Pub Date : 2015-11-01DOI: 10.4103/1947-2714.170600
A. Mirrakhimov
Hypercalcemia of malignancy is a common finding typically found in patients with advanced stage cancers. We aimed to provide an updated review on the etiology, pathogenesis, clinical presentation, and management of malignancy-related hypercalcemia. We searched PubMed/Medline, Scopus, Embase, and Web of Science for original articles, case reports, and case series articles focused on hypercalcemia of malignancy published from 1950 to December 2014. Hypercalcemia of malignancy usually presents with markedly elevated calcium levels and therefore, usually severely symptomatic. Several major mechanisms are responsible for the development of hypercalcemia of malignancy including parathyroid hormone-related peptide-mediated humoral hypercalcemia, osteolytic metastases-related hypercalcemia, 1,25 Vitamin D-mediated hypercalcemia, and parathyroid hormone-mediated hypercalcemia in patients with parathyroid carcinoma and extra parathyroid cancers. Diagnosis should include the history and physical examination as well as measurement of the above mediators of hypercalcemia. Management includes hydration, calcitonin, bisphosphonates, denosumab, and in certain patients, prednisone and cinacalcet. Patients with advanced underlying kidney disease and refractory severe hypercalcemia should be considered for hemodialysis. Hematology or oncology and palliative care specialists should be involved early to guide the options of cancer targeted therapies and help the patients and their closed ones with the discussion of comfort-oriented care.
恶性肿瘤高钙血症是一种常见的发现,通常在晚期癌症患者中发现。我们旨在提供恶性肿瘤相关高钙血症的病因、发病机制、临床表现和治疗的最新综述。我们检索了PubMed/Medline、Scopus、Embase和Web of Science,检索了1950年至2014年12月发表的关于恶性肿瘤高钙血症的原创文章、病例报告和病例系列文章。恶性肿瘤的高钙血症通常表现为钙水平明显升高,因此通常症状严重。恶性肿瘤高钙血症发生的主要机制包括甲状旁腺癌和甲状旁腺癌患者中甲状旁腺激素相关肽介导的体液性高钙血症、溶骨转移相关的高钙血症、1,25维生素d介导的高钙血症和甲状旁腺激素介导的高钙血症。诊断应包括病史和体格检查以及上述高钙血症介质的测定。治疗包括水合作用、降钙素、双膦酸盐、地诺单抗,某些患者使用强的松和cinacalcet。晚期潜在肾脏疾病和难治性严重高钙血症患者应考虑进行血液透析。血液学或肿瘤学和姑息治疗专家应该尽早参与指导癌症靶向治疗的选择,并帮助患者和他们的亲人讨论以舒适为导向的护理。
{"title":"Hypercalcemia of Malignancy: An Update on Pathogenesis and Management","authors":"A. Mirrakhimov","doi":"10.4103/1947-2714.170600","DOIUrl":"https://doi.org/10.4103/1947-2714.170600","url":null,"abstract":"Hypercalcemia of malignancy is a common finding typically found in patients with advanced stage cancers. We aimed to provide an updated review on the etiology, pathogenesis, clinical presentation, and management of malignancy-related hypercalcemia. We searched PubMed/Medline, Scopus, Embase, and Web of Science for original articles, case reports, and case series articles focused on hypercalcemia of malignancy published from 1950 to December 2014. Hypercalcemia of malignancy usually presents with markedly elevated calcium levels and therefore, usually severely symptomatic. Several major mechanisms are responsible for the development of hypercalcemia of malignancy including parathyroid hormone-related peptide-mediated humoral hypercalcemia, osteolytic metastases-related hypercalcemia, 1,25 Vitamin D-mediated hypercalcemia, and parathyroid hormone-mediated hypercalcemia in patients with parathyroid carcinoma and extra parathyroid cancers. Diagnosis should include the history and physical examination as well as measurement of the above mediators of hypercalcemia. Management includes hydration, calcitonin, bisphosphonates, denosumab, and in certain patients, prednisone and cinacalcet. Patients with advanced underlying kidney disease and refractory severe hypercalcemia should be considered for hemodialysis. Hematology or oncology and palliative care specialists should be involved early to guide the options of cancer targeted therapies and help the patients and their closed ones with the discussion of comfort-oriented care.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"26 1","pages":"483 - 493"},"PeriodicalIF":0.0,"publicationDate":"2015-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74407813","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-11-01DOI: 10.4103/1947-2714.170608
S. Nazarbaghi, M. R. Amiri-Nikpour, R. Mahmodlou, Nasim Arjmand, Yousef Rezaei
Background: Despite the widespread use of thymectomy in myasthenia gravis (MG) patients, it has remained controversial as to whether this procedure is of a similar efficacy and clinical outcome among MG patients with thymoma and thymic hyperplasia. Aim: We sought to determine the long-term clinical outcomes of MG patients who received extended transsternal thymectomy associated with pyridostigmine and prednisolone postoperatively. Materials and Methods: In a retrospective study from January 1999 to December 2013, MG patients who underwent thymectomy were followed up. Out of 41 MG patients admitted in our center, 25 patients had undergone thymectomy adjunctive to pyridostigmine and prednisolone therapy postoperatively. The primary endpoints included improvement in individual diplopia, ptosis, dysphagia, dysarthria, dyspnea, and limb weakness. In addition, according to the MG Foundation of America (MGFA) criteria, response to therapy was defined as complete stable remission (CSR), pharmacologic remission (PR), and minimal manifestation (MM) as secondary endpoints. Results: Majority of the patients were male (60%) and the mean age of the patients was 32.2 ± 13.9 years. Fifteen (60%) and 10 patients (40%) had thymoma and thymic hyperplasia, respectively. All the patients were followed up during a mean period of of 86.9 ± 50.3 months (minimum 10 months and maximum 168 months). The rates of CSR, PR, and MM were comparable between the thymoma and thymic hyperplasia groups (P = 0.584). Based on the Kaplan Meier analysis, the probabilities of CSR, PR, and MM were not significantly different between patients with thymoma and thymic hyperplasia. Conclusion: The extended transsternal thymectomy, along with the postoperative regimen of pyridostigmine and prednisolone was associated with a high rate of clinical improvement among MG patients with thymoma or thymic hyperplasia.
