A Case of Diltiazem-Induced Pustular Rash in an 83-Year-Old Female.

Acute generalized exanthematous pustulosis (AGEP) is a rare, acute skin eruption characterized by the development of numerous nonfollicular sterile pustules. Most cases are caused by drug reactions, among which Diltiazem has been incriminated. Herein, we present an 83-year-old female who presented for evaluation of generalized skin rash 3 days after initiation of Diltiazem. She was eventually diagnosed with AGEP, Diltiazem was discontinued, and systemic steroids were administered with the resolution of symptoms. This case report has the objective of encouraging clinicians to include AGEP in the differential diagnosis of skin eruption following the initiation of Diltiazem.

Complicated Traumatic Pneumothorax Requiring VATS With Lobectomy and Pleurodesis Arising Following SARS-CoV-2 (COVID-19) Recovery.

A case is presented in which COVID-19 pneumonia led a young male patient to develop a pneumothorax requiring lobectomy and pleurodesis after the resolution of COVID-19 pneumonia. The literature review showed a few similar cases with clear evidence suggesting that prior COVID-19 infection may be considered a risk factor for pneumothorax. It is crucial for clinicians to take such risk factors into consideration for better clinical outcomes.

Proportion of thyroid cancer and other cancers in the democratic republic of Congo.

BACKGROUND: Cancer diagnosis is increasing around the world and in the Democratic Republic of the Congo (DRC). The proportion of thyroid cancer has increased over the past three decades. There are very few studies on cancer epidemiology, and in particular on thyroid cancer in the DRC. AIM: To establish the most recent proportion of thyroid cancer in the DRC compared to other cancers. METHODS: This is a retrospective and descriptive study of 6106 consecutive cancer cases listed in the pathological registers of 4 Laboratories in the city of Kinshasa. This study included all cancer cases recorded in the registers between 2005 and 2019. RESULTS: From a sample of 6106 patients, including all cancer types, 68.3% cases were female and 31.7% were male. Breast and cervical cancer were the most common types of cancer in women and, prostate and skin cancer were the most common types in men. Thyroid cancer was sixth in proportion in women and eleventh in men compared to all cancers. Papillary carcinoma was the most common of thyroid cancers. Rare cancers such as anaplastic and medullary thyroid carcinomas had a proportion of 7% and 2%, respectively. CONCLUSION: Newer diagnostic tools led to a surge in cancer diagnoses in the DRC. Thyroid cancer has more than doubled its proportion over the last several decades in the country.

Impact of gut microbiome in the development and treatment of pancreatic cancer: Newer insights.

The gut microbiome plays an important role in the variation of pharmacologic response. This aspect is especially important in the era of precision medicine, where understanding how and to what extent the gut microbiome interacts with drugs and their actions will be key to individualizing therapy. The impact of the composition of the gut microbiome on the efficacy of newer cancer therapies such as immune checkpoint inhibitors and chimeric antigen receptor T-cell treatment has become an active area of research. Pancreatic adenocarcinoma (PAC) has a poor prognosis even in those with potentially resectable disease, and treatment options are very limited. Newer studies have concluded that there is a synergistic effect for immunotherapy in combination with cytotoxic drugs, in the treatment of PAC. A variety of commensal microbiota can affect the efficacy of conventional chemotherapy and immunotherapy by modulating the tumor microenvironment in the treatment of PAC. This review will provide newer insights on the impact that alterations made in the gut microbial system have in the development and treatment of PAC.

Interaction between age and gender on survival outcomes in extramedullary multiple myeloma over the past two decades.

