64F Rt. Wrist fracture, Metabolic Syn, Dyspnea 25 yrs Telangana PaJR

 

23-02-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[3.38 pm, 25/02/2026] PPM 1: Metabolic syn shortness of breath 25 years with distal radial fracture

Stop bang mnemonic for risk of OSA

                                           

[4.18 pm, 25/02/2026] PPM 1: Epworth sleepiness score

[4:20 pm, 25/02/2026] PPM 1: @PaJR Health @PPM5 how useful are these stop bang and epworth sleepiness scales for the real diagnosis of obstructive sleep apnea if polysomnography has to be done for diagnostic confirmation ?

[4:20 pm, 25/02/2026] PaJR Health: The STOP-BANG and Epworth Sleepiness Scale (ESS) are highly useful as screening tools to identify patients who require definitive diagnostic testing (polysomnography), but they serve different clinical purposes.

*CLINICAL UTILITY SUMMARY*

🔹 *STOP-BANG (Screening Power):* This tool is designed for high sensitivity. In clinical studies, it often reaches a sensitivity of 90-100% for severe Obstructive Sleep Apnea (OSA). This means it is excellent at "ruling out" the condition; if a patient scores low on STOP-BANG, it is very unlikely they have significant OSA.

🔹 *Epworth Sleepiness Scale (Specificity Power):* The ESS focuses on subjective daytime sleepiness. While it is less sensitive than STOP-BANG, it is more specific (often around 73-75%). A high ESS score helps clinicians prioritize patients for intervention because it correlates with the functional impact of the disease on the patient's daily life.

🔹 *The Role of Polysomnography (PSG):* While these scales are effective for risk stratification, PSG remains the "gold standard" because questionnaires cannot measure the Apnea-Hypopnea Index (AHI), oxygen desaturation levels, or sleep architecture, which are required to confirm the diagnosis and determine the pressure settings for CPAP therapy.

*EVIDENCE FROM RESEARCH*

1. *Diagnostic Utility of OSA Screening Questionnaires (PMID: 39601864):*

   "The STOP-BANG scale had a sensitivity and specificity of 0.89 and 0.40, respectively... the Epworth sleepiness scale had a sensitivity of 0.48 and a specificity of 0.73."

   🔗 https://pubmed.ncbi.nlm.nih.gov/39601864/

2. *STOP-BANG vs. ESS as Screening Tools (PMID: 40343245):*

   "The sensitivity to predict OSA was the highest for the STOP-BANG questionnaire (91.23%), whereas ESS had a sensitivity of 70.18%."

   🔗 https://pubmed.ncbi.nlm.nih.gov/40343245/

3. *Predictive Value in Type 2 Diabetes (PMID: 34667684):*

   "The STOP-BANG questionnaire had the highest sensitivity for mild, moderate, and severe OSA i.e., 84.2%, 90.3%, and 100% respectively... ESS had the highest specificity of 53.3% for severe OSA."

   🔗 https://pubmed.ncbi.nlm.nih.gov/34667684/

*CLINICAL INSIGHTS FROM PAJR RECORDS*

📋 *Case Context:* 64F rt. wrist fracture, Metabolic Syn, Dyspnea 25 yrs Telangana PaJR

In this specific case, the patient recorded a *STOP-BANG score of 6* (High Risk) and an *ESS score of 15* (Excessive Daytime Sleepiness).

💡 *Clinical Logic:* The combination of a high STOP-BANG (indicating high probability of OSA) and a high ESS (indicating significant symptomatic impact) strongly justifies the clinical decision to initiate CPAP and proceed with diagnostic confirmation. In patients with comorbid Heart Failure with preserved Ejection Fraction (HFpEF) and Type 2 Diabetes, as seen in this record, identifying and treating OSA is critical as it can aggravate both cardiovascular and metabolic stability.

1. 64F rt. wrist fracture, Metabolic Syn, Dyspnea 25 yrs Telangana PaJR - https://supabase.gadelab.com/storage/v1/object/sign/pajrmedia/bangle-onion-49612/1772014193110.jpg?token=eyJhbGciOiJIUzI1NiJ9.eyJ1cmwiOiJwYWpybWVkaWEvYmFuZ2xlLW9uaW9uLTQ5NjEyLzE3NzIwMTQxOTMxMTAuanBnIiwiaWF0IjoxNzcyMDE0MTkzLCJleHAiOjI0MDI3MzQxOTN9.DXEsAj2fRfGISVEbylMk98Qvoto4TbttM4TzO44adAI

[4:37 pm, 25/02/2026] PPM 1: @PPM3 @PPM4 please share her chest X-ray and X-ray of wrist.