{"title":"Clinical Outcomes of Myasthenia Gravis with Thymoma and Thymic Hyperplasia Undergoing Extended Transsternal Thymectomy: A Single-Center Experience","authors":"S. Nazarbaghi, M. R. Amiri-Nikpour, R. Mahmodlou, Nasim Arjmand, Yousef Rezaei","doi":"10.4103/1947-2714.170608","DOIUrl":"https://doi.org/10.4103/1947-2714.170608","url":null,"abstract":"Background: Despite the widespread use of thymectomy in myasthenia gravis (MG) patients, it has remained controversial as to whether this procedure is of a similar efficacy and clinical outcome among MG patients with thymoma and thymic hyperplasia. Aim: We sought to determine the long-term clinical outcomes of MG patients who received extended transsternal thymectomy associated with pyridostigmine and prednisolone postoperatively. Materials and Methods: In a retrospective study from January 1999 to December 2013, MG patients who underwent thymectomy were followed up. Out of 41 MG patients admitted in our center, 25 patients had undergone thymectomy adjunctive to pyridostigmine and prednisolone therapy postoperatively. The primary endpoints included improvement in individual diplopia, ptosis, dysphagia, dysarthria, dyspnea, and limb weakness. In addition, according to the MG Foundation of America (MGFA) criteria, response to therapy was defined as complete stable remission (CSR), pharmacologic remission (PR), and minimal manifestation (MM) as secondary endpoints. Results: Majority of the patients were male (60%) and the mean age of the patients was 32.2 ± 13.9 years. Fifteen (60%) and 10 patients (40%) had thymoma and thymic hyperplasia, respectively. All the patients were followed up during a mean period of of 86.9 ± 50.3 months (minimum 10 months and maximum 168 months). The rates of CSR, PR, and MM were comparable between the thymoma and thymic hyperplasia groups (P = 0.584). Based on the Kaplan Meier analysis, the probabilities of CSR, PR, and MM were not significantly different between patients with thymoma and thymic hyperplasia. Conclusion: The extended transsternal thymectomy, along with the postoperative regimen of pyridostigmine and prednisolone was associated with a high rate of clinical improvement among MG patients with thymoma or thymic hyperplasia.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"43 1","pages":"503 - 508"},"PeriodicalIF":0.0,"publicationDate":"2015-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74427631","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-11-01DOI: 10.4103/1947-2714.170624
Bharivi Jani, Fadi Rzouq, S. Saligram, A. Nawabi, Marian Nicola, Katie Dennis, Carly Ernst, Ali Abbaszadeh, John A Bonino, M. Olyaee
Context: Groove pancreatitis is a rare form of chronic pancreatitis affecting the "groove" of the pancreas among the pancreatic head, duodenum, and common bile duct. The exact cause is unknown, although there are associations with long-term alcohol abuse, smoking, peptic ulcer disease, heterotopic pancreas, gastric resection, biliary disease, and anatomical or functional obstruction of the minor papilla. The diagnosis can be challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography are the preferred imaging modalities. The treatment of choice is conservative although surgical intervention can sometimes be required. Case Report: A 57-year-old male with a history of human immunodeficiency virus and hepatitis B presented with 4 days of epigastric pain. Abdominal exam revealed absent bowel sounds and epigastric tenderness. He had a creatinine of 1.72 mg/dL, potassium of 2.9 mmol/L, and a normal lipase level of 86 U/L. Liver enzymes and total bilirubin were normal. Computed tomography abdomen showed high-grade obstruction of the second portion of the duodenum without any obvious mass. An esophagogastroduodenoscopy showed a mass at the duodenal bulb causing luminal narrowing, with biopsies negative for malignancy. Magnetic resonance imaging revealed a mass in the region of the pancreatic head and descending duodenum. EUS revealed a 3 cm mass in the region of pancreatic head with irregular borders and no vascular invasion. Fine needle aspiration (FNA) was nondiagnostic. The patient then underwent a Whipple′s procedure. Pathology of these specimens was negative for malignancy but was consistent with para-duodenal or groove pancreatitis. Conclusion: The low incidence of groove pancreatitis is partly due to lack of familiarity with the disease. Groove pancreatitis should be considered in the differential for patients presenting with pancreatic head lesions and no cholestatic jaundice, especially when a duodenal obstruction is present, and neither duodenal biopsies nor pancreatic head FNA confirm adenocarcinoma.
