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Cureus May 2024The Van Wyk-Grumbach syndrome (VWGS) (hypothyroidism, ovarian mass, and precocious puberty) has been extensively documented in the literature as long-term hypothyroidism...
The Van Wyk-Grumbach syndrome (VWGS) (hypothyroidism, ovarian mass, and precocious puberty) has been extensively documented in the literature as long-term hypothyroidism manifesting as an ovarian mass. The authors of this study describe this entity in a young girl, aged 10, who presented with abdominal pain with a multiloculated ovarian cyst. She was evaluated, and it was discovered that she had delayed bone age, precocious puberty, and a small height. Following her diagnosis of autoimmune thyroiditis and the initiation of thyroxine replacement therapy, the ovarian cysts spontaneously regressed. To avoid needless assessment and surgical mishaps, this entity should be considered in situations of ovarian mass, particularly those with precocious puberty and thyroid disorders.
PubMed: 38947684
DOI: 10.7759/cureus.61382 -
Cureus May 2024Gastrointestinal (GI) endoscopies are essential for detecting and treating various digestive tract problems. While typically safe, these treatments can entail the risk...
Gastrointestinal (GI) endoscopies are essential for detecting and treating various digestive tract problems. While typically safe, these treatments can entail the risk of severe adverse events (SAEs), especially in individuals with a low body mass index (BMI). The current study aimed to evaluate whether post-endoscopy SAEs are more common in patients with low BMI and find risk factors for serious adverse outcomes in Saudi Arabian patients from Khamis Mushait, Aseer region, Saudi Arabia. The data of 398 adult patients with abdominal endoscopies between April and November 2023 were analyzed. Patients were divided into two groups: low BMI (BMI ≤ 18.5) and control (18.5 ≤ BMI ≤ 30). They were matched for age, gender, comorbidities, endoscopy type, and other pertinent characteristics. Low-BMI patients (Group I, n = 108) were substantially younger and had lower levels of albumin and total protein than the control group (Group II, n = 209). Comorbidities varied between groups, with diabetes mellitus more prevalent in Group II and inflammatory bowel disease (IBD) more commonplace in Group I. Treatment options also differed, with Group I receiving more biological treatments, steroids, and feeding tubes. Endoscopic procedures and indications were comparable among groups, with no significant variations in post-endoscopy complications. The endoscopy results varied from gastritis to colon malignancy, with no SAEs recorded in either group. Unlike earlier findings, this study found no higher incidence of SAEs in low-BMI individuals having abdominal endoscopy. This might be because of the restricted guidelines of different medical authorities, including clear informed consent that illustrates any risks, benefits, alternatives, sedation plan, and potential diagnostic or therapeutic interventions. Also, professional endoscopists and consultants who ensure adequate visualization of the GI mucosa, using mucosal cleansing and insufflation as necessary, should avoid any risk of abdominal hemorrhage. These findings highlight the significance of personalized risk assessment and pre-procedural optimization, including nutritional assistance, in this patient population. More prospective research with larger sample sizes is needed to validate these findings and create targeted techniques for improving outcomes in individuals with a low BMI having endoscopic operations.
PubMed: 38947624
DOI: 10.7759/cureus.61276 -
Cureus May 2024Thymoma and thymic carcinomas are a few of the rarest malignancies seen in humankind. They are mostly seen in the Asian population, many of which are reported in the...
Thymoma and thymic carcinomas are a few of the rarest malignancies seen in humankind. They are mostly seen in the Asian population, many of which are reported in the Southeast Asia region like Japan, China, Vietnam, etc. They usually can be a sequela of other underlying conditions such as myasthenia gravis or some unknown mutations that express later in life. Our patient is a young 41-year-male, a healthy and active individual who presented for evaluation of acute shortness of breath, two months after recovering from SARS-CoV-19 infection. His shortness of breath progressed while on oxygen and diuretics, a Point of Care Ultrasound (POCUS) showed cardiac tamponade and moderate pleural effusion. A Computerized Tomographic (CT) scan of the chest/abdomen/pelvis showed cardiomegaly, pleural effusion, and a mass abutting the heart. A pericardiocentesis revealed malignant cells. Thymic carcinoma was confirmed with a core biopsy and the patient was initiated on treatment rapidly to help improve symptoms and contain the growing mass. .
PubMed: 38947614
DOI: 10.7759/cureus.61455 -
Annals of Coloproctology Jun 2024As introduced, multimodal pain management bundle for ileostomy reversal may be considered to reduce postoperative pain and hospital stay. The aim of this study was to...