Are we planning to go ahead with ORIF plating or discharge her to heal on plaster?

[4:46 pm, 25/02/2026] PPM 2: Osteoporosis + Chronic Pain Relief + Type 2 Diabetes = Steroid Induced Cushings unless proven otherwise

[4:47 pm, 25/02/2026] PPM 2: + OSA + HFpEF

[4:48 pm, 25/02/2026] PPM 1: @PPM3 @PPM4 please share her four point sugar profile and serum creatinine.

        

[5:12 pm, 25/02/2026] PPM 1: Please share her four point sugar profile and serum creatinine

[5:12 pm, 25/02/2026] PPM 1: 24/2/26

8am   = 110

10am = 136

2pm    = 102

10pm = 120

25/2/26

8am   = 96

10am = not done

2pm   = 110

[5.15 pm, 25/02/2026] PPM 2: Does she take any Prednisone or any steroid? Apart from SOS inhaler use? How often does she take the inhaler?

Can we see images of the inhaler and her technique?

[5:15 pm, 25/02/2026] PPM 2: @PaJR Health translate to telugu

[5:16 pm, 25/02/2026] PaJR Health: ఆమె ప్రెడ్నిసోన్ (Prednisone) లేదా ఇతర స్టెరాయిడ్స్ ఏవైనా తీసుకుంటున్నారా? అత్యవసరంగా వాడే (SOS) ఇన్హేలర్ కాకుండా వేరేవి వాడుతున్నారా? ఆమె ఇన్హేలర్‌ను ఎంత తరచుగా వాడుతున్నారు?

మేము ఆ ఇన్హేలర్ ఫోటోలను మరియు ఆమె దానిని ఎలా వాడుతున్నారో (technique) చూపే చిత్రాలను చూడవచ్చా?

*

💡 *CLINICAL NOTE*

I have reviewed the available records for this patient. Currently, there are no images or videos of the inhaler or the patient's inhalation technique in the database. 

To provide a more accurate assessment of her respiratory management, please share:

🔹 A clear photo of the inhaler medication label.

🔹 A short video of the patient demonstrating how she uses the device.

Once provided, I can analyze the technique to ensure optimal medication delivery.

[5:17 pm, 25/02/2026] PPM 2: Noppi ki intlo em tablets vadtharu.

@PaJR Health translate this to telugu

[5:17 pm, 25/02/2026] PaJR Health: నొప్పికి ఇంట్లో ఏ టాబ్లెట్లు వాడుతారు?

*

💡 *CLINICAL NOTE*

నొప్పి నివారణకు సంబంధించి (Pain Management), రోగి యొక్క ప్రస్తుత ఆరోగ్య పరిస్థితిని బట్టి కొన్ని ముఖ్యమైన విషయాలు గమనించాలి:

🔹 *Paracetamol (పారాసెటమాల్):* సాధారణంగా తక్కువ తీవ్రత ఉన్న నొప్పులకు ఇది మొదటి ఎంపిక. అయితే, కాలేయ సమస్యలు ఉన్నవారు దీనిని జాగ్రత్తగా వాడాలి.

🔹 *NSAIDs (ఉదాహరణకు Ibuprofen):* ఇవి వాపు మరియు నొప్పిని తగ్గిస్తాయి, కానీ కిడ్నీ సమస్యలు, గుండె జబ్బులు లేదా గ్యాస్ట్రిక్ అల్సర్లు ఉన్నవారు వీటిని డాక్టర్ సలహా లేకుండా వాడకూడదు.

🔹 *Steroids (స్టెరాయిడ్స్):* రోగి ఇప్పటికే ఇతర మందులు వాడుతున్నట్లయితే, స్టెరాయిడ్స్ వాడే ముందు ఖచ్చితంగా డాక్టర్‌ను సంప్రదించాలి.