{"title":"Groove Pancreatitis: A Rare form of Chronic Pancreatitis","authors":"Bharivi Jani, Fadi Rzouq, S. Saligram, A. Nawabi, Marian Nicola, Katie Dennis, Carly Ernst, Ali Abbaszadeh, John A Bonino, M. Olyaee","doi":"10.4103/1947-2714.170624","DOIUrl":"https://doi.org/10.4103/1947-2714.170624","url":null,"abstract":"Context: Groove pancreatitis is a rare form of chronic pancreatitis affecting the \"groove\" of the pancreas among the pancreatic head, duodenum, and common bile duct. The exact cause is unknown, although there are associations with long-term alcohol abuse, smoking, peptic ulcer disease, heterotopic pancreas, gastric resection, biliary disease, and anatomical or functional obstruction of the minor papilla. The diagnosis can be challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography are the preferred imaging modalities. The treatment of choice is conservative although surgical intervention can sometimes be required. Case Report: A 57-year-old male with a history of human immunodeficiency virus and hepatitis B presented with 4 days of epigastric pain. Abdominal exam revealed absent bowel sounds and epigastric tenderness. He had a creatinine of 1.72 mg/dL, potassium of 2.9 mmol/L, and a normal lipase level of 86 U/L. Liver enzymes and total bilirubin were normal. Computed tomography abdomen showed high-grade obstruction of the second portion of the duodenum without any obvious mass. An esophagogastroduodenoscopy showed a mass at the duodenal bulb causing luminal narrowing, with biopsies negative for malignancy. Magnetic resonance imaging revealed a mass in the region of the pancreatic head and descending duodenum. EUS revealed a 3 cm mass in the region of pancreatic head with irregular borders and no vascular invasion. Fine needle aspiration (FNA) was nondiagnostic. The patient then underwent a Whipple′s procedure. Pathology of these specimens was negative for malignancy but was consistent with para-duodenal or groove pancreatitis. Conclusion: The low incidence of groove pancreatitis is partly due to lack of familiarity with the disease. Groove pancreatitis should be considered in the differential for patients presenting with pancreatic head lesions and no cholestatic jaundice, especially when a duodenal obstruction is present, and neither duodenal biopsies nor pancreatic head FNA confirm adenocarcinoma.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"48 1","pages":"529 - 532"},"PeriodicalIF":0.0,"publicationDate":"2015-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79855458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-11-01DOI: 10.4103/1947-2714.170606
P. Karmacharya, R. Pathak, Sailu Ghimire, P. Shrestha, Sushil Ghimire, D. Poudel, Raju Khanal, Shirin Shah, M. Aryal, R. Alweis
Upper airway hematoma (UAH) is a rare but life-threatening complication of oral anticoagulants requiring early recognition. However, no consensus exists regarding the best approach to treatment. We therefore, sought to systematically review the published literature on UAH to elaborate its demographic and clinical characteristics, treatment, complications, and outcomes. A systematic electronic search of PubMed and EMBASE for case reports, case series, and related articles of UAH related to warfarin published from inception (November 1950) to March 2015 was carried out. Categorical variables were expressed as percentage and continuous variables as mean ± standard deviation (SD). Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0.All cases were reported to have UAH as a complication of anticoagulation therapy with warfarin. Demographic and clinical characteristics, treatment, complications and outcomes of UAH were studied. Thirty-eight cases of UAH were identified from 34 reports in the literature. No gender preponderance (male = 52.78%) was seen and the average age of presentation was 60.11 ± 12.50 years. Dysphagia, sore throat, and neck swelling were the most common symptoms and the mean international normalized ratio (INR)at presentation was 8.07 ± 4.04. Most cases had sublingual hematoma (66.57%) followed by retropharyngeal hematoma (27.03%). Of the cases, 48.65% were managed conservatively while the rest underwent either cricothyrotomy or intubation with the time to resolution being 7.69 ± 5.44 days. UAH is a rare butpotentially serious complication of warfarin therapy. It is more common in the elderly population with supratherapeutic INR; inciting events were present in many cases. Overall, it has a good prognosis with significant morbidity present only if concomitant respiratory compromise is present. Reversal of anticoagulation with low threshold for artificial airway placement in the event of airway compromise leads to a favorable outcome in most cases.
