Traumatic or spontaneous hemarthroses are an important cause of joint effusions, and can complicate innate or acquired coagulopathies. The elbow is an unusual location for a spontaneous hemarthrosis; we describe a previously unreported case of warfarin-induced spontaneous elbow hemarthrosis, diagnosed by point-of-care ultrasound. On the basis of clinical and ultrasound findings arthrocentesis was deferred, and the patient was successfully treated with warfarin reversal and conservative care. Physical examination is unreliable for the detection of a joint effusion, and misdiagnosis and can lead to unnecessary investigation or resource use. Point-of-care ultrasound allows accurate, prompt, direct visualization of a joint effusion, and non-invasive confirmation of a hemarthrosis. Ultrasound can facilitate accurate diagnosis and characterization of joint effusions to improve the care of patients with coagulopathy.
Arthrocentesis ; Diagnosis ; Diagnostic Errors ; Elbow* ; Hemarthrosis* ; Humans ; Joints ; Physical Examination ; Point-of-Care Systems* ; Ultrasonography* ; Warfarin

The Gynecologic Oncology Group (GOG) has conducted multiple trials related to malignancies of the uterine corpus. Recently, several of these trials have been presented and/or published. Areas of focus included the feasibility of laparoscopic staging for endometrial cancer, the adjuvant management of locally advanced endometrial cancer, whole abdominal irradiation in maximally resected advanced endometrial carcinoma, and combination chemotherapy regimens for stage I and II carcinosarcoma after primary surgery and for advanced or recurrent carcinosarcoma. This article will discuss the background and details of each of these important advances.
Carcinosarcoma ; Drug Therapy, Combination ; Endometrial Neoplasms ; Female

The Gynecologic Oncology Group (GOG) has conducted multiple trials related to malignancies of the uterine corpus. Recently, several of these trials have been presented and/or published. Areas of focus included the feasibility of laparoscopic staging for endometrial cancer, the adjuvant management of locally advanced endometrial cancer, whole abdominal irradiation in maximally resected advanced endometrial carcinoma, and combination chemotherapy regimens for stage I and II carcinosarcoma after primary surgery and for advanced or recurrent carcinosarcoma. This article will discuss the background and details of each of these important advances.
Carcinosarcoma ; Drug Therapy, Combination ; Endometrial Neoplasms ; Female

Malignant transformation of urachal adenoma is exceedingly rare, with intestinal metaplasia as the most common contributing mechanism. It is recommended that a urachal adenoma be regarded as a pre-malignant condition and be subject to endoscopic surveillance. A local en block excision of the tumor mass with urachalectomy and umbilectomy results in possible long-term survival. The median survival after platinum-based chemotherapy is limited for patients with extravesical disease. Here we report a case of synchronous urothelial carcinoma of the bladder and urachal adenoma that transformed into adenocarcinoma.
Adenocarcinoma ; Adenoma ; Humans ; Metaplasia ; Urinary Bladder ; Urinary Bladder Neoplasms

A static, unilateral, and focal bone depression located lingually within the ascending ramus, identical to the Stafne's bone cavity of the angle of the mandible, is being reported. During development of the mandible, submandibular gland inclusion may lead to the formation of a lingual concavity, which could contain fatty tissue, blood vessels, or soft tissue. However, similar occurrences in the ascending ramus at the level of the parotid gland are extremely rare. Similar cases were previously reported in dry, excavated mandibles, and 3 cases were reported in living patients. A 52-year-old African American male patient was seen for pain in the mandibular teeth. Panoramic radiography showed an unusual concavity within the left ascending ramus. Cone-beam computed tomography confirmed this incidental finding. The patient was cleared for the extraction of non-restorable teeth and scheduled for annual follow-up.
Adipose Tissue ; Blood Vessels ; Cone-Beam Computed Tomography* ; Depression* ; Follow-Up Studies ; Humans ; Incidental Findings ; Male ; Mandible ; Middle Aged ; Parotid Gland ; Radiography, Panoramic ; Salivary Glands* ; Submandibular Gland ; Tooth