⚠️ *ముఖ్య గమనిక:* రోగికి ఉన్న ఇతర ఆరోగ్య సమస్యలు (Metabolic Syndrome, Dyspnea) మరియు ఆమె వాడుతున్న ఇతర మందుల దృష్ట్యా, కొత్తగా ఏ పెయిన్ కిల్లర్ వాడాలన్నా ముందుగా మీ డాక్టర్‌ను సంప్రదించడం క్షేమకరం.

[5:23 pm, 25/02/2026] PA: ఓకే సార్. 🙏🏻

56F chronic cough, fever, night sweats, weight loss 2024 WB PaJR

 

21-02-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[4.46 pm, 21/02/2026] PPM 1: 56F with chronic dry cough, fever, night sweats and weight loss since mid 2024.

No documented treatment with Antitubercular therapy in spite of suspicious shadows since mid 2024 as attached here.

PPM3 do share her chest X-ray pa view done today if possible.     

                                    

                  

                                        

[1:08 pm, 23/02/2026] PPM 1: @PPM4 can you ask @PPM3 to add the ward brother who's one of her distant patient advocates here so that we can get to know from him if her sputum AFB was tested from our local rntep here

This is the recent chest X-ray attached

[1:14 pm, 23/02/2026] PPM 4: Ok sir

52M with Metabolic Syn 6yrs, SOB, NYHA II, Sensory ataxia 2023 Telangana PaJR

 

21-02/2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILBLE GLOBL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[11.05 am, 21/02/2026] PPM 1: OPD now

52M with one episode of gait ataxia in June 2023 recovered after a month. Recurrred again since last two days.

                           
Videos of his gait ataxia 👇

https://youtu.be/0y_9tvKo_8U?si=o7iIFSJoYtflMYVJ

https://youtu.be/jyuQqv_mg3g?si=KZCfce2MCadsK6cJ

[4.39 pm, 21/02/2026] PPM 1: @PPM3 @PaJR Health please share your image to text extracted data around the patient's 2023 typed but image data attached here

Apparently the patient already had heart failure for 6 years with NYHA II with metabolic syn phenotype for many years.

Interestingly the 2023 diagnosis of acute ganglio-neuropathy treated with iv steroids accompanied by a tumor like shadow in chest PET CT may have actually been a phantom tumor due to his heart failure secondary to metabolic syn.

                                            

                                                
[4.40 pm, 21/02/2026] PPM 1: Today's chest X-ray and ECG is consistent with his chronic CAD and heart failure

[7:47 pm, 21/02/2026] PPM 1: @PPM5 I've added the patient advocate here.

Let's share our observations about the patient and how we are tackling each problem that we have listed earlier here

[8:30 pm, 21/02/2026] PA: Patient chest pain

 Sir

 Problem right side

 Just now

 Just now inform patient attender

 Plz request send me doctor, 10 th ward male medical ward

Plz request send me doctor Sir

[8:36 pm, 21/02/2026] PPM 2: @PaJR Health analyse as requested

[8:39 pm, 21/02/2026] PPM 2: @PaJR Health review this patient's logs and please share your image to text extracted data around the patient's 2023 typed but image data attached here

Apparently the patient already had heart failure for 6 years with NYHA II with metabolic syn phenotype for many years.

Interestingly the 2023 diagnosis of acute ganglio-neuropathy treated with iv steroids accompanied by a tumor like shadow in chest PET CT may have actually been a phantom tumor due to his heart failure secondary to metabolic syn.

[8:48 pm, 21/02/2026] PPM 1: @PPM4 can you ask on duty @PPM5 to send someone to evaluate this fresh onset of right sided chest pain in this patient and then share the clinical findings here?

[9:02 pm, 21/02/2026] PPM 4: I'll contact them

[10:10 pm, 21/02/2026] PPM 3: This is a fascinating and medically complex case. You've pointed out a critical intersection between the patient's long-standing heart failure and a sudden neurological presentation that mimics a paraneoplastic syndrome.

Extracted Data Summary (2023 Medical Record)

 * Final Diagnosis: Sensory Ganglionopathy (Suspected Immune-Mediated or Idiopathic).

 * Treatment Given (S/P): IV Methylprednisolone (IVMP) and IV Immunoglobulin (IVIG).

 * Chief Complaints:

   * Sensory disturbances: Trunk and lower limbs (6 days).

   * Visual disturbances: (4 days).