{"title":"Upper Airway Hematoma Secondary to Warfarin Therapy: A Systematic Review of Reported Cases","authors":"P. Karmacharya, R. Pathak, Sailu Ghimire, P. Shrestha, Sushil Ghimire, D. Poudel, Raju Khanal, Shirin Shah, M. Aryal, R. Alweis","doi":"10.4103/1947-2714.170606","DOIUrl":"https://doi.org/10.4103/1947-2714.170606","url":null,"abstract":"Upper airway hematoma (UAH) is a rare but life-threatening complication of oral anticoagulants requiring early recognition. However, no consensus exists regarding the best approach to treatment. We therefore, sought to systematically review the published literature on UAH to elaborate its demographic and clinical characteristics, treatment, complications, and outcomes. A systematic electronic search of PubMed and EMBASE for case reports, case series, and related articles of UAH related to warfarin published from inception (November 1950) to March 2015 was carried out. Categorical variables were expressed as percentage and continuous variables as mean ± standard deviation (SD). Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0.All cases were reported to have UAH as a complication of anticoagulation therapy with warfarin. Demographic and clinical characteristics, treatment, complications and outcomes of UAH were studied. Thirty-eight cases of UAH were identified from 34 reports in the literature. No gender preponderance (male = 52.78%) was seen and the average age of presentation was 60.11 ± 12.50 years. Dysphagia, sore throat, and neck swelling were the most common symptoms and the mean international normalized ratio (INR)at presentation was 8.07 ± 4.04. Most cases had sublingual hematoma (66.57%) followed by retropharyngeal hematoma (27.03%). Of the cases, 48.65% were managed conservatively while the rest underwent either cricothyrotomy or intubation with the time to resolution being 7.69 ± 5.44 days. UAH is a rare butpotentially serious complication of warfarin therapy. It is more common in the elderly population with supratherapeutic INR; inciting events were present in many cases. Overall, it has a good prognosis with significant morbidity present only if concomitant respiratory compromise is present. Reversal of anticoagulation with low threshold for artificial airway placement in the event of airway compromise leads to a favorable outcome in most cases.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"59 1","pages":"494 - 502"},"PeriodicalIF":0.0,"publicationDate":"2015-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86459591","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-11-01DOI: 10.4103/1947-2714.170629
E. Nwose, P. Bwititi
Dear Editor, In a recent Case Study article, Thawabi and Studyvin reported two cases of euglycemic diabetic ketoacidosis (euglycemic DKA) that were misleading at initial presentation.[1] The authors meticulously attended to the patients, including performing physical examinations and requesting robust pathology tests. It is established that DKA is a complex metabolic disorder and that understanding the pathophysiology is essential for optimal management.[2,3] It is important to mention that DKA is a clinical condition that has recently generated debate over its dysfunctional metabolic basis,[4,5] and it is pertinent to highlight that ketonuria can be absent or masked by alkalosis in some cases.[6] Therefore, there could be false negative ketonuria with normoglycemia, and without other biochemistry criteria it is possible to miss a diagnosis of DKA. It has been recommended that “careful search for the precipitating cause … and that patient education incorporating a variety of healthcare beliefs and socioeconomic issues are critical to an effective prevention program,”[3] and the significance and success of preventive mechanisms have been reported.[7,8] The pathophysiology of DKA is comprised of four causes, which are dehydration, fasting, insulin deficiency, and stress hormone excess; and it needs to be emphasized that “stress in any form can lead to metabolic decompensation.”[9] What is being brought to the fore is the apparent difficulty to adopt guidelines and the need for careful search for the precipitating cause, especially in the low-mid-income communities (LMIC). In other words, it is pertinent to appreciate in the report of Thawabi and Studyvin the following: Some of what was done may be difficult to do in LMIC. What can be done, which is feasible in LMIC? What was done, which may be difficult to do in LMIC: For instance, the clinical biochemistry profile for diagnosis of DKA shows blood glucose greater than 200 mg/dL, blood ketone level greater than 3 mmol/L with positive ketonuria, and venous bicarbonate <15 mEq/L or pH <7.3.[6,10] The authors assessed arterial pH, perhaps as part of blood investigations including partial pressure of carbon dioxide (pCO2). It is easier to collect venous samples and it is known that arterial and venous pH compare well.[11,12] Thus, where collection of arterial blood is a challenge, venous pH can be measured. Reports of this nature have implications for LMIC: It is arguable that clinical practice guidelines are neither rules nor procedures to comply with and, by default, clinicians in the LMIC may not have the resources to implement such guidelines. Hence, some communities lack access to modern health-care services such as blood gas analyzers. The implication is that if a patient presents with euglycemia, where the resources to perform blood gas analysis as well as ketonemia tests are unavailable, a clinician may be subjected to make diagnosis of DKA based on keton
