Outpatient insulin use in type 2 diabetes mellitus and acute respiratory distress syndrome outcomes: A retrospective cohort study.

BACKGROUND: The impact of type 2 diabetes mellitus (T2DM) on acute respiratory distress syndrome (ARDS) is debatable. T2DM was suspected to reduce the risk and complications of ARDS. However, during coronavirus disease 2019 (COVID-19), T2DM predisposed patients to ARDS, especially those who were on insulin at home. AIM: To evaluate the impact of outpatient insulin use in T2DM patients on non-COVID-19 ARDS outcomes. METHODS: We conducted a retrospective cohort analysis using the Nationwide Inpatient Sample database. Adult patients diagnosed with ARDS were stratified into insulin-dependent diabetes mellitus (DM) (IDDM) and non-insulin-dependent DM (NIDDM) groups. After applying exclusion criteria and matching over 20 variables, we compared cohorts for mortality, duration of mechanical ventilation, incidence of acute kidney injury (AKI), length of stay (LOS), hospitalization costs, and other clinical outcomes. RESULTS: Following 1:1 propensity score matching, the analysis included 274 patients in each group. Notably, no statistically significant differences emerged between the IDDM and NIDDM groups in terms of mortality rates (32.8% vs 31.0%, P = 0.520), median hospital LOS (10 d, P = 0.537), requirement for mechanical ventilation, incidence rates of sepsis, pneumonia or AKI, median total hospitalization costs, or patient disposition upon discharge. CONCLUSION: Compared to alternative anti-diabetic medications, outpatient insulin treatment does not appear to exert an independent influence on in-hospital morbidity or mortality in diabetic patients with non-COVID-19 ARDS.

The Determinants of Eosinophilia in Patients With Severe Asthma.

Background: Asthma is defined by the Global Initiative for Asthma (GINA) as a heterogeneous disease characterized by chronic airway inflammation. The pathogenesis of the disease is better understood with the comprehension of immunological pathways. These pathways differ by the type of recruited cells and released interleukin (IL). Thus, asthma can be classified into subtypes based on the underlying immune mechanism: eosinophilic asthma (EA) and non-eosinophilic asthma (NEA). Patients with EA tend to respond better to inhaled corticosteroid as compared to those with NEA. The distinction of EA is very important in the light of emergent type 2 inflammation targeted therapies. Methods: We performed a 1-year (2018) retrospective cohort analysis of the Nationwide Inpatient Database (NIS). We included all adult patients presenting with severe asthma. Patients were stratified into two groups: eosinophilic severe asthma and non-eosinophilic severe asthma. The primary outcomes measures were the prevalence of chronic steroid use, status asthmaticus, family history of asthma, food, drug and environmental allergies, presence of nasal polyps, allergic rhinitis, allergic dermatitis, need for mechanical ventilation, need for oxygen supplementation, gastroesophageal reflux disease, in-hospital mortality, and length of stay. We performed descriptive statistics. Continuous parametric variables were reported using a mean and standard deviation. Continuous nonparametric variables were reported using a median and interquartile range. To compare the characteristics of the two groups, we used the independent t-test for continuous parametric variables and the Mann-Whitney U test for continuous nonparametric variables. The Chi-square test was used to assess differences in categorical variables. Results: A total of 2,646 patients were included, out of which 882 belonged to the eosinophilic group and 1,764 were in the non-eosinophilic group. Comparing EA versus NEA, we have found that eosinophilic group was characterized by higher percentage of steroid use (18.3% vs. 9.5%, P < 0.001). This group also had higher rates of status asthmaticus and positive family history (P = 0.009 and 0.004, respectively). The presence of allergies, allergic rhinitis, nasal polyps, and allergic dermatitis was higher among patients with eosinophilia. The need for mechanical ventilation and supplemental oxygen was also higher among this group (P < 0.001 for both); however, there was no significant difference in mortality rate (P = 0.347) and the length of hospital stay was similar in both groups (P < 0.001). Conclusion: We showed herein that the eosinophilic subtype of asthma differs widely from the non-eosinophilic phenotype. Clinically, patients with eosinophilia might exhibit different symptomatology, more atopy, and concomitant comorbidities. However, this group might have better response to steroid therapy and might benefit from the new emergent T2 immune targeted therapy. The identification of EA is crucial for better disease control.

The calcium-clot connection: investigating the association between primary hyperparathyroidism and acