A 90-year-old man presented with a 1-month history of progressive edema in both legs and several episodes of malaise and dizziness that were associated with hypoglycemia. On examination, a nontender epigastric mass was palpated. A plain radiograph of the chest showed a round, irregular opacity inside the gastric chamber and a colonic segment below the right hemidiaphragm (Panel A). Upper gastrointestinal endoscopy revealed a diffusely eroded, exophytic mass arising from the subcardial area (Panel B). Histologic features were consistent with a high-grade, poorly differentiated gastric adenocarcinoma. The patient received a diagnosis of advanced gastric cancer; he was given treatment to alleviate his symptoms and died 5 months later.
Jorge L. Polo, M.D., Ph.D.
Juan C. Porres, M.D., Ph.D.
Fundación Jiménez Díaz, Madrid, Spain
source: nejm.org *Munchausen by Internet* is a pattern of behavior akin to Munchausen syndrome (renamed factitious disorder imposed on self), a psychiatric disorder, wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves. In Munchausen by Internet, users seek attention by feigning illnesses in online venues such as chat rooms, message boards, and Internet Relay Chat (IRC). It is different from catfishing, where the person feigns an identity to seek attention by online dating. The accommodation reflex (or accommodation-convergence reflex) is a reflex action of the eye, in response to focusing on a near object, then looking at a distant object (and vice versa), comprising coordinated changes in vergence, lens shape and pupil size (accommodation). It is dependent on cranial nerve II (afferent limb of reflex), superior centers (interneuron) and cranial nerve III (efferent limb of reflex). The change in the shape of the lens is controlled by the ciliary muscles inside the eye. Changes in contraction of the ciliary muscles alter the focal distance of the eye, causing nearer or farther images to come into focus on the retina; this process is known as accommodation. The reflex, controlled by the parasympathetic nervous system, involves three responses; pupil accommodation, lens accommodation, and convergence.