{"title":"Misleading Presentation of Euglycemic Diabetic Ketoacidosis: Implication for Low-Mid-Income Communities","authors":"E. Nwose, P. Bwititi","doi":"10.4103/1947-2714.170629","DOIUrl":"https://doi.org/10.4103/1947-2714.170629","url":null,"abstract":"Dear Editor, \u0000 \u0000In a recent Case Study article, Thawabi and Studyvin reported two cases of euglycemic diabetic ketoacidosis (euglycemic DKA) that were misleading at initial presentation.[1] The authors meticulously attended to the patients, including performing physical examinations and requesting robust pathology tests. \u0000 \u0000It is established that DKA is a complex metabolic disorder and that understanding the pathophysiology is essential for optimal management.[2,3] It is important to mention that DKA is a clinical condition that has recently generated debate over its dysfunctional metabolic basis,[4,5] and it is pertinent to highlight that ketonuria can be absent or masked by alkalosis in some cases.[6] Therefore, there could be false negative ketonuria with normoglycemia, and without other biochemistry criteria it is possible to miss a diagnosis of DKA. \u0000 \u0000It has been recommended that “careful search for the precipitating cause … and that patient education incorporating a variety of healthcare beliefs and socioeconomic issues are critical to an effective prevention program,”[3] and the significance and success of preventive mechanisms have been reported.[7,8] The pathophysiology of DKA is comprised of four causes, which are dehydration, fasting, insulin deficiency, and stress hormone excess; and it needs to be emphasized that “stress in any form can lead to metabolic decompensation.”[9] What is being brought to the fore is the apparent difficulty to adopt guidelines and the need for careful search for the precipitating cause, especially in the low-mid-income communities (LMIC). In other words, it is pertinent to appreciate in the report of Thawabi and Studyvin the following: \u0000 \u0000 \u0000 \u0000 \u0000 \u0000Some of what was done may be difficult to do in LMIC. \u0000 \u0000 \u0000What can be done, which is feasible in LMIC? \u0000 \u0000 \u0000 \u0000 \u0000 \u0000 \u0000What was done, which may be difficult to do in LMIC: For instance, the clinical biochemistry profile for diagnosis of DKA shows blood glucose greater than 200 mg/dL, blood ketone level greater than 3 mmol/L with positive ketonuria, and venous bicarbonate <15 mEq/L or pH <7.3.[6,10] The authors assessed arterial pH, perhaps as part of blood investigations including partial pressure of carbon dioxide (pCO2). It is easier to collect venous samples and it is known that arterial and venous pH compare well.[11,12] Thus, where collection of arterial blood is a challenge, venous pH can be measured. \u0000 \u0000Reports of this nature have implications for LMIC: It is arguable that clinical practice guidelines are neither rules nor procedures to comply with and, by default, clinicians in the LMIC may not have the resources to implement such guidelines. Hence, some communities lack access to modern health-care services such as blood gas analyzers. The implication is that if a patient presents with euglycemia, where the resources to perform blood gas analysis as well as ketonemia tests are unavailable, a clinician may be subjected to make diagnosis of DKA based on keton","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"75 1","pages":"537 - 539"},"PeriodicalIF":0.0,"publicationDate":"2015-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74081889","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-10-01DOI: 10.4103/1947-2714.168677
S. Gulati, C. Kiefer, N. Karim
Context: Lung cancers are known to metastasize to unusual sites. Despite this knowledge often times the diagnosis of a primary lung cancer gets delayed especially when the patient presents without respiratory symptoms. Case Report: The patient discussed in our review is a 47-year-old female, smoker who had presented to several hospitals with months of headache, nausea and intermittent episodes of vomiting. She was noted to have hypernatremia due to diabetes insipidus and a pituitary lesion on her magnetic resonance images. The pituitary mass on biopsy was found to represent a metastatic focus from a primary lung adenocarcinoma. Conclusion: Clinicians should be aware of malignancies that are well known to metastasize to the posterior pituitary. Conversely, since not every patient presents with symptoms of metastasis, there is a need to recognize the clinical syndromes (e. g., diabetes insipidus-like symptoms or more subtle symptoms like cranial nerve palsies) associated with potential metastasis to the pituitary.