Objective: Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. Methods: A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. Results: The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. Conclusions Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Objective: Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. Methods: A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. Results: The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. Conclusions Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Objective: Although stroke guidelines recommend antiplatelets be started 24 hoursafter tissue plasminogen activator (tPA), select mechanical thrombectomy (MT)patients with luminal irregularities or underlying intracranial atherosclerotic diseasemay benefit from earlier antiplatelet administration. Methods: We explore the safety of early (< 24 hours) post-tPA antiplatelet use byretrospectively reviewing patients who underwent MT and stent placement for acuteischemic stroke from June 2015 to April 2018 at our institution. Results: Six patients met inclusion criteria. Median presenting and pre-operativeNational Institutes of Health Stroke Scale scores were 14 (Interquartile Range [IQR]5.5-17.3) and 16 (IQR 13.7-18.7), respectively. Five patients received standard intravenous(IV) tPA and one patient received intra-arterial tPA. Median time from symptomonset to IV tPA was 120 min (IQR 78-204 min). Median time between tPA and antiplateletadministration was 4.9 hours (IQR 3.0-6.7 hours). Clots were successfullyremoved from the internal carotid artery (ICA) or middle cerebral artery (MCA) in 5patients, the anterior cerebral artery (ACA) in one patient, and the vertebrobasilarjunction in one patient. All patients underwent MT before stenting and achievedthrombolysis in cerebral infarction 2B recanalization. Stents were placed in the ICA(n=4), common carotid artery (n=1), and basilar artery (n=1). The median time fromstroke onset to endovascular access was 185 min (IQR 136-417 min). No patientsexperienced symptomatic post-procedure intracranial hemorrhage (ICH). Medianmodified Rankin Scale score on discharge was 3.5. Conclusions Antiplatelets within 24 hours of tPA did not result in symptomatic ICHin this series. The safety and efficacy of early antiplatelet administration after tPA inselect patients following mechanical thrombectomy warrants further study.

Essure (Bayer) received approval from the U.S. Food and Drugs Administration as a permanent non-hormonal contraceptive implant in November 2002. While the use of Essure in the management of hydrosalpinx prior to in vitro fertilization (IVF) remains off-label, it has been used specifically for this purpose since at least 2007. Although most published reports on Essure placement before IVF have been reassuring, clinical experience remains limited, and no randomized studies have demonstrated the safety or efficacy of Essure in this context. In fact, no published guidelines deal with patient selection or counseling regarding the Essure procedure specifically in the context of IVF. Although Essure is an irreversible birth control option, some patients request the surgical removal of the implants for various reasons. While these patients could eventually undergo hysterectomy, at present no standardized technique exists for simple Essure removal with conservation of the uterus. This article emphasizes new aspects of the Essure procedure, as we describe the first known association between the placement of Essure implants and the subsequent development of fluid within the uterine cavity, which resolved after the surgical removal of both devices.
Contraception ; Counseling* ; Fertilization in Vitro* ; Humans ; Hysterectomy ; Laparoscopy ; Patient Selection ; Uterus

OBJECTIVE: Obsessive compulsive and related disorders are a collection of debilitating psychiatric disorders in which the role of glutamate dysfunction in the underpinning neurobiology is becoming well established. N-acetyl cysteine (NAC) is a glutamate modulator with promising therapeutic effect. This paper presents a systematic review of clinical trials and case reports exploring the use of NAC for these disorders. A further objective was to detail the methodology of current clinical trials being conducted in the area. METHODS: PubMed, Web of Science and Cochrane Library Database were searched for human clinical trials or case reports investigating NAC in the treatment of obsessive compulsive disorder (OCD) or obsessive compulsive related disorders. Researchers with known involvement in NAC studies were contacted for any unpublished data. RESULTS: Four clinical trials and five case reports/series were identified. Study durations were commonly 12-weeks, using 2,400-3,000 mg/day of NAC. Overall, NAC demonstrates activity in reducing the severity of symptoms, with a good tolerability profile and minimal adverse effects. Currently there are three ongoing randomized controlled trials using NAC for OCD (two adults and one pediatric), and one for excoriation. CONCLUSION: Encouraging results have been demonstrated from the few pilot studies that have been conducted. These results are detailed, in addition to a discussion of future potential research.
Adult ; Cysteine* ; Glutamic Acid ; Humans ; Neurobiology ; Obsessive-Compulsive Disorder