Background and aim:Acute dizziness often leads to hospital admission because of suspected stroke. A targeted clinical examination comprising positional tests and assessment of gaze stability, nystagmus and vertical ocular misalignment is a well-documented tool for distinguishing between central and peripheral causes. The purpose of the study was to investigate whether implementation of a treatment algorithm incorporating a targeted clinical examination for acute dizziness was associated with changes in resource use, shorter hospital stays and improved diagnostic accuracy. Materials and method:A retrospective analysis was conducted of all patients admitted to the Department of Neurology at Akershus University Hospital in Norway between 2015 and 2023. The study period was divided into three periods: before (2015-17), during (2018-20) and after (2021-23) implementation of the treatment algorithm. Comparisons were made of brain CT and MRI, assessment by an otolaryngologist, length of hospital stay, and the proportion of patients discharged with a specific diagnosis of dizziness before and after implementation of the algorithm. Results:Among patients discharged with dizziness as the primary diagnosis, there was a significant increase in the proportion undergoing CT (from 87.5% to 90.9%), while the use of MRI decreased significantly (from 34.7% to 24.5%). Assessment by an otolaryngologist decreased significantly (from 21.5% to 6.8%). There was a small, non-significant reduction in length of hospital stay, in contrast to a statistically significant increase in length of stay in the reference group. The proportion of patients discharged with a specific diagnosis of dizziness increased from 20% in the period before implementation to 34% in the period after implementation. Interpretation:Implementation of a treatment algorithm incorporating a targeted clinical examination for acute dizziness in a neurology department was associated with reduced resource use (apart from a small increase in the use of CT) and improved diagnostic accuracy.
Background:Non-healing wounds in older patients can have multiple causes, including infection, inflammatory disease and malignancy. Diagnostic uncertainty can delay appropriate treatment. Case presentation:A man in his seventies presented to the emergency department with a lower leg ulcer. The lesion was initially considered to be secondary to minor trauma with infection and was treated with clindamycin. As the ulceration progressed, biopsies were performed, with pyoderma gangrenosum and squamous cell carcinoma as differential diagnoses. Histopathology showed only ulceration and a mixed inflammatory infiltrate. Interpretation:This case demonstrates the importance of reconsidering the diagnosis in progressive, non-healing ulcers. Non-specific biopsy findings and lack of response to treatment should prompt further investigation and early specialist involvement to avoid delayed diagnosis of malignancy.
Background:Adnexal torsion is a gynaecological emergency in which twisting of the ovary and/or fallopian tube around the vascular pedicle leads to impaired perfusion and ischemia. Non-specific symptoms in children and adolescents can delay diagnosis. Case presentation:We present the case of a teenage girl admitted to hospital with lower abdominal pain and a palpable mass. She had a history of chronic constipation and had not had a bowel movement for 5 days. Initial ultrasound evaluation of the mass by gynaecologists and radiologists was interpreted as being of extragenital origin. Her mild symptoms, ultrasound findings and constipation history prompted an initial diagnostic evaluation for faecal impaction. However, CT imaging later revealed a right adnexal mass with suspected torsion. Laparoscopic detorsion with cyst excision was performed, preserving the ovary, with an uneventful recovery. Interpretation:This case illustrates the diagnostic challenges associated with ovarian torsion in early adolescence. A laparoscopic, fertility-sparing detorsion is advised, with the aim of preserving the adnexa.
A major change has taken place in the treatment of human epidermal growth factor receptor 2 (HER2) positive breast cancer in recent decades, largely as a result of the development of targeted anti-HER2 treatment. This type of breast cancer accounts for approximately 13 % of all breast cancer cases diagnosed annually. Treatment options have evolved from a single HER2-targeted monoclonal antibody (trastuzumab) to a range of targeted and potent drugs. Collectively, these advances have led to significant improvements in prognosis and survival for patients with HER2-positive breast cancer. This clinical review outlines the development of HER2-targeted therapies and key principles of current treatment for both localised and metastatic disease.