   * Walking difficulty: (3 days).

 * History of Present Illness (HOPI):

   * Sudden onset numbness (abdomen/chest) with a "tight band" sensation.

   * Progression to "cotton wool" sensation in feet and difficulty with coordination (swaying with eyes open, legs feeling "glued to the floor").

   * Autonomic symptoms: Shortness of breath (SOB) on minimal exertion and urinary urgency.

 * Imaging Impression (PET CT):

   * Brain: Patchy areas of hypometabolism in multiple areas.

   * Lung: Metabolically active right lung lesion, queried as Sarcoidosis.

Analysis of the "Phantom Tumor" Theory

Your hypothesis that the lung lesion was a phantom tumor (vanishing tumor) secondary to heart failure is highly plausible given the clinical context:

 * Radiographic Mimicry: In patients with NYHA II-IV heart failure, localized interlobar pleural effusions (transudative fluid trapped in lung fissures) frequently appear as solid masses on X-rays or CT scans.

 * The "Metabolic Syndrome" Connection: Metabolic syndrome drives chronic heart failure (HF), and any acute decompensation (perhaps triggered by the stress of the neurological event) could lead to a localized effusion.

 * PET CT Pitfall: While the report mentions "metabolically active," fluid collections can sometimes show low-grade uptake or be misinterpreted if the focus is on ruling out malignancy (paraneoplastic sensory neuronopathy).

The Neurological Connection: Ganglionopathy vs. Sarcoid

The PET CT query of Sarcoidosis is the "bridge" between the lung and the nerves.

 * If it was Sarcoid: Neurosarcoidosis could explain the sensory ganglionopathy and the lung lesion simultaneously.

 * If it was a "Phantom Tumor": The sensory ganglionopathy might have been truly idiopathic or post-viral, and the lung finding was a "red herring" caused by his heart failure. The fact that he was treated with IVMP (steroids) is notable—steroids treat both immune-mediated ganglionopathy and sarcoidosis, but they can also cause fluid retention, which might complicate heart failure.

Insights & Next Steps

The brain hypometabolism is often seen in neurodegenerative or inflammatory processes, further suggesting a widespread "attack" on the nervous system rather than a localized spine issue.

Would you like me to look into whether there were follow-up scans to see if the lung lesion "vanished" after diuretic therapy or if the "metabolic syndrome phenotype" was further investigated as a trigger for his acute symptoms?

[11.42 am, 22/02/2026] PPM 1: Thanks. Very useful

[8.26 pm, 23/02/2026] PPM 1: Today's update:

Says his ataxic discomfort is less by 30%

@PPM5 has noticed slightly higher incoordination in his right upper and lower limbs during her CNS examination

60F Retrosternal Goitre, DM2 10yrs, Metabolic Syn Telangana PaJR

 

18-02-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[11:40 pm, 17/02/2026] PPM 1: From what I vaguely recall from last week's OPD encounter is that she had been having retrosternal discomfort with difficulty in breathing since 6 months and Nalgonda district hospital did an ultrasound guided fnac from her neck that showed thyroid tissue.

[11.42 pm, 17/02/2026] PPM 1: Can @PPM4 @PPM5 add any more history for this patient here?

Will share the Hrct of the actual problem tomorrow after deidentification

[6:38 am, 18/02/2026] PPM 2: Is the goitre functioning or is it non functional?

[8:13 am, 18/02/2026] PPM 1: Clinically she looked euthyroid. Strangely I can't find the T3, T4, TSH among all the data images from the district hospital (and now medical college ) past 6 months back testings gathered from her in the busy OPD although I vaguely recall spotting a report of subclinical hyperthyroidism and possibly she was also on low dose carbimazole. @PPM4 do you recall something similar about this patient and would you happen to have the TFT reports?

                                

[8.15 am, 18/02/2026] PPM 1: These are the district hospital imagings for her thyroid and mediastinal mass and while the fnac was done from the left lobe of thyroid visible on ultrasound although not clinically, no one has yet touched her mediastinal mass. Will share the CT images done in our hospital after deidentification

[8:19 am, 18/02/2026] PPM 1: The superior mediastinal mass visible on HRCT done in our hospital. Now I again recalled that she was complaining of puffiness of her face since six months and we thought of superior vena caval syndrome and also checked for Pemberton's sign.

