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Medscape
2 days ago
- General
- Medscape
Anemia in a Heavy Smoker
Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@ with the subject line "Case Challenge Suggestion." We look forward to hearing from you. Background and Initial Presentation A 40-year-old man presents to the emergency department with complaints of repeated vomiting and dizziness for the past 2 days. He has no fever or diarrhea. He has been experiencing dyspepsia and abdominal fullness after meals for a month. These symptoms have increased during this time, causing him to decrease his food intake week by week. He has tried over-the-counter drugs, such as antacids and pantoprazole, with no effect. This condition has been associated with epigastric pain; his general practitioner tested him for Helicobacter pylori , which was negative. The patient has been a heavy smoker for the past 15 years, smoking one pack per day. Since his symptoms began, he has tried to quit smoking using nicotine patches. He attributed his dyspepsia to the use of the nicotine patch, considering his negative H pylori test. He therefore decreased the duration of his nicotine patch use, but his symptoms only minimally improved. He has also experienced easy fatigability over the past 4 months. He noted that at times during the previous month, his eyes have become yellow. His family history shows that his father died of colon cancer in his 50s. The patient's presentation is suspicious for hemolytic anemia, so it will be important to confirm this with a Coombs test and a peripheral blood smear for schistocytes.[1] ESR and CRP and GGT levels will not help diagnose the cause of hemolytic anemia. Physical Examination and Workup Examination: Blood pressure: 100/60 mm Hg Pulse: 95 beats/min Temperature: 37.5 °C (99.5 °F) General examination: Pallor of the inner lips; hand creases apparent, not faded Abdominal examination: Splenomegaly Laboratory investigations: Sodium: 130 mEq/L (range, 135-145) Potassium: 3 mEq/L (range, 3.5-5.2) Creatinine: 1.5 mg/dl (range, 0.7-1.3) Blood urea nitrogen: 50 mg/dL (range, 6-24) Coombs test: 3+ (range, 0-4) Hemoglobin: 9 g/dL (range for men, 13.2-16.6) Calcium level: 9 mg/dL (range, 8.5-10.2) Complete blood film shows schistocytes count of 6% (range, normal is < 0.5%, although usual values are < 0.2%) Mean corpuscular volume: 90 fl (range, 80-100) Platelet: 150,000/µL (range, 150,000-450,000) White blood cells: 6000/µL (range, 4,500-11,000) ESR: 120 mm/hr (range for men, < 50 years old: < 15) CRP: 70 mg/dL (range, < 0.3) A CT of the abdomen with contrast was taken, showing the lesions in Figure 1. Figure 1. Abdominal CT with contrast showing lesions. MAHA as a paraneoplastic syndrome in infiltrative gastric cancer is the most likely diagnosis. MAHA as a paraneoplastic syndrome is a rare presentation of metastatic gastric cancer, with only about 50 cases documented in the literature. MAHA is caused by tumor-associated thrombotic microangiopathy and is considered an oncologic emergency.[2] It is associated with poor prognosis.[3] In one single-center analysis, most of the patients with MAHA showed infiltrative diffuse gastric cancer with partial or complete signet ring cellular morphology. All patients had metastatic disease at the time of presentation of MAHA, either at first diagnosis or recurrence.[2] Gastric cancer (GC) is a major cause of cancer-related deaths, mostly due to diagnosis at advanced stages of the disease;[4] it is often asymptomatic in the early stages.[5] Asymptomatic cancers can present with nonspecific paraneoplastic symptoms such as anemia or endocrine disturbances. Rapid development of pernicious anemia due to adenocarcinoma of the stomach has been reported in the literature.[6] Advanced GC symptoms may include iron deficiency anemia.[5] Anemia due to bleeding in cancers presents as microcytic anemia with low iron and ferritin levels (although ferritin can be elevated as part of the immune response to cancer).[7] Anemia due to malabsorption is usually due to deficiencies of B12 or folate causing macrocytic anemia or to iron malabsorption causing microcytic anemia.[7,8] In this patient, the Coombs test result was positive for hemolytic anemia, and the blood smear indicated elevated schistocytes. His anemia is normocytic hemolytic anemia due to destruction of the red blood cells with elevated lactate dehydrogenase and schistocytes. The presence of clear invasive GC provides a cause of his anemia. In the CT of the abdomen with contrast (Figure 1), circumferential wall thickening up to 15 mm was seen throughout the stomach. Multiple enlarged pathologic lymph nodes were noted perigastric, peripancreatic, within the porta-hepatis, and para-aortic. The largest was seen at porta hepatis measuring 30 x 14 mm. Mild ascites was present. The liver echo pattern was inhomogeneous with multiple bilobar hypodense non-enhancing hepatic focal lesions: one in segment VI/VII measuring 8 x 7 mm and the other in segment III subcapsular exophytic lesion measuring 14 x 12 mm. An upper GI endoscopy was performed and biopsies were taken. Endoscopy showed thickened mucosa of the stomach with decreased gastric rugae and volume (Figure 2). Figure 2. Upper GI endoscopy showing thickened stomach mucosa with decreased gastric rugae and volume. The pathology report of the gastric antral biopsies showed diffuse signet ring cellular morphology stage III. Of note, in all newly diagnosed patients with GC, testing for microsatellite instability (MSI) status by PCR/next-generation sequencing or mismatch repair status by immunohistochemistry is recommended.