PURPOSE
As introduced, multimodal pain management bundle for ileostomy reversal may be considered to reduce postoperative pain and hospital stay. The aim of this study was to evaluate clinical efficacy of perioperative multimodal pain bundle for ileostomy.
METHODS
Medical records of patients who underwent ileostomy reversal after rectal cancer surgery from April 2017 to March 2020 were analyzed. Sixty-seven patients received multimodal pain bundle protocol with ileostomy reversal (group A) and 41 patients underwent closure of ileostomy with conventional pain management (group B).
RESULTS
Baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists classification, diabetes mellitus, and smoking history, were not significantly different between the groups. The pain score on postoperative day 1 was significant lower in group A (visual analog scale, 2.6 ± 1.3 vs. 3.2 ± 1.2; P = 0.013). Overall consumption of opioid in group A was significant less than group B (9.7 ± 9.5 vs. 21.2 ± 8.8, P < 0.001). Hospital stay was significantly shorter in group A (2.3 ± 1.5 days vs. 4.1 ± 1.5 days, P < 0.001). There were no significant differences between the groups in postoperative complication rate.
CONCLUSION
Multimodal pain protocol for ileostomy reversal could reduce postoperative pain, usage of opioid and hospital stay compared to conventional pain management.
PubMed: 38946091
DOI: 10.3393/ac.2022.01137.0162 -
International Journal of Surgery Case... Jun 2024Goblet cell adenocarcinoma of the appendix is a rare diagnosis with features of both adenocarcinomas and carcinoid tumors. Commonly presenting with chronic abdominal...
INTRODUCTION
Goblet cell adenocarcinoma of the appendix is a rare diagnosis with features of both adenocarcinomas and carcinoid tumors. Commonly presenting with chronic abdominal pain, appendicitis, or abdominal distention, it can also be incidentally discovered during appendectomies.
CASE PRESENTATION
A 50-year-old man with right lower abdominal pain was admitted to our hospital, which is a critical care center. A computed tomography(CT) scan showed ileal narrowing, but endoscopy found no strictures. He was admitted with suspected bowel obstruction and improved with an ileal tube. Laparoscopic surgery revealed a tumor of the appendix. Histologically, he was diagnosed goblet cell adenocarcinoma, suggesting tumor infiltration of nerve fibers impairing peristalsis.
DISCUSSION
Goblet cell adenocarcinoma of the appendix has unique histology and a poor prognosis. Treatment typically involves surgery and chemotherapy. This case highlights challenges in preoperative diagnosis, with the tumor causing bowel pseudo-obstruction by invading the intestinal wall and nerve plexus. Extensive infiltration of Auerbach's plexus was observed, consistent with the length of intestinal stenosis.
CONCLUSION
This case describes goblet cell adenocarcinoma of the appendix leading to bowel pseudo-obstruction due to ileal end stenosis. It emphasizes the importance of considering this diagnosis in cases of bowel obstruction without an obvious mass.
PubMed: 38945017
DOI: 10.1016/j.ijscr.2024.109938 -
International Journal of Surgery Case... Jun 2024Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively.
INTRODUCTION
Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively.
PRESENTATION OF CASE
We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility.
DISCUSSION
This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses.
CONCLUSION
BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition.
PubMed: 38945015
DOI: 10.1016/j.ijscr.2024.109863 -
Urology Jun 2024To determine whether early vs. delayed autotransplantation are associated with adverse outcomes in patients undergoing renal autotransplantation.
OBJECTIVE
To determine whether early vs. delayed autotransplantation are associated with adverse outcomes in patients undergoing renal autotransplantation.
METHODS
Patients who underwent renal autotransplantation from June 2012 to September 2022 were divided into two groups based on timing of autotransplant in relation to initial intervention or diagnosis (early cohort: ≤1-year; delayed cohort: >1-year). Primary outcomes were perioperative complications, aborted surgery, renal function (glomerular filtration rate [GFR]), and postoperative complications at most recent follow-up.
RESULTS
Autotransplantation patients (N=72) were predominantly female (68%) and White (54%), with a median age of 49 years. 90% of patients had undergone previous interventions, including stenting (40%) and nephrostomy tubes (49%), primarily for obstruction (64%). Early vs. delayed cohorts had median preoperative disease durations of 143 (IQR 83-222) vs. 673 days (IQR 529-1,703, p<0.001), with similar median follow-up times (879 vs. 818 days, p=0.8). Groups were similar in demographics and comorbidities. There were no significant differences in rates of aborted surgery (15% vs. 4.2%, p=0.3), perioperative complications (15% vs. 17%, p>0.9), long-term complications (49% vs. 48%, p>0.9), or changes in GFR (median change +3 vs. +4, p=0.7). Outcomes were comparable across preoperative disease durations ranging from 6 to 24 months. These findings were confirmed following adjustments for sex, body mass index, American Society of Anesthesiologists classification, race, preoperative creatinine levels, laterality, gastroesophageal reflux disease, diabetes, hypertension, nephrolithiasis, hyperlipidemia, history of colon surgery, urologic surgery, abdominal surgery, and prior interventions in separate logistic models.