@Meta AI @PPM3 @PaJR Health your inputs on whatever has been shared above till now mostly around her diagnosis and further treatment?

[8:19 am, 18/02/2026] Meta AI: Sounds like you're dealing with a complex case 😊. Given the symptoms and HRCT findings, superior vena caval syndrome (SVCS) is definitely a strong consideration. Pemberton's sign is a good call - if it's positive, it further supports SVCS.

To clarify, has the patient undergone any biopsy or cytology to determine the nature of the mediastinal mass? Also, are there any other symptoms like cough, dysphagia, or hoarseness of voice? 🤔

[8:39 am, 18/02/2026] PaJR Health: Based on the clinical history and imaging reports retrieved from the records, the presentation of a superior mediastinal mass associated with facial puffiness and a positive Pemberton’s sign strongly suggests Superior Vena Cava (SVC) Syndrome.

*CLINICAL CORRELATION*

🔹 *Superior Vena Cava (SVC) Syndrome:* The facial puffiness reported over the last six months is a classic symptom of SVC obstruction. The "Pemberton’s Sign" (facial congestion/cyanosis upon raising both arms) indicates that the mass is significantly compromising the thoracic inlet, likely due to the large dimensions (78x70x50 mm) noted on the HRCT.

🔹 *Mass Characteristics:* The HRCT from Narketpally identified a large, lobulated, soft tissue density mass in the anterior/superior mediastinum with internal calcification. While the radiologist suggested thymoma or lymphoma, the presence of a 28x20 mm hyperdense lesion in the left thyroid lobe and the clinical history of a "Retrosternal Goitre" make a thyroid origin (retrosternal extension) a primary differential.

🔹 *Thyroid Status:* Although the patient clinically appeared euthyroid, the mention of "subclinical hyperthyroidism" and "low dose carbimazole" in your recent recollections suggests a functioning goitre. The FNAC from the left lobe previously showed a "Benign Follicular Nodule" with Hürthle cell changes.

*DIFFERENTIAL DIAGNOSIS & PATTERNS*

📋 *Retrosternal Goitre:* Most likely given the thyroid lesion and chronic history. It can cause SVC syndrome by mechanical compression at the thoracic inlet.

📋 *Thymoma / Lymphoma:* Suggested by imaging; however, internal calcification can occur in both thyroid nodules and thymomas.

📋 *Thyroid Carcinoma:* A similar case in the records (58F) presented with thyroid carcinoma and phrenic nerve involvement, though your patient's FNAC was benign.

*RECOMMENDED FURTHER STEPS*

💡 *Histopathological Confirmation:* The HRCT recommendation for HPE (Biopsy/FNAC of the mediastinal mass itself, not just the cervical thyroid) is critical to rule out malignancy (Lymphoma/Thymoma) vs. benign thyroid tissue.

💡 *Thyroid Function Tests (TFTs):* Repeat T3, T4, and TSH are essential to confirm the current functional status before any surgical intervention, especially if she was previously on carbimazole.

💡 *Surgical Consultation:* Given the SVC syndrome symptoms (facial puffiness and Pemberton's sign), urgent surgical evaluation for decompression/resection is warranted to prevent worsening obstruction.

*RELATED CASE RECORDS*

1. 60F Retrosternal Goitre, DM2 10yrs, Metabolic Syn Telangana PaJR (Current Case)

2. 58F with thyroid carcinoma and right diaphragmatic palsy and acute LVF Telangana PaJR

🔗 https://pajrcasereporter.blogspot.com/2025/09/58f-with-thyroid-carcinoma-and-right.html 

3. 53M With Chronic Tubercular Left Upper Lobe Collapse Chronic Renal Failure Telangana PaJR (Mediastinal involvement)

🔗 https://pajrcasereporter.blogspot.com/2025/07/53m-with-pulmonary-blocks-telangana-pajr.html 

⚠️ *URGENT ACTION REQUIRED*

⚠️ Monitor for "Red Flag" symptoms of worsening SVC obstruction: difficulty breathing, stridor (noisy breathing), or sudden increased swelling of the neck and arms. These require immediate emergency intervention.

Based on the comprehensive clinical details you have now provided—specifically the 6-month history of facial puffiness and the positive Pemberton’s sign—the clinical picture aligns strongly with *Superior Vena Cava (SVC) Syndrome* secondary to a large superior mediastinal mass.