[4] Testing for MSI status also should be done in patients with locally advanced and unresectable or metastatic GC to tailor treatment.[5] Signet ring cell cancer grade 3 usually shows recurrence within 2 years after standard treatment of radical surgery and chemotherapy. Signet ring cell cancer is often chemoresistant; even the use of adjuvant chemotherapy is controversial.[9] Adequate surgical resection is considered the main therapeutic option for signet ring cell GC;[10] surgery is recommended for appropriate metastatic GC candidates.[4] Advanced GC signet ring cell type is treated with 5-fluorouracil (5-FU);[11] for stage III, the treatment regimen is chemotherapy with a 5-FU-based combination.[2] For patients who are candidates for treatment with PD-1 inhibitors, PD-L1 testing may be considered. A specimen with a combined positive score ≥ 1 is viewed as exhibiting PD-L1 expression.[4] The patient was referred to surgery for a radical gastrectomy. After 1 month, he started chemotherapy with a 5-FU-based combination. After completing his 13-month course of chemotherapy, the patient began to experience cough and dyspnea. He presented to the emergency department with cyanosis and severe dyspnea. On examination, his temperature was normal but his oxygen saturation was 70%, and there was decreased air entry on both sides of the chest. A chest radiograph demonstrated bilateral pleural effusion. Chest CT with contrast was performed to exclude metastasis (Figure 3). The chest CT showed bilateral encysted pleural effusion with mild pericardial effusion. The lungs exhibited areas of atelectasis in relation to the effusion. Lung biopsies confirmed metastasis. Figure 3. Chest CT with contrast showing bilateral encysted pleural effusion. The findings indicated recurrence with metastatic presentation. Because of the late stage of disease and the type of tumor, the oncologist recommended personalized palliative immunotherapy to prolong survival and improve the patient's general condition. Immunotherapy options for GC include immunomodulators, checkpoint inhibitors,[4,5,12] and vaccines targeting the tumor.[12] The patient has recurrent disease following treatment with a 5-FU-containing regimen, and he had received a radical gastrectomy when he presented at stage III. His dyspnea is considered a rare presentation of GC, although it can occur in cases of pulmonary metastasis, pulmonary lymphangitic carcinomatosis, or pulmonary tumor thrombotic microangiopathy.[13] Immunotherapy for signet ring cell GC includes immune checkpoint inhibitors targeting PD-1 and PD-L1. In selected cases of signet ring cell cancer, where MSI is high with deficient mismatch repair proteins, immunotherapy with PD-1 could be effective.[10] PD-1 and PD-L1 checkpoint inhibitors decrease T-cell tolerance to the tumor cells, enhancing the body's adaptive immune response against cancer cells.[12] This patient had high MSI and started PD-1 inhibitor immunotherapy. His pulmonary symptoms improved, with decreased dyspnea and fatigue and increased oxygen saturation. Later chest CT showed absence of pleural effusion and pericardial effusion, and the metastatic nodules regressed. Signet ring cell GC comprises about 17% of primary gastric tumors.[14,15] Patients with signet ring cell gastric carcinoma usually exhibit higher TNM staging at presentation as compared with patients with non-signet ring cell tumors.[15] More patients with signet cell GC receive chemotherapy than those with non-signet cell cancer. Bone metastasis was higher in patients with signet ring cell cancer as compared with those with non-signet ring cell cancer GC in a large cohort (> 36,000) of GC patients.[15] First-line treatment for stage IV signet ring cell cancer includes palliative chemotherapy with docetaxel-5-FU-oxaliplatin. If the patient has stage IV disease at diagnosis, radical gastrectomy with chemotherapy (13 months) provides longer survival than chemotherapy alone (7 months).[14] However, in the REGATTA trial, palliative gastrectomy in stage IV disease did not provide any survival benefit over chemotherapy alone.[16] PD-1 inhibitor immunotherapy may be effective in patients with signet ring cell cancer with high MSI and deficient tumor mismatch repair.[10] As noted previously, PD-1 and PD-L1 checkpoint inhibitors decrease T-cell tolerance to the tumor cells, enhancing the body's adaptive immune response against cancer cells.[12] Although the patient's chest CT showed bilateral pleural effusion, that is not a prognostic marker for PD-1 inhibitor response. As noted earlier, signet ring cell cancer is often chemoresistant, and grade 3 usually shows recurrence within 2 years after the standard treatment of radical surgery and chemotherapy,[17] neither of which are prognostic markers for PD-1 inhibitor response.
