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Intravascular large B-cell lymphoma is seen in less than one per million people and can be an extremely difficult antemortem diagnosis to make due to a vast diversity of presenting symptoms. We present a case of an otherwise healthy 74-year-old woman whose predominant symptom was pitting oedema, and who likely died from multiorgan failure after >14 months of extensive workup that was unable to secure a definitive diagnosis.

Background: Obesity, defined as a body mass index (BMI) greater than 30 kg/m2, is a well-known risk factor for venous thromboembolism (VTE). Despite this observation, obese patients are under-represented in anticoagulation safety trials. Current guidelines recommend patients with active malignancy and VTE to be treated with long-term low molecular weight heparin (LMWH), but it is unclear whether this practice is safe in obese cancer patients. Objectives: We hypothesized there would be an increased risk of major or clinically significant non-major bleeding in obese cancer patients receiving long-term, actual weight-adjusted LMWH compared to non-obese patients with cancer- associated VTE. Methods: We conducted a single centre retrospective cohort study of obese cancer patients referred to our thrombosis clinic from January 2010 to December 2015. We included all obese cancer patients assessed at the Thrombosis unit who received anticoagulation with LMWH. Obesity was defined as weight above 90 Kg or BMI of 30 kg/m2 or more. The obese patients' data was compared to a non-obese control group of patients with active malignancy treated with LMWH. Major bleeding was defined as a hemoglobin drop of > 20 g/L; clinically overt bleeding; bleeding requiring 2 units or more of packed red blood cells; a hemorrhage requiring permanent cessation of anti-coagulation; or any retroperitoneal or intracranial hemorrhage. Diagnosis of deep venous thrombosis was confirmed when compression ultrasound of the lower extremities showed evidence of thrombus in the calf trifurcation or more proximal veins; or calf thrombosis associated with pulmonary embolism (PE). PE was confirmed when the ventilation-perfusion lung showed at least a large mismatched defect or CT pulmonary angiography demonstrated at least one segmental intra-luminal filling defect. Results: In total, 102 obese cancer patients and 81 non-obese cancer patients met our eligibility criteria. In the obese cohort, 43 (42%) were male, median age 64 (24-89), median weight 96.5 kg (67.3-158), and median BMI 33.7 kg/m2 (27.2-57). 90 (88%) patients had a solid tumour. Median dose of LMWH was 18,000 units (10,000 - 30,000): 78 (76%) were prescribed dalteparin and 22 (22%) tinzaparin. Median follow-up was 191 days (3 - 2622). Baseline characteristics of the control group were similar (Table 1). Total bleeding episodes were significantly different in the 2 groups: total bleeding events were 10 (9.8%) in the obese group (4 were under-dosed based on their weight) and 1 in the control group [RR=7.9; 95% CI (1.04 -60.76) p=0.046)]. Major bleeding events occurred in 6 (5.9%) obese and in none of the non-obese patients [RR=10.4; 95% CI (0.59 -181.05) p=0.11)]. Platelet counts were appropriate in all cases but one, where a non-major bleed occurred in an obese patient with a platelet count of 27. Recurrent VTE occurred in 8 (7.8%) obese and 4 control patients. In the obese cohort, 5 of those patients were receiving under-dosed LMWH based on their weight. There was no statistically significant difference regarding VTE recurrence risk in the obese and control groups [RR=1.59; 95% CI (0.50 -5.09) p=0.44)]. Interestingly, 31 of 96 obese patients (31%) with BMI 30 or above weighed less than 90 kg. Conclusions: Our findings differ from the available literature. In the CLOT trial, total and major bleeding episodes in the LMWH group occurred in 14% and 7%, respectively, with VTE recurrence of 9%. In comparison, our results demonstrate total and major bleeding episodes in our obese cancer patients on LMWH of 9.8% and 5.9%, respectively, with VTE recurrence of 7.8%. Total bleeding was statistically significant compared to a non-obese cancer population, however, limitations in sample size and event rate need to be taken into consideration when interpreting these results. Disclosures Kovacs: Daiichi Sankyo Pharma: Research Funding; Bayer: Honoraria, Research Funding; LEO Pharma: Honoraria; Pfizer: Honoraria, Research Funding. Lazo-Langner:Bayer: Honoraria; Pfizer: Honoraria; Daiichi Sankyo: Research Funding. Louzada:Celgene: Consultancy, Honoraria; Pfizer: Honoraria; Bayer: Honoraria; Janssen: Consultancy, Honoraria.

to formally evaluate patient concerns and patient-perceived satisfaction with photodynamic therapy (PDT) using topical application of 5-aminolevulinic acid for Bowen disease (BD).Initial focus groups and mailout questionnaire.tertiary care hospital.a novel 32-item self-reported patient satisfaction questionnaire was mailed out to all patients treated with PDT for BD from January 1, 2000, to March 31, 2008.a written questionnaire addressing side effects experienced, self-perceived effectiveness, and the personal and social consequences of PDT.one hundred thirty-two adults were treated with PDT for BD over this time period. Ninety-five patients (47% male, 53% female) completed the questionnaire. A majority (90%) indicated a very favourable impression of the effectiveness of PDT for BD and that side effects were mild. The most significant side effects were a burning sensation (21%) and crusting or scabbing (14%). Side effects were judged to be predictable. The process of treatment and overall time demands were judged by only 7% of respondents to be problematic. The most substantial limitations with PDT were social limitations secondary to treatment (26%), self-consciousness (28%), and skin appearance in the immediate posttreatment period (30%). Respondent reliability in response to questions was excellent.PDT is favourably received by those diagnosed with BD. PDT resulted in a high degree of perceived satisfaction for those patients with BD. Based on these data, PDT is supported as a viable method of treatment for BD.

Clinical scar assessment lacks standardized methodology and consensus on the most appropriate evaluation instrument. This study empirically evaluated whether area scars could be validly assessed by naive observers with the objective to develop and validate a novel multidimensional visual analogue scale (VAS) for the assessment of area scars.Standardized digital photographs of radial forearm free flap (RFFF) donor sites were obtained. Naive observers evaluated the images in three sequential psychophysical experiments, which led to the development of the new scar scale. These experiments involved initial evaluation of four dimensions (pigmentation, vascularity, observer comfort, acceptability) using a paired comparison (PC) paradigm and correlation with ratings of overall severity using a VAS, and initial VAS test phase followed by formal debriefing, and, subsequently, evaluation of a VAS for the four dimensions in addition to contour. Validation involved determination of intra- and interrater reliability and correlational analysis.Across all three experiments, 56 observers evaluated 101 images, generating 12 720 observations for analysis. PC data demonstrated that observers could assess scars with high reliability and internal consistency for all dimensions (95%). Overall (VAS) severity correlated highly with all dimensions, including contour. The new VAS yielded high levels of correlation (r = .72-.98, p.01).Comprehensive VAS analysis demonstrates high reliability in mirroring PC results for multiple dimensions of area scars. These data support our novel multidimensional VAS method as a valid, reliable, simple, and time-efficient instrument for clinical and research use. We introduce the Western Scar Index as a new measurement tool with many potential applications.