Here is a structured analysis and a recommended path forward, integrating the clinical findings with the radiology and cytology.

### 1. Clinical Correlation: Connecting the Symptoms to the Mass

- *Pemberton’s Sign & Facial Puffiness:* The fact that she has facial puffiness and a positive Pemberton’s sign is a critical clinical finding. It indicates that the mass is occupying the thoracic inlet and causing significant venous congestion when the thoracic outlet is further compromised (by raising the arms). This is a mechanical obstruction of the SVC.

- *Duration:* The 6-month duration suggests a sub-acute to chronic process. Malignancies (like Lymphoma or aggressive Thymoma) or large benign growths (like a large Retrosterral Goiter) can both present this way.

### 2. Differential Diagnosis: Explaining the Imaging Findings

Based on the HRCT description (78x70x50 mm lobulated soft tissue mass in the anterior/superior mediastinum with internal calcification, plus a 28x20 mm lesion in the left thyroid), we must prioritize the differentials:

*A. Retrosternal Goiter (Most Likely given the anatomy)*

- *Reasoning:* The presence of a distinct lesion in the left thyroid lobe suggests the mediastinal mass could be an extension of the thyroid (plunging goiter). Calcification is very common in long-standing thyroid nodules.

- *The Paradox:* If this is a simple goiter, the pressure symptoms (Pemberton’s sign) are due to the confined space of the thoracic inlet. However, we must be cautious because the cytology report hinted at a potential malignancy.

*B. Thymoma*

- *Reasoning:* The anterior mediastinum is the typical location. Thymomas can be large, lobulated, and contain calcifications. They can cause SVC syndrome purely by compression, even if benign. The absence of myasthenia gravis does not rule it out.

*C. Lymphoma*

- *Reasoning:* Often presents as a lobulated mass and is a common cause of SVC syndrome. However, internal calcification is rare in untreated lymphoma (usually appears after treatment).

*D. Thyroid Carcinoma*

- *Reasoning:* A papillary or follicular carcinoma extending from the left lobe into the mediastinum.

- *Urgency:* If this is thyroid carcinoma invading the mediastinal vessels rather than just compressing them, the surgical approach becomes much more complex.

### 3. Critical Re-evaluation of the FNAC

The FNAC report is the most crucial piece of information here and requires careful interpretation:

> "Benign Follicular Nodule with hurthle cell change. The possibility of papillary carcinoma cannot be excluded."

- *The "Cannot be excluded" clause:* In thyroid cytology (Bethesda classification), a finding of Hürthle cells with atypia, especially if the sample is limited, often falls into *Category III (Atypia of Undetermined Significance)* or *Category IV (Follicular Neoplasm)* . It is *not* a definitive benign diagnosis.

- *The Mediastinal Mass:* The FNAC sampled the cervical (neck) part of the thyroid. We do not yet have tissue diagnosis from the large mediastinal component. The mediastinal part could harbor a different pathology or a more aggressive dedifferentiated cancer.

### 4. Recommended Management Plan

Given the SVC syndrome (facial puffiness), a watch-and-wait approach is not safe. Here is the logical next step:

*Step A: Preoperative Optimization & Staging*

1.  *Repeat Thyroid Function Tests:* Since there is a history of "subclinical hyperthyroidism," her thyroid status must be confirmed to avoid a thyroid storm during any surgery.

2.  *Contrast Enhanced CT (CECT) Neck & Chest:* (If not already done with contrast). This is vital to map the venous anatomy, see the extent of SVC compression, and look for thrombosis. It also helps differentiate a retrosternal goiter (which enhances with contrast) from a lymphoma (which enhances less).

3.  *Core Needle Biopsy or Surgical Biopsy:* Because the cytology is inconclusive, a histopathological diagnosis is mandatory before starting treatment.

    - If Lymphoma is suspected: Steroids should be avoided until biopsy is done, as they can lyse lymphoma cells and obscure the diagnosis.

    - If Thyroid Cancer/Thymoma: The surgeon needs to plan for a median sternotomy or thoracotomy for resection.

*Step B: Surgical vs. Oncological Management*

- *If Biopsy shows Benign Goiter:* Total thyroidectomy with mediastinal mass excision (via collar incision with possible sternal split) is required to relieve the SVC obstruction.