Irish Times
26-05-2025
- Health
- Irish Times
‘Come to Ireland, get well paid and a holiday': The GPs lured from the UK to Ireland
Kelly-Anne Speight hangs up her stethoscope in the Mayo GP practice she works at when she finishes her shift and walks the few minutes down to the River Moy. 'As soon as I finished work, I landed down at the quay, I was paddling on the water really quickly,' she said. From Enniskillen in Co Fermanagh, Ms Speight moved to Ireland from Scotland in March this year to work as a general practitioner. She now works across two practices: one in Ballina, Mayo and the other in Enniscrone, Co Sligo – working two days in each per week. READ MORE Having studied and worked in Glasgow and Stirling for a number of years, the move was prompted by her partner being from Ballina, as well as hearing about the beauty of the west of Ireland. [ A Portuguese nurse in Ireland: 'Nurses are a lot more valued here' Opens in new window ] A keen endurance athlete, she thought she'd miss Scotland's landscape, but Ireland also has its natural beauty, she said. 'I'm certainly learning that there's plenty of hills in Ireland and beautiful coastal routes. We were down by the sea cliffs, we did Slieve League. And than in Ballina, you're right at the River Moy,' she added. Kelly-Anne Speight, working at Moy View Practice, Ballina, Co Mayo. A keen endurance athlete, the one thing she thought she'd miss about living in Scotland was its landscape, but Ireland also has its natural beauty, she said. Photograph: Robin Hill Photography But it is not just the landscape between the two states that is similar. The work is, too, making the transition quite simple. The main difference she has noticed is between the rural and urban practices, though she notices this between Mayo and Sligo, as much as between Ireland and Scotland. 'Stereotypically, in rural areas, you tend to get stoic farmers who tend to be a little bit later when presenting, so when they do they tend to be unwell. I quite like that as a challenge,' she said. Dr Speight isn't the only UK-based doctor who has made this move in recent times. According to Dr Diarmuid Quinlan, medical director of the Irish College of GPs , there has been a recent increase in the number of UK doctors, mainly from England, who are seeking to work in Ireland. Dr Quinlan said this is a result of GP employment difficulties in the NHS, combined with the close geographical proximity. A recent survey by the British Medical Association of more than 1,400 family doctors found one in five GPs in England said they plan to change their career because they cannot find any or enough work as a doctor. 'We have a major shortage of GPs in Ireland. We currently have 4,600, and we probably need north of 6,500. We have mutual recognition for the Royal College of GPs qualification here in the Republic, so doctors from the UK would integrate into the Irish system seamlessly and be very welcome,' he said. Earlier this month, the Department of Health announced a new scheme in a bid to improve access to locum cover for up to 239 GPs in rural and remote areas from this summer. [ Almost 40% of doctors working in Ireland last year had qualified overseas, says medical council Opens in new window ] Under the scheme, the Health Service Executive (HSE) will bear the cost of securing the locum, ensuring GPs have the necessary support to maintain continuity of care to their patients in their communities. Dr Quinlan said this scheme is 'hugely welcomed', adding that often doctors in these rural practices cannot take time off work due to an inability to find cover. 'What I would like to see is locums from the UK thinking: 'Maybe I'll come over to Ireland for the summer, get well-paid work, and a holiday at the same time',' he said. 'We have an acute need for GP locums, particularly down the western seaboard and the midlands, which are fabulous places. So any GP who would like to come and work in Ireland, that would be very welcome.' Caroline Puckering is one such individual. She has been working as a locum for just over two years in the UK, after completing her training there. Originally from west Cork, she wants her three young children to know their Irish roots, and so she brings them back to Ireland every summer. This summer, she has registered with the Medical Council and has begun interviewing for locum positions in Ireland. A permanent move to the Republic is also being considered, she added. 'The reasons I want to come is because I'm originally Irish, and I want my children to experience Ireland. So I'm going to locum a little bit and still continue to locum in the UK,' she said. 'There are lots of jobs for GPs in Ireland and they're very familiar with UK GPs wanting to work in Ireland. In the UK, there's a little bit of a GP job crisis so a lot of them are looking at coming to Ireland.' Ms Speight experiences a lot of joy in her work since she moved to Ireland. The GP practices she works in 'are really part of the community'. 'You really get to know your patients. There's a lot of job satisfaction in that.'