BACKGROUND: Extramedullary multiple myeloma (MM) (EMM) is a rare and aggressive subentity of MM that can be present at diagnosis or develop anytime during the disease course. There is a paucity of data on the clinical characteristics and overall epidemiology of EMM. Furthermore, there is a scarcity of data on how the interaction of age and gender influences the survival of EMM. AIM: To evaluate the clinical characteristics of patients with EMM over the past 2 decades and to identify epidemiologic characteristics that may impact overall prognosis. METHODS: A total of 858 patients diagnosed with EMM, between 2000 and 2017, were ultimately enrolled in our study by retrieving the Surveillance, Epidemiology, and End Results database. We analyzed demographics, clinical characteristics, and overall mortality (OM) as well as cancer-specific mortality (CSM) of EMM. Variables with a P value < 0.1 in the univariate Cox regression were incorporated into the multivariate Cox model to determine the independent prognostic factors, with a hazard ratio (HR) of greater than 1 representing adverse prognostic factors. RESULTS: From a sample of 858 EMM, the male gender (63.25%), age range 60-79 years (51.05%), and non-Hispanic whites (66.78%) were the most represented. Central Nervous System and the vertebral column was the most affected site (33.10%). Crude analysis revealed higher OM in the age group 80+ [HR = 6.951, 95% confidence interval (95%CI): 3.299-14.647, P = 0], Non-Hispanic Black population (HR = 1.339, 95%CI: 1.02-1.759, P = 0.036), Bones not otherwise specified (NOS) (HR = 1.74, 95%CI: 1.043-2.902, P = 0.034), and widowed individuals (HR = 2.107, 95%CI: 1.511-2.938, P = 0). Skin involvement (HR = 0.241, 95%CI: 0.06-0.974, P = 0.046) and a yearly income of $75000+ (HR = 0.259, 95%CI: 0.125-0.538, P = 0) had the lowest OM in the crude analysis. Crude analysis revealed higher CSM in the age group 80+, Non-Hispanic Black, Bones NOS, and widowed. Multivariate cox proportional hazard regression analyses only revealed higher OM in the age group 80+ (HR = 9.792, 95%CI: 4.403-21.774, P = 0) and widowed individuals (HR = 1.609, 95%CI: 1.101-2.35, P = 0.014). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups. Eyes, mouth, and ENT involvement had the lowest CSM in the multivariate analysis. There was no interaction between age and gender in the adjusted analysis for OM and CSM. CONCLUSION: EMM is a rare entity. To our knowledge, there is a scarcity of data on the clinical characteristics and prognosis factors of patients with extramedullary multiple myeloma. In this retrospective cohort, using a United States-based population, we found that age, marital status, and tumor site were independent prognostic factors. Furthermore, we found that age and gender did not interact to influence the mortality of patients with EMM.

Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding: A nationwide analysis.

BACKGROUND: The optimal timing of esophagogastroduodenoscopy (EGD) and the impact of clinico-demographic factors on hospitalization outcomes in non-variceal upper gastrointestinal bleeding (NVUGIB) remains an area of active research. AIM: To identify independent predictors of outcomes in patients with NVUGIB, with a particular focus on EGD timing, anticoagulation (AC) status, and demographic features. METHODS: A retrospective analysis of adult patients with NVUGIB from 2009 to 2014 was performed using validated ICD-9 codes from the National Inpatient Sample database. Patients were stratified by EGD timing relative to hospital admission (≤ 24 h, 24-48 h, 48-72 h, and > 72 h) and then by AC status (yes/no). The primary outcome was all-cause inpatient mortality. Secondary outcomes included healthcare usage. RESULTS: Of the 1082516 patients admitted for NVUGIB, 553186 (51.1%) underwent EGD. The mean time to EGD was 52.8 h. Early (< 24 h from admission) EGD was associated with significantly decreased mortality, less frequent intensive care unit admission, shorter length of hospital stays, lower hospital costs, and an increased likelihood of discharge to home (all with P < 0.001). AC status was not associated with mortality among patients who underwent early EGD (aOR 0.88, P = 0.193). Male sex (OR 1.30) and Hispanic (OR 1.10) or Asian (aOR 1.38) race were also independent predictors of adverse hospitalization outcomes in NVUGIB. CONCLUSION: Based on this large, nationwide study, early EGD in NVUGIB is associated with lower mortality and decreased healthcare usage, irrespective of AC status. These findings may help guide clinical management and would benefit from prospective validation.

A Case Report of Acute Severe Necrotizing Pancreatitis following the Johnson & Johnson Vaccine against the Novel SARS-CoV-2.

Acute pancreatitis is an inflammatory condition, which is a leading gastrointestinal cause of hospitalization in the United States. Several conditions are associated with acute pancreatitis. More recently, there have been a few cases reported of acute pancreatitis following the Pfizer-BioNTech COVID-19 mRNA vaccine. To our knowledge, no cases of acute pancreatitis have been yet reported following the Johnson & Johnson's Janssen COVID-19 vaccine (J& J vaccine). Herein we report a 34-year-old male with no significant past medical history admitted with acute necrotizing pancreatitis, the day following the receipt of the J&J vaccine. Based on the Naranjo and the modified Naranjo scale, the patient met the requirements for probable drug induced pancreatitis. This case report has the objective to raise awareness of a potentially severe side effect of the J&J vaccine. We hope to use this case to support screening all patients for previous history of acute pancreatitis before administration of the J& J vaccine.

Epidemiologic risk factors for patients admitted with chronic pancreatitis and pancreatic ductal adenocarcinoma in the United States.

