Tullio phenomenon in superior semicircular canal dehiscence (SSCD)

A 68-year-old woman presented with worsening sound-induced vertigo (Tullio phenomenon) and left-sided hearing loss. Weber's test lateralised to the affected ear and audiography confirmed mild conductive hearing loss. Neurological assessment was remarkable for torsional/vertical noise and vibration-induced nystagmus. The patient demonstrated low threshold cervical vestibular-evoked myogenic potential responses, and superior semicircular canal dehiscence was suspected. Otoscopy, tympanography and stapedial reflexes were normal bilaterally.peer-reviewe

The elephant man syndrome

We describe a case of Proteus syndrome in a 34-year-old man who started to notice growths over his left frontal and temporal regions about 15 years ago. An abdominal ultrasound confirmed splenomegaly which was palpable on clinical examination. A skull X-ray showed well-circumscribed lesions over the left frontal bone and at the mastoid processes with a hazy appearance of the matrix, a narrow zone of transition and no periosteal reaction. CT demonstrated hyperostosis of the skull.peer-reviewe

A rare case of pulmonary alveolar microlithiasis

A 47-year-old asymptomatic man with no significant family history was referred to our faculty because of an abnormal chest X-ray (CXR). The CXR, similar to his CXR 10 years previously, showed bilaterally increased interstitial markings suggestive of pulmonary fibrosis. High-resolution CT (HRCT) showed multiple bilateral branching calcifications, mostly in the lung bases (figures 1 and 2), with ground-glass opacities in the lingula, and no enlarged mediastinal lymph nodes. A repeat HRCT after 4 months remained similar. After discussion at a multidisciplinary team meeting, a diagnosis of pulmonary alveolar microlithiasis (PAM) was reached.peer-reviewe

Lower back pain in a patient on long-term haemodialysis

A 60-year-old woman with end-stage renal disease secondary to adult polycystic kidney disease, presented with a 6-month history of worsening sacral and rectal pain. She reported anorexia and significant weight loss. She was on haemodialysis for 5 years prior to receiving a renal transplant, which failed after 8 years. She was then recommenced haemodialysis for another 4 years to date. She underwent bilateral nephrectomy of her native kidneys prior to transplantation. Clinical examination showed cachexia, hepatomegaly and a right iliac fossa graft. Rectal examination was normal. Passive movements of both lower limbs were painful; however, there was no neurological deficit.peer-reviewe

Bilateral primary testicular lymphoma

A 56-year-old man presented to his general practitioner with a painless, rapidly growing left testicular mass over a period of 3 months. The patient was a known case of type II diabetes mellitus and hypertension with no relevant surgical history. He did not report any dysuria, fever or weight loss. On examination, there was bilateral diffuse, non-tender testicular enlargement without regional lymphadenopathy. Sonographic assessment revealed an enlarged left hypoechoic testicle measuring approximately 5 cm in width and 8 cm in length. It demonstrated a diffusely heterogenous infiltrative pattern and increased internal Doppler flow. The right testicle measured 5 cm × 6 cm with otherwise similar sonographic findings.peer-reviewe

Beware the person with the glass eye and the large liver

A 67-year-old woman presented to the emergency department reporting of epigastric fullness, fatigue and weight loss. Physical examination revealed three fingerbreadths of hepatomegaly. Blood tests were unremarkable, save for a moderately raised erythrocyte sedimentation rate. An urgent CT of her abdomen demonstrated two large liver lesions of low attenuation on the non-enhanced scan, showing heterogeneous enhancement in the arterial phase with contrast washout after a 5 min delay, an appearance typical of hypervascular metastasis. Ultrasound-guided biopsy of one of these lesions was performed as a primary tumour was not identified. This revealed metastatic melanoma, however the primary lesion was not apparent on clinical examination.peer-reviewe

CHA2 DS2 -VASc score and adverse outcomes in patients with heart failure with reduced ejection fraction and sinus rhythm