Free Malaysia Today
18-05-2025
- Health
- Free Malaysia Today
Mandatory drug price display is a double-edged sword
A private doctor acquaintance of mine in the Klang Valley has been a worried man these days. The GP (general practitioner) started his private clinic a few years ago after going through some difficult times in the public hospital where he had worked. He opened his clinic in a semi-urban area, using up most of his hard-earned savings and with a little help from family members. He is his own boss, besides providing jobs for another doctor, four nurses and a security guard. Given the approved consultation fee structure drawn up 30 years ago, and the cost of living which has escalated over the decades, he says it is a struggle to make ends meet. 'I get about 40 patients a day, from 8am to 10pm, charging RM20 per consultation in my area. So for 30 days, I earn RM24,000 a month. With the two doctors being paid an average of RM8,000 each and the total for four nurses at RM8,000, this income is just enough for salaries. 'I also have to pay the security guard RM1,700, rent of RM3,000 a month, while the utility bill comes to around RM2,000. The profits are minimal actually, but this is how the disbursement of medicine helps us out,' he told FMT. He said it was a struggle for most individual operators like him, and many GPS faced this problem. Big chain networks Private doctors say the new mandatory price display that came into force on May 1 will have little impact on the big players in the industry. The big third-party operators with a chain of clinics and linked to major commercial pharmacies are likely not to fill the pinch. On the contrary, they stand to benefit the most from the impact of this new move. One doctor gave the example of Japan's Sumitomo Corporation, which has invested in two Malaysian companies and formed the leading clinic network. According to the company's profile, more than RM100 million was invested over the years to buy up clinics and third-party operators owning a number of clinics each. In addition, these chains are reportedly linked to huge pharmaceutical companies which have taken control of the drug market. In 2021, Sumitomo Pharma Co Ltd set up Sumitomo Pharma Malaysia Sdn Bhd, a wholly-owned subsidiary. Price war According to one doctor, the clinics in the chain have been prevented from dishing out medicines for chronic illnesses such as high blood pressure and diabetes. Patients are instead diverted to the pharmacies controlled by the chain. 'These big companies order medicine in bulk; with the sheer numbers they have, they get the wholesale prices which are much cheaper. They can afford to charge lower selling prices because of the sheer volume they deal with,' he said. He said small clinics, especially those who operate independently, cannot afford to charge these prices because they would have obtained their stock at a much higher price after ordering in much smaller amounts. The doctors feel that the mandatory price display rule is a precursor to stopping GPs from selling medicines completely and handing the responsibility solely to pharmacies, especially those owned and operated by giant companies. New monopoly Sources in the know claim that with the entry of big players who are also closely linked to major pharmaceutical companies, a different form of monopoly is taking place in the Malaysian healthcare sector. According to former health minister Dr S Subramaniam, a cost-benefit analysis conducted by the health ministry in collaboration with the Malaysia Productivity Corporation has clearly outlined the long-term impact of the move. 'The analysis clearly outlines the potential closure of up to 2,600 private clinics, with a projected RM206 billion net economic loss over 15 years and the risk of job losses ranging from 91,000 to 136,000,' he had told FMT. I wonder if the health ministry paid any attention to these projections, let alone the nation losing billions which will be repatriated to the home countries of these giants. Win-win solution needed A group of doctors who spoke to me believe that an urgent long overdue review of the fee structure for private practitioners can save thousands of clinics from closing down and thus save many jobs. The government has not done so despite having more than 10 health ministers over the last three decades. Obviously, they are taking a populist approach by pleasing voters. Besides the new structure, the GPs feel that the introduction of a ceiling price for all medication could help smaller players, who are on the verge of being swallowed by the big guys. 'They should allow us to display the ceiling prices of the drugs and decide how much discount we can give the patients at our discretion. This will level the playing field to a great extent,' said one doctor. In view of the seriousness of the matter, there is a suggestion that a special independent committee comprising all stakeholders be set up to look at the matter holistically. There have been too many major policy decisions being made without proper and effective consultation lately. Now that the health ministry has given a three-month grace period before enforcing the new policy, there is ample time for the authorities to take another look at it. The views expressed are those of the writer and do not necessarily reflect those of FMT.