BACKGROUND: Epidemiological studies of chronic pancreatitis (CP) and its association with pancreatic ductal adenocarcinoma (PDAC) are limited. Understanding demographic and ethno-racial factors may help identify patients at the highest risk for CP and PDAC. AIM: To evaluate the ethno-racial risk factors for CP and its association with PDAC. The secondary aim was to evaluate hospitalization outcomes in patients admitted with CP and PDAC. METHODS: This retrospective cohort study used the 2016 and 2017 National Inpatient Sample databases. Patients included in the study had ICD-10 codes for CP and PDAC. The ethnic, socioeconomic, and racial backgrounds of patients with CP and PDAC were analyzed. RESULTS: Hospital admissions for CP was 29 per 100000, and 2890 (0.78%) had PDAC. Blacks [adjusted odds ratio (aOR) 1.13], men (aOR 1.35), age 40 to 59 (aOR 2.60), and being overweight (aOR 1.34) were significantly associated with CP (all with P < 0.01). In patients with CP, Whites (aOR 1.23), higher income, older age (aOR 1.05), and being overweight (aOR 2.40) were all significantly associated with PDAC (all with P < 0.01). Men (aOR 1.81) and Asians (aOR 15.19) had significantly increased mortality (P < 0.05). Hispanics had significantly increased hospital length of stay (aOR 5.24) (P < 0.05). CONCLUSION: Based on this large, nationwide analysis, black men between 40-59 years old and overweight are at significantly increased risk for admission with CP. White men older than 40 years old and overweight with higher income were found to have significant associations with CP and PDAC. This discrepancy may reflect underlying differences in healthcare access and utilization among different socioeconomic and ethno-racial groups.

A Rare Case of Acquired Bleeding Disorder in a 24-Year-Old Hispanic Female.

Vitamin K is a fat-soluble vitamin that has a major role in coagulation pathways thus its deficiency can lead to major bleeding disorders. Vitamin K deficiency in an otherwise healthy adult is rare. Inadequate oral intake of vitamin K remains the most common cause of vitamin K deficiency. Here, we report a young female who presented for evaluation of heavy menstrual bleeding and was found to be deficient in vitamin K-dependent coagulation factors, with correction upon mixing study. She was diagnosed with vitamin K deficiency due to poor oral intake. With this case, we report a rare and avertible cause of major bleeding to raise awareness among clinicians about patients' daily nutritional requirements.

Management of Newly Diagnosed Chronic Myeloid Leukemia During COVID-19 Hospitalization: A Teaching Case.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by the dysregulated production and uncontrolled proliferation of mature and maturing granulocytes. CML has the potential to cause secondary immunodeficiency in affected patients. COVID-19 infection has been associated with worse outcomes in immunocompromised patients, including patients with hematologic cancers, requiring hospitalization. Herein we present a 61-year-old male with known COVID-19 infection who presented for the evaluation of acute hypoxic respiratory failure and was found to have marked leukocytosis of 125,000. The patient was eventually diagnosed with CML, and his respiratory failure resolved with conventional COVID-19 pneumonia treatment. With this case report, we hope to assist clinicians in the workup of marked leukocytosis in the setting of COVID-19 pneumonia and aim to help clinicians in the management of patients admitted with COVID-19 pneumonia and concomitant CML.

How High Can You Get: A Case Report of an Unusual Cause of Ascending Paralysis.

Secondary hyperkalemic paralysis is a life-threatening manifestation of hyperkalemia seen with a potassium level of 7 or above 7 milliequivalents per liter (Meq/L) in an acute or chronic state. Standard hyperkalemic treatment should be initiated upon diagnosis with emergency dialysis in refractory cases. Here we present the case of a patient with end-stage renal disease (ESRD) compliant with dialysis three times a week. The patient presented with generalized ascending flaccid paralysis and was found to have serum potassium of 9.6 Meq/L. Spontaneous resolution of the paralysis was observed shortly after the completion of one hemodialysis session. The goal of this case report is to raise awareness of a life-threatening complication of electrolyte imbalances in ESRD even in patients that are compliant with dialysis.

IgG4-Related Disease Retroperitoneal Fibrosis: An Unusual Cause of Low Back Pain.

IgG4-related disease (IgG4-RD) is a cluster of rare fibroinflammatory diseases that more commonly affect organs such as major salivary glands, biliary tree, periorbital tissues, kidneys, lungs, lymph nodes, retroperitoneum, and less frequently, meninges, aorta, prostate, thyroid gland, pericardium, and the skin. The clinical picture mainly depends on the affected organ and the effects on the surrounding organs, however, the histopathologic findings are very similar regardless of the organ affected. Most patients have a subclinical presentation of the disease and the only clinical manifestation is related to the anatomic location of the disease, whereas some patients may have constitutional symptoms such as weight loss and are often misdiagnosed as having other pathologies (i.e., malignancies, other inflammatory conditions, etc.). Up to 40 percent of patients can have symptoms of allergy or asthma. Patients often have diseases confined to one organ but multiorgan involvement is not uncommon. Patients with multiple organs involvement can have an elevation of up to 30-40 upper limit of normal serum IgG4 concentration; patients with fewer organ involvement can have normal serum IgG4 concentration despite histopathologic findings of the disease.  Idiopathic retroperitoneal fibrosis (RPF) is a commonly encountered subtype of IgG4-RD. Idiopathic retroperitoneal fibrosis accounts for approximately 70 percent of cases and can be divided into IgG4-RD and non-IgG4-RD. Most cases of RPF are incidental findings on radiology studies but should be suspected in any patients complaining of back pain and flank pain, with new-onset kidney dysfunction.