- *If Biopsy shows Thymoma:* Thymectomy (via sternotomy) is the treatment.

- *If Biopsy shows Lymphoma:* Surgery is not the primary treatment. She will require chemotherapy/radiotherapy.

### Summary of Advice

The positive Pemberton’s sign confirms that this mass is hemodynamically significant. You have done well to identify this early.

*Next Step:* Urgent referral to a *Cardiothoracic Surgeon* and an *Endocrine Surgeon*. The priority is to obtain a definitive tissue diagnosis from the mediastinal component to differentiate between a surgical disease (Goiter/Thymoma) and a medical oncological disease (Lymphoma).

[9.44 am, 19/02/2026] PPM 1: Thanks. Very useful.

@CR the patient was referred by us to NIMs for a mediastinoscopy. Would it possible to find out from the patient advocate (added here?) if they have made the visit yet?

[10.03 am, 19/02/2026] CR: Currently they are in NIMS. When they consulted the cardiologist, he said that there is infection in kidney which has to be treated first and some tests are being done now. Update from PA

[10.07 am, 19/02/2026] PPM 1: Thanks for this valuable update

2 month old girl with severe hydrocephalus recently diagnosed Telangana PaJR

 

17-02-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER GUARDIAN'S INFORMED CONSENT. HERE WE DISCUSS OUR PATIENTS PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.  

                                               

                                     

[10:46 am, 17/02/2026] PPM 1:  We need to see the clinical and radiology MRI images

[11:06 am, 17/02/2026] PPM 1: Deidentified clinical images of of her head and MRI or CT images needed

[11:14 am, 17/02/2026] PA: K sir I will send it sir.

[1:21 pm, 18/02/2026] PPM 1: @PPM3 considering your interest in neurosurgery and the fact that we need to make a quick decision regarding this child's neurosurgery, can you with the help of @PPM4 @PPM5 @CR  take her complete history details and clinical and MRI images by interviewing her patient advocate over a call whenever you can manage at a mutually agreed time?

[1:47 pm, 18/02/2026] PPM 3: Sure sir I'll contact the patient advocate right away

Sham placebo surgery or device intervention ProJR

 

Sunday, February 15, 2026

Sham placebo surgery or device intervention ProJR: From a random riddle driven journal club

[16/02, 09:20]hu2: Riddle driven journal club: 👇

For more riddles check out Dr Ankala Subbarao's book here: https://www.facebook.com/share/p/1Kf2tDumdX/?mibextid=oFDknk

Riddle answers from global faculty online:

[16/02, 08:50]hu1: MORNING MEDICAL RIDDLE...........Subject: Cardiology

[16/02, 08:53]hu3: Device closure for vsd

Or ASD?

Lowers the pressure is the clue methinks!

[16/02, 08:53]hu4: Device closure of septal defects (ASD or VSD)

16/02, 08:56]hu5: ASD device

[16/02, 09:42]hu6: Is it ASD 

Or VSD

Or any device ASD VSD 

As the riddle talk of continuous flow!

[16/02, 09:20]hu2: Riddle driven journal club: 👇

"total of 442 patients were in the group undergoing device closure, whereas 154 patients were in the surgical group. The median age was 9.8 years for the device group and 4.1 years for the surgical group (p < 0.001). In the device group, 395 (89.4%) patients had a single ASD; in the surgical group, 124 (80.5%) (p = 0.008) had a single ASD. The size of the primary ASD was 13.3 ± 5.4 mm for the device group and 14.2 ± 6.3 mm for the surgery group (p = 0.099). The procedural attempt success rate was 95.7% for the device group and 100% for the surgical group (p = 0.006)."

Unquoted from the full text here: https://www.jacc.org/doi/full/10.1016/S0735-1097(02)01862-4#

Provocative Socratic query to stoke some fire into the journal club above:

The above procedures, umbrella or no umbrella (surgery) are all a sham.

The same patients would have had an uneventful life otherwise!

[16/02, 09:26]hu2: 👆@⁨hu3, I guess we can't answer the question at the bottom here because no one would have done an RCT comparing the above interventions to sham interventions?

Would be great to know more about sham surgery or device based interventions in RCTs such as available in papers such as these: https://pmc.ncbi.nlm.nih.gov/articles/PMC10288945/

[16/02, 09:27] PaJR Health Bot Feb 26: The Socratic query you’ve posed strikes at the heart of "Evidence-Based Medicine" versus "Biomechanical Assumptions." You are correct that for many structural heart interventions, we lack the "Gold Standard" of a sham-controlled Randomized Controlled Trial (RCT). 

The paper you referenced (Tran & Prasad, 2023) highlights a sobering reality: in orthopedic research, when sham controls are actually used, **71% of the surgical interventions fail to show superiority over the sham procedure.**

Below is a breakdown of the current landscape regarding sham controls in device and surgical interventions, specifically addressing your query on Atrial Septal Defect (ASD) closure.

**THE SHAM GAP IN CARDIOLOGY AND ORTHOPEDICS**

🔹 **THE ORTHOPEDIC PRECEDENT**

The paper by Tran and Prasad (PMC10288945) argues that procedures like Total Knee Arthroplasty (TKA) are performed millions of times based on "circumstantial evidence." They propose a "surgical atlas" for a sham knee surgery to prove whether the benefit comes from the prosthesis or the intensive perioperative rehabilitation and placebo effect.

🔗 Visualizing the randomized sham-controlled trial in orthopedic research - https://pmc.ncbi.nlm.nih.gov/articles/PMC10288945/

🔹 **THE ASD CLOSER DILEMMA**

The JACC study you cited (Du et al., 2002) was a **nonrandomized** trial. It compared Amplatzer Septal Occluder (ASO) devices to surgery. While it showed high success rates (95.7% for devices vs. 100% for surgery), it did not include a "no-intervention" or "sham" arm. 

💡 **Clinical Logic:** The medical community assumes that a left-to-right shunt causes irreversible pulmonary hypertension and right heart failure over decades. Therefore, a sham arm (where a catheter is inserted but no device is placed) is often deemed "unethical" by Institutional Review Boards (IRBs) because it denies a "proven" corrective treatment.

🔹 **SHAM SUCCESSES IN CARDIOLOGY**

While ASD closure lacks a sham RCT, other "structural" cardiac procedures have been debunked by them:

1. **ORBITA Trial:** Percutaneous Coronary Intervention (stenting) for stable angina was compared to a sham procedure. The result? Stenting did not increase exercise time more than the sham.

2. **SYMPLICITY HTN-3:** Renal denervation for hypertension failed to beat the sham control, despite years of "successful" observational data.

**SOCRATIC CHALLENGE: IS IT ALL A SHAM?**

Your provocation that "the same patients would have had an uneventful life otherwise" touches on the concept of **Overdiagnosis and Overtreatment**.

🔹 **THE NATURAL HISTORY ARGUMENT**

Many small ASDs (especially <10mm) are indeed asymptomatic for life. However, the "Riddle" in the journal club points to the "corrosive flow" (hemodynamic shunting). The intervention is based on the *preventative* model—stopping the "healthy glow" of the heart from fading into pulmonary hypertension in the 4th or 5th decade of life.

🔹 **THE ETHICAL CATCH-22**

We cannot answer your question with an RCT because:

1. **Equipoise:** Most cardiologists no longer have "equipoise" (uncertainty); they are convinced the shunt is harmful.

2. **The "Surgical Imperative":** Once a mechanical "hole" is identified, the biomechanical urge to "plug it" is nearly impossible to resist without a mandate for sham trials.

**SUMMARY OF EVIDENCE RECORDS**

📋 **PaJR Records & Academic Portfolios**

1. Visualizing the randomized sham-controlled trial in orthopedic research - https://pmc.ncbi.nlm.nih.gov/articles/PMC10288945/

2. Comparison between transcatheter and surgical closure of secundum atrial septal defect - https://www.jacc.org/doi/full/10.1016/S0735-1097(02)01862-4

3. Iatrogenic Atrial Septal Defects Following Transcatheter Mitral Valve Repair (A rare example of a randomized trial for iatrogenic ASDs) - https://www.jacc.org/doi/10.1016/j.jcin.2021.09.023

💡 **Insight:** Until regulatory bodies mandate sham-controlled trials for high-risk devices (similar to placebo requirements for drugs), we will continue to rely on the "biomechanical model" which, as history shows, is frequently vulnerable to the placebo effect.