-control study including 148 consecutive sporadic GEP-NENs and 210 age- and sex-matched controls. We collected data on clinical features, cancer family history and other potential risk factors.
RESULTS: Mean age was 58.3 ± 15.8 years; 50% males, primary site was pancreas (50.7%), followed by ileum (22.3%). The 62.8% and 29.1% of cases were G1 and G2, respectively; the 40% had locally advanced or metastatic disease at diagnosis. Independent risk factors for GEP-NENs were: family history of non-neuroendocrine GEP cancer (OR 2.16, 95% CI 1.31-3.55, p = 0.003), type 2 diabetes mellitus (T2DM) (OR 2.5, 95% CI 1.39-4.51, p = 0.002) and obesity (OR 1.88, 95% CI 1.18-2.99, p = 0.007). In the T2DM subjects, metformin use was a protective factor (OR 0.28, 95% CI 0.08-0.93, p = 0.049). T2DM was also associated with a more advanced (OR 2.39, 95% CI 1.05-5.46, p = 0.035) and progressive disease (OR 2.47, 95% CI 1.08-5.34, p = 0.03). Stratifying cases by primary site, independent risk factors for pancreatic NENs were T2DM (OR 2.57, 95% CI 1.28-5.15, p = 0.008) and obesity (OR 1.98, 95% CI 1.11-3.52, p = 0.020), while for intestinal NENs family history of non-neuroendocrine GEP cancer (OR 2.46, 95% CI 1.38-4.38, p = 0.003) and obesity (OR 1.90, 95% CI 1.08-3.33, p = 0.026).
CONCLUSIONS: This study reinforces a role for family history of non-neuroendocrine GEP cancer, T2DM and obesity as independent risk factors for GEP-NENs and suggests a role of metformin as a protective factor in T2DM subjects. If confirmed, these findings could have a significant impact on prevention strategies for GEP-NENs.