{"title":"Diabetes Insipidus: An Unusual Presentation of Adenocarcinoma of the Lung in a Patient with no Identifiable Lung Mass","authors":"S. Gulati, C. Kiefer, N. Karim","doi":"10.4103/1947-2714.168677","DOIUrl":"https://doi.org/10.4103/1947-2714.168677","url":null,"abstract":"Context: Lung cancers are known to metastasize to unusual sites. Despite this knowledge often times the diagnosis of a primary lung cancer gets delayed especially when the patient presents without respiratory symptoms. Case Report: The patient discussed in our review is a 47-year-old female, smoker who had presented to several hospitals with months of headache, nausea and intermittent episodes of vomiting. She was noted to have hypernatremia due to diabetes insipidus and a pituitary lesion on her magnetic resonance images. The pituitary mass on biopsy was found to represent a metastatic focus from a primary lung adenocarcinoma. Conclusion: Clinicians should be aware of malignancies that are well known to metastasize to the posterior pituitary. Conversely, since not every patient presents with symptoms of metastasis, there is a need to recognize the clinical syndromes (e. g., diabetes insipidus-like symptoms or more subtle symptoms like cranial nerve palsies) associated with potential metastasis to the pituitary.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"41 1","pages":"476 - 479"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74200132","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-10-01DOI: 10.4103/1947-2714.168678
H. Al-khalisy, I. Nikiforov, Qurat Mansoora, J. Goldman, P. Cheriyath
Septic arthritis of the temporomandibular joint (TMJ) is a rare event that has only been reported a few dozen times worldwide. This case is remarkable for septic arthritis of the TMJ joint in an otherwise healthy male. Case Report: A 24-year-old male presented to the emergency department with periauricular swelling, erythema, fever, myalgia′s and generalized joint pain. He had previously sought medical attention and was placed on ciprofloxacin. However, he developed facial swelling and a rash and had to discontinue the antibiotic. On physical exam the patient had a large swelling and tenderness in his left periauricular area, with erythema and deviation of the right mandible which limited his ability to open the mouth. A computed tomography showed mild asymmetric soft tissue swelling in the left pharyngeal region but did not show joint effusion. Subsequent magnetic resonance imaging did show effusion of the joint space. The effusion was drained, and the synovial fluid was submitted for gram stain, culture, and sensitivity. The cultures grew menthicillin sensitive Staphyloccocus Aureus. The patient was discharged to complete a two week course of intravenous (IV) Ceftriaxone and IV Vancomycin via home infusion. Conclusion: Septic Arthritis of the TMJ is a rare event with very specific clinical symptoms. Due to the low sensitivity of the computed tomography scan, magnetic resonance imaging should be considered when computed tomography scan is negative for TMJ effusion.
{"title":"Septic Arthritis in the Temporomandibular Joint","authors":"H. Al-khalisy, I. Nikiforov, Qurat Mansoora, J. Goldman, P. Cheriyath","doi":"10.4103/1947-2714.168678","DOIUrl":"https://doi.org/10.4103/1947-2714.168678","url":null,"abstract":"Septic arthritis of the temporomandibular joint (TMJ) is a rare event that has only been reported a few dozen times worldwide. This case is remarkable for septic arthritis of the TMJ joint in an otherwise healthy male. Case Report: A 24-year-old male presented to the emergency department with periauricular swelling, erythema, fever, myalgia′s and generalized joint pain. He had previously sought medical attention and was placed on ciprofloxacin. However, he developed facial swelling and a rash and had to discontinue the antibiotic. On physical exam the patient had a large swelling and tenderness in his left periauricular area, with erythema and deviation of the right mandible which limited his ability to open the mouth. A computed tomography showed mild asymmetric soft tissue swelling in the left pharyngeal region but did not show joint effusion. Subsequent magnetic resonance imaging did show effusion of the joint space. The effusion was drained, and the synovial fluid was submitted for gram stain, culture, and sensitivity. The cultures grew menthicillin sensitive Staphyloccocus Aureus. The patient was discharged to complete a two week course of intravenous (IV) Ceftriaxone and IV Vancomycin via home infusion. Conclusion: Septic Arthritis of the TMJ is a rare event with very specific clinical symptoms. Due to the low sensitivity of the computed tomography scan, magnetic resonance imaging should be considered when computed tomography scan is negative for TMJ effusion.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"38 1","pages":"480 - 482"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85573271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-10-01DOI: 10.4103/1947-2714.168669
N. Abel, K. Contino, N. Jain, N. Grewal, Elizabeth Grand, I. Hagans, K. Hunter, Satyajeet Roy