CONCLUSIONS
Disease duration before autotransplantation does not influence outcomes, offering reassurance for clinical decision-making in complex cases.
PubMed: 38942394
DOI: 10.1016/j.urology.2024.06.050 -
The Lancet. Oncology Jun 2024The standard of care for patients with intermediate-to-high risk renal cell carcinoma is partial or radical nephrectomy followed by surveillance. We aimed to investigate...
Perioperative nivolumab versus observation in patients with renal cell carcinoma undergoing nephrectomy (PROSPER ECOG-ACRIN EA8143): an open-label, randomised, phase 3 study.
BACKGROUND
The standard of care for patients with intermediate-to-high risk renal cell carcinoma is partial or radical nephrectomy followed by surveillance. We aimed to investigate use of nivolumab before nephrectomy followed by adjuvant nivolumab in patients with high-risk renal cell carcinoma to determine recurrence-free survival compared with surgery only.
METHODS
In this open-label, randomised, phase 3 trial (PROSPER EA8143), patients were recruited from 183 community and academic sites across the USA and Canada. Eligible patients were aged 18 years or older with an Eastern Cooperative Oncology Group performance status of 0-1, with previously untreated clinical stage T2 or greater or T N+ renal cell carcinoma of clear cell or non-clear cell histology planned for partial or radical nephrectomy. Selected patients with oligometastatic disease, who were disease free at other disease sites within 12 weeks of surgery, were eligible for inclusion. We randomly assigned (1:1) patients using permuted blocks (block size of 4) within stratum (clinical TNM stage) to either nivolumab plus surgery, or surgery only followed by surveillance. In the nivolumab group, nivolumab 480 mg was administered before surgery, followed by nine adjuvant doses. The primary endpoint was investigator-reviewed recurrence-free survival in patients with renal cell carcinoma assessed in all randomly assigned patients regardless of histology. Safety was assessed in all randomly assigned patients who started the assigned protocol treatment. This trial is registered with ClinicalTrials.gov, NCT03055013, and is closed to accrual.
FINDINGS
Between Feb 2, 2017, and June 2, 2021, 819 patients were randomly assigned to nivolumab plus surgery (404 [49%]) or surgery only (415 [51%]). 366 (91%) of 404 patients assigned to nivolumab plus surgery and 387 (93%) of 415 patients assigned to surgery only group started treatment. Median age was 61 years (IQR 53-69), 248 (30%) of 819 patients were female, 571 (70%) were male, 672 (88%) were White, and 77 (10%) were Hispanic or Latino. The Data and Safety Monitoring Committee stopped the trial at a planned interim analysis (March 25, 2022) because of futility. Median follow-up was 30·4 months (IQR 21·5-42·4) in the nivolumab group and 30·1 months (21·9-41·8) in the surgery only group. 381 (94%) of 404 patients in the nivolumab plus surgery group and 399 (96%) of 415 in the surgery only group had renal cell carcinoma and were included in the recurrence-free survival analysis. As of data cutoff (May 24, 2023), recurrence-free survival was not significantly different between nivolumab (125 [33%] of 381 had recurrence-free survival events) versus surgery only (133 [33%] of 399; hazard ratio 0·94 [95% CI 0·74-1·21]; one-sided p=0·32). The most common treatment-related grade 3-4 adverse events were elevated lipase (17 [5%] of 366 patients in the nivolumab plus surgery group vs none in the surgery only group), anaemia (seven [2%] vs nine [2%]), increased alanine aminotransferase (ten [3%] vs one [<1%]), abdominal pain (four [1%] vs six [2%]), and increased serum amylase (nine [2%] vs none). 177 (48%) patients in the nivolumab plus surgery group and 93 (24%) in the surgery only group had grade 3-5 adverse events due to any cause, the most common of which were anaemia (23 [6%] vs 19 [5%]), hypertension (27 [7%] vs nine [2%]), and elevated lipase (18 [5%] vs six [2%]). 48 (12%) of 404 patients in the nivolumab group and 40 (10%) of 415 in the surgery only group died, of which eight (2%) and three (1%), respectively, were determined to be treatment-related.
INTERPRETATION
Perioperative nivolumab before nephrectomy followed by adjuvant nivolumab did not improve recurrence-free survival versus surgery only followed by surveillance in patients with high-risk renal cell carcinoma.