AIMS: The aim of this study was to determine whether the CHA2 DS2 -VASc score can predict adverse outcomes such as death, ischaemic stroke, and major haemorrhage, in patients with systolic heart failure in sinus rhythm. METHODS AND RESULTS: CHA2 DS2 -VASc scores were calculated for 1101 patients randomized to warfarin and 1123 patients randomized to aspirin. Adverse outcomes were defined as death or ischaemic stroke, death alone, ischaemic stroke alone, and major haemorrhage. Using proportional hazards models, we found that each 1-point increase in the CHA2 DS2 -VASc score was associated with increased hazard of death or ischaemic stroke events [hazard ratio (HR) for the warfarin arm = 1.21, 95% confidence interval (CI) 1.13-1.30, P < 0.001; for aspirin, HR = 1.20, 95% CI 1.11-1.29, P < 0.001]. Similar increased hazards for higher CHA2 DS2 -VASc scores were observed for death alone, ischaemic stroke alone, and major haemorrhage. Overall performance of the CHA2 DS2 -VASc score was assessed using c-statistics for full models containing the risk score, treatment assignment, and score-treatment interaction, with the c-statistics for the full models ranging from 0.57 for death to 0.68 for major haemorrhage. CONCLUSIONS: The CHA2 DS2 -VASc score predicted adverse outcomes in patients with systolic heart failure in sinus rhythm, with modest prediction accuracy

Bleeding Risk and Antithrombotic Strategy in Patients With Sinus Rhythm and Heart Failure With Reduced Ejection Fraction Treated With Warfarin or Aspirin

We sought to assess the performance of existing bleeding risk scores, such as the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score or the Outpatient Bleeding Risk Index (OBRI), in patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm (SR) treated with warfarin or aspirin. We calculated HAS-BLED and OBRI risk scores for 2,305 patients with HFrEF in SR enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial. Proportional hazards models were used to test whether each score predicted major bleeding, and comparison of different risk scores was performed using Harell C-statistic and net reclassification improvement index. For the warfarin arm, both scores predicted bleeding risk, with OBRI having significantly greater C-statistic (0.72 vs 0.61; p = 0.03) compared to HAS-BLED, although the net reclassification improvement for comparing OBRI to HAS-BLED was not significant (0.32, 95% confidence interval [CI] −0.18 to 0.37). Performance of the OBRI and HAS-BLED risk scores was similar for the aspirin arm. For participants with OBRI scores of 0 to 1, warfarin compared with aspirin reduced ischemic stroke (hazard ratio [HR] 0.51, 95% CI 0.26 to 0.98, p = 0.042) without significantly increasing major bleeding (HR 1.24, 95% CI 0.66 to 2.30, p = 0.51). For those with OBRI score of ≥2, there was a trend for reduced ischemic stroke with warfarin compared to aspirin (HR 0.56, 95% CI 0.27 to 1.15, p = 0.12), but major bleeding was increased (HR 4.04, 95% CI 1.99 to 8.22, p <0.001). In conclusion, existing bleeding risk scores can identify bleeding risk in patients with HFrEF in SR and could be tested for potentially identifying patients with a favorable risk/benefit profile for antithrombotic therapy with warfarin

Left atrial volume and cardiovascular outcomes in systolic heart failure: effect of antithrombotic treatment

AimsLeft atrium (LA) dilation is associated with adverse cardiovascular (CV) outcomes. Blood stasis, thrombus formation and atrial fibrillation may occur, especially in heart failure (HF) patients. It is not known whether preventive antithrombotic treatment may decrease the incidence of CV events in HF patients with LA enlargement. We investigated the relationship between LA enlargement and CV outcomes in HF patients and the effect of different antithrombotic treatments.Methods and resultsTwo-dimensional echocardiography with LA volume index (LAVi) measurement was performed in 1148 patients with systolic HF from the Warfarin versus Aspirin in Reduced Ejection Fraction (WARCEF) trial. Patients were randomized to warfarin or aspirin and followed for 3.4 ± 1.7 years. While the primary aim of the trial was a composite of ischaemic stroke, death, and intracerebral haemorrhage, the present report focuses on the individual CV events, whose incidence was compared across different LAVi and treatment subgroups. After adjustment for demographics and clinical covariates, moderate or severe LA enlargement was significantly associated with total death (hazard ratio 1.6 and 2.7, respectively), CV death (HR 1.7 and 3.3), and HF hospitalization (HR 2.3 and 2.6) but not myocardial infarction (HR 1.0 and 1.4) or ischaemic stroke (1.1 and 1.5). The increased risk was observed in both patients treated with warfarin or aspirin. In warfarin-treated patients, a time in therapeutic range &gt;60% was associated with lower event rates, and an interaction between LAVi and time in therapeutic range was observed for death (P = 0.034).ConclusionsIn patients with systolic HF, moderate or severe LA enlargement is associated with death and HF hospitalization despite treatment with antithrombotic medications. The possibility that achieving a more consistent therapeutic level of anticoagulation may decrease the risk of death requires further investigation