Background: Hypertension is a common medical disease, occurring in about one third of young adults and almost two thirds of individuals over the age of 60. With the release of the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC-8) guidelines, there have been major changes in blood pressure management in the various subgroups. Aim: Optimal blood pressure management and markers of end-organ damage in African-American adult patients were compared between patients who were managed according to the JNC-8 hypertension management guidelines and those who were treated with other regimens. Materials and Methods: African-American patients aged 18 years or older with an established diagnosis of hypertension were included in the study who were followed up in our internal medicine clinic between January 1, 2013 and December 31, 2103; the data on their systolic and diastolic blood pressure readings, heart rate, body mass index (BMI), age, gender, comorbidities, and medications were recorded. Patients were divided into four groups based on the antihypertensive therapy as follows - Group 1: Diuretic only; Group 2: Calcium channel blocker (CCB) only; Group 3: Diuretic and CCB; Group 4: Other antihypertensive agent. Their blood pressure control, comorbidities, and associated target organ damage were analyzed. Results: In all 323 patients, blood pressures were optimally controlled. The majority of the patients (79.6%) were treated with either a diuretic, a CCB, or both. Intergroup comparison analysis showed no statistically significant difference in the mean systolic blood pressure, mean diastolic blood pressure, associated comorbidities, or frequency of target organ damage. Conclusion: Although diuretics or CCBs are recommended as first-line agents in African-American patients, we found no significant difference in the optimal control of blood pressure and frequency of end-organ damage compared to management with other agents.
{"title":"Eighth Joint National Committee (JNC-8) Guidelines and the Outpatient Management of Hypertension in the African-American Population","authors":"N. Abel, K. Contino, N. Jain, N. Grewal, Elizabeth Grand, I. Hagans, K. Hunter, Satyajeet Roy","doi":"10.4103/1947-2714.168669","DOIUrl":"https://doi.org/10.4103/1947-2714.168669","url":null,"abstract":"Background: Hypertension is a common medical disease, occurring in about one third of young adults and almost two thirds of individuals over the age of 60. With the release of the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC-8) guidelines, there have been major changes in blood pressure management in the various subgroups. Aim: Optimal blood pressure management and markers of end-organ damage in African-American adult patients were compared between patients who were managed according to the JNC-8 hypertension management guidelines and those who were treated with other regimens. Materials and Methods: African-American patients aged 18 years or older with an established diagnosis of hypertension were included in the study who were followed up in our internal medicine clinic between January 1, 2013 and December 31, 2103; the data on their systolic and diastolic blood pressure readings, heart rate, body mass index (BMI), age, gender, comorbidities, and medications were recorded. Patients were divided into four groups based on the antihypertensive therapy as follows - Group 1: Diuretic only; Group 2: Calcium channel blocker (CCB) only; Group 3: Diuretic and CCB; Group 4: Other antihypertensive agent. Their blood pressure control, comorbidities, and associated target organ damage were analyzed. Results: In all 323 patients, blood pressures were optimally controlled. The majority of the patients (79.6%) were treated with either a diuretic, a CCB, or both. Intergroup comparison analysis showed no statistically significant difference in the mean systolic blood pressure, mean diastolic blood pressure, associated comorbidities, or frequency of target organ damage. Conclusion: Although diuretics or CCBs are recommended as first-line agents in African-American patients, we found no significant difference in the optimal control of blood pressure and frequency of end-organ damage compared to management with other agents.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"3 1","pages":"438 - 445"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87839108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-10-01DOI: 10.4103/1947-2714.168673
M. Ashmaig
Background: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. Cytokeratins (CKs) which may also be expressed in vascular smooth muscle cells (SMCs) are generally considered to be markers for the differentiation of epithelial cells. Small, dense, low-density lipoprotein (sdLDL) particles, also termed LDL-IV, independently predict risk of CVD. Aims: The aims of this study were to develop an analytical method, apart from ultracentrifugation capable of isolating sdLDL in order to study any associated proteins. Materials and Methods: Using modified gradient gel electrophoresis (GGE), de-identified sdLDL-enriched plasma was used to physically elute and isolate sdLDL particles. To validate the finding, additional plasma from 77 normal and 48 higher risk subjects were used to measure sdLDL particles and CK8. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting method were used to identify the characteristics of proteins associated with sdLDL. An enzyme-linked immunosorbent assay (ELISA) method was developed and validated for the measurement of CK8 in plasma. Results: The validation of the CK8 ELISA method showed good analytical performance. The isolated sdLDL particles were verified with nondenaturing GGE with the apolipoprotein B component confirmed by Western immunoblotting. Confirmed by SDS-PAGE and Western immunoblotting, CK8 was associated with sdLDL. Two-tailed statistical analysis showed that CK8 and sdLDL particles were significantly higher in the high-risk CVD group compared to control group (P < 0.01 and P < 0.01, respectively). Conclusion: This study reports a novel association between CK8 and sdLDL in individuals with CVD who have a predominance of sdLDL.