FUNDING
US National Institutes of Health National Cancer Institute and Bristol Myers Squibb.
PubMed: 38942046
DOI: 10.1016/S1470-2045(24)00211-0 -
Medicine Jun 2024Although the link between hepatic steatosis and lung function has been confirmed, the focus has largely been on central airways. The association between hepatic... (Observational Study)
Observational Study
Elevated neutrophil-to-lymphocyte ratio combined with decreased lymphocyte-to-monocyte ratio is associated with increased peripheral airway resistance in patients with hepatic steatosis.
Although the link between hepatic steatosis and lung function has been confirmed, the focus has largely been on central airways. The association between hepatic steatosis and increased peripheral airway resistance has not yet been explored. Hepatic steatosis and increased peripheral resistance are connected with immunity dysregulation. High neutrophil-to-lymphocyte ratio (NLR) and low lymphocyte-to-monocyte ratio (LMR) have been recognized as indicators of immunity dysregulation. In this study, the association between hepatic steatosis and increased peripheral airway resistance was evaluated, and the effect of immunity dysregulation (high NLR/low LMR) on the increased peripheral airway resistance among patients with hepatic steatosis was explored. In this retrospective study, chest or abdomen CT scans and spirometry/impulse oscillometry (IOS) from 2018 to 2019 were used to identify hepatic steatosis and increased central/peripheral airway resistance in patients. Among 1391 enrolled patients, 169 (12.1%) had hepatic steatosis. After 1:1 age and abnormal ALT matching was conducted, clinical data were compared between patients with and without hepatic steatosis. A higher proportion of patients with hepatic steatosis had increased peripheral airway resistance than those without hepatic steatosis (52.7% vs 40.2%, P = .025). Old age, high body mass index, history of diabetes, and high NLR/low LMR were significantly correlated with increased peripheral airway resistance. The presence of hepatic steatosis is associated with increased peripheral airway. High NLR/low LMR is an independent associated factor of increased peripheral airway resistance in patients with hepatic steatosis. It is advisable for patients with hepatic steatosis to regularly monitor their complete blood count/differential count and undergo pulmonary function tests including IOS.
Topics: Humans; Male; Female; Middle Aged; Retrospective Studies; Neutrophils; Lymphocytes; Monocytes; Airway Resistance; Fatty Liver; Adult; Aged; Leukocyte Count; Lymphocyte Count
PubMed: 38941417
DOI: 10.1097/MD.0000000000038530 -
PloS One 2024Obesity is a high-morbidity chronic condition and risk factor for multiple diseases that necessitate imaging. This study assesses the relationship between BMI and...
OBJECTIVE
Obesity is a high-morbidity chronic condition and risk factor for multiple diseases that necessitate imaging. This study assesses the relationship between BMI and same-year utilization of CT and MR imaging in a large healthcare population.
METHODS
In this retrospective population-based study, all patients aged ≥18 years with a documented BMI in the multi-institutional Cosmos database were included. Cohorts were identified based on ≥1 documented BMI in 2021 within pre-defined ranges. For each cohort, we assessed the percentage of patients undergoing head, neck, chest, spine, or abdomen/pelvis CT and MR during the same year. Disease severity was quantified based on emergency department (ED) visits and mortality.
RESULTS
In our population of 49.6 million patients, same-year CT and MR utilization was 14.5 ±0.01% and 6.0±0.01%, respectively. The underweight cohort had the highest CT (25.8±0.1%) and MR (8.01 ± 0.05) imaging utilization. At high extremes of BMI (>50 kg/m2), CT utilization mildly increased (18.4±0.1%), but MR utilization decreased (5.3±0.04%). While morbidity differences may explain some BMI-utilization relationships, lower MR utilization in the BMI>50 cohort contrasts with higher age-adjusted mortality (1.8±0.03%) and ED utilization (32.4±0.1%) in this cohort relative to normal weight (1.5±0.01% and 25.7±0.02%, respectively).
CONCLUSION
Underweight patients had disproportionately high CT/MR utilization, and high extremes of BMI are associated with mildly higher CT and lower MR utilization than the normal weight cohort. The elevated mortality and ED utilization in severely obese patients contrasts with their lower MR imaging utilization. Our findings may assist public health efforts to accommodate obesity trends.
Topics: Humans; Body Mass Index; Magnetic Resonance Imaging; Male; Female; Tomography, X-Ray Computed; Middle Aged; Retrospective Studies; Adult; Obesity; Aged; Emergency Service, Hospital; Morbidity
PubMed: 38941332
DOI: 10.1371/journal.pone.0306087