For whom the bell of proportionality tolls: Three proposals for strengthening proportionality compliance

The State-centric bias in proportionality in international humanitarian law, where non-State armed groups (NSAGs) are expected to adhere to the same rigour of proportionality as States, regardless of how unrealistic that expectation is, has not often been considered in ideas to improve compliance with proportionality. This article puts forth three proposals – a Comprehensive Proportionality Assessment Framework, capacity-building for military actors, and rapid multidisciplinary assessment teams – that aim to reduce State-centric bias and strengthen proportionality compliance not just for States but for all parties to conflict, including NSAGs.

Congenital Epulis: A Two-Case Report

Congenital epulis is a rare benign tumor of the newborn that could be detected in the prenatal period. Females are more often affected than males and the premaxillary region is usually the predilection site for this oral mass. Excision is the treatment of choice and no recurrences have been reported so far. We present our experience with two cases of congenital epulis, detected in the second trimester of gestation and treated shortly after birth with no further complications. Histopathology should differentiate between congenital epulis and other congenital oral tumors even if its clinical appearance is usually enough to make a tentative diagnosis. A multidisciplinary assessment in the management of this tumor can avoid unwanted complications such as airway obstruction or bleeding.

Hypersensitivity Pneumonitis: Diagnostic and Therapeutic Challenges

Hypersensitivity pneumonitis (HP) is one of the most common interstitial lung diseases (ILD), that presents unique challenges for a confident diagnosis and limited therapeutic options. The disease is triggered by exposure to a wide variety of inciting antigens in susceptible individuals which results in T-cell hyperactivation and bronchioloalveolar inflammation. However, the genetic risk and the pathogenic mechanisms remain incompletely elucidated. Revised diagnostic criteria have recently been proposed, recommending to classify the disease in fibrotic and non-fibrotic HP which has strong therapeutic and outcome consequences. Confident diagnosis depends on the presence of clinical features of ILD, identification of the antigen(s), typical images on high-resolution computed tomography (HRCT), characteristic histopathological features, and lymphocytosis in the bronchoalveolar lavage. However, identifying the source of antigen is usually challenging, and HRCT and histopathology are often heterogeneous and not typical, supporting the notion that diagnosis should include a multidisciplinary assessment. Antigen removal and treating the inflammatory process is crucial in the progression of the disease since chronic persistent inflammation seems to be one of the mechanisms leading to lung fibrotic remodeling. Fibrotic HP has a few therapeutic options but evidence of efficacy is still scanty. Deciphering the molecular pathobiology of HP will contribute to open new therapeutic avenues and will provide vital insights in the search for novel diagnostic and prognostic biomarkers.

An evaluation of the Stratford multiagency, multidisciplinary, assessment clinic

Purpose This study aims to assess a novel clinic whereby new patients were discussed in a multi-agency, multi-disciplinary panel and given feedback on the same day. The objectives were to determine the impacts on time to commencing treatment, need for further assessment, discharges and staff and patient experiences. Design/methodology/approach Outcomes from the new assessment clinic were compared to previous individual assessments. Feedback questionnaires were given to patients, while a focus group was conducted with staff. Findings There was a significant reduction in the time to agreeing a treatment plan (34 days to <1 day), the need for further assessment (61%–23.2%) and a significant increase in the proportion discharged from secondary care (26.9%–49.8%). Clinician and patient feedback on the clinic was positive. Practical implications The model of a multi-agency, multi-disciplinary clinic could be used for assessing new referrals to community mental health teams. Originality/value The use of a multi-agency, multi-disciplinary clinic is a novel approach within community mental health teams which led to improvements in efficiency, while demonstrating positive patient and clinician feedback.

Anti-MDA5 Antibody-Positive Interstitial Pneumonia with Autoimmune Features Presenting as Amyopathic Hypodermatitic Dermatomyositis: A Case Report

Dermatomyositis (DM) and its variant, clinically amyopathic DM, are widely recognized entities. DM sine dermatitis, a variant without skin involvement, is less widely reported. DM with neither muscle nor skin manifestations has not been reported. We herein describe the first account of a patient with a myositis-specific antibody presenting with an array of clinical findings in the absence of both muscle and pathognomonic skin disease. This case report details the multidisciplinary assessment of an anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive individual with inflammatory polyarthropathy, mucocutaneous capillary changes, and evidence of interstitial lung disease but lacking overt skin and muscle disease. This presentation is paradoxically but appositely deemed to represent a unique form of DM, which may be best described as “amyopathic hypodermatitic dermatomyositis.” Early recognition and documentation of these cases will help to characterize this variant in the future, determine its frequency, and guide management.