{"title":"Cytokeratin 8 in Association with sdLDL and ELISA Development","authors":"M. Ashmaig","doi":"10.4103/1947-2714.168673","DOIUrl":"https://doi.org/10.4103/1947-2714.168673","url":null,"abstract":"Background: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. Cytokeratins (CKs) which may also be expressed in vascular smooth muscle cells (SMCs) are generally considered to be markers for the differentiation of epithelial cells. Small, dense, low-density lipoprotein (sdLDL) particles, also termed LDL-IV, independently predict risk of CVD. Aims: The aims of this study were to develop an analytical method, apart from ultracentrifugation capable of isolating sdLDL in order to study any associated proteins. Materials and Methods: Using modified gradient gel electrophoresis (GGE), de-identified sdLDL-enriched plasma was used to physically elute and isolate sdLDL particles. To validate the finding, additional plasma from 77 normal and 48 higher risk subjects were used to measure sdLDL particles and CK8. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting method were used to identify the characteristics of proteins associated with sdLDL. An enzyme-linked immunosorbent assay (ELISA) method was developed and validated for the measurement of CK8 in plasma. Results: The validation of the CK8 ELISA method showed good analytical performance. The isolated sdLDL particles were verified with nondenaturing GGE with the apolipoprotein B component confirmed by Western immunoblotting. Confirmed by SDS-PAGE and Western immunoblotting, CK8 was associated with sdLDL. Two-tailed statistical analysis showed that CK8 and sdLDL particles were significantly higher in the high-risk CVD group compared to control group (P < 0.01 and P < 0.01, respectively). Conclusion: This study reports a novel association between CK8 and sdLDL in individuals with CVD who have a predominance of sdLDL.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"20 1","pages":"459 - 466"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78203500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-10-01DOI: 10.4103/1947-2714.168657
C. Shenoy, M. Shenoy, Gururaja Rao
Dyslipidemias are one of the common metabolic disorders. A link between dermatological disorders like psoriasis and dyslipidemia has been established in the recent past. Many dermatological disorders could have a systemic inflammatory component which explains such association. Chronic inflammatory dermatological disorders could also have other metabolic imbalances that may contribute to dyslipidemia. Presence of such abnormal metabolism may justify routine screening of these disorders for associated dyslipidemia and other metabolic abnormalities and early treatment of such comorbidities to improve quality of life. Some of the drugs used by dermatologists such as retinoids are also likely to be a cause of dyslipidemia. Hence, it is imperative that the dermatologists obtain scientific knowledge on the underlying mechanisms involved in dyslipidemia and understand when to intervene with therapies. A systematic review of the English language literature was done by using Google Scholar and PubMed. In this review, attempts are made to list the dermatological disorders associated with dyslipidemia; to simplify the understanding of underlying mechanisms; and to give a brief idea about the interventions.
{"title":"Dyslipidemia in Dermatological Disorders","authors":"C. Shenoy, M. Shenoy, Gururaja Rao","doi":"10.4103/1947-2714.168657","DOIUrl":"https://doi.org/10.4103/1947-2714.168657","url":null,"abstract":"Dyslipidemias are one of the common metabolic disorders. A link between dermatological disorders like psoriasis and dyslipidemia has been established in the recent past. Many dermatological disorders could have a systemic inflammatory component which explains such association. Chronic inflammatory dermatological disorders could also have other metabolic imbalances that may contribute to dyslipidemia. Presence of such abnormal metabolism may justify routine screening of these disorders for associated dyslipidemia and other metabolic abnormalities and early treatment of such comorbidities to improve quality of life. Some of the drugs used by dermatologists such as retinoids are also likely to be a cause of dyslipidemia. Hence, it is imperative that the dermatologists obtain scientific knowledge on the underlying mechanisms involved in dyslipidemia and understand when to intervene with therapies. A systematic review of the English language literature was done by using Google Scholar and PubMed. In this review, attempts are made to list the dermatological disorders associated with dyslipidemia; to simplify the understanding of underlying mechanisms; and to give a brief idea about the interventions.","PeriodicalId":19703,"journal":{"name":"North American Journal of Medical Sciences","volume":"132 1","pages":"421 - 428"},"PeriodicalIF":0.0,"publicationDate":"2015-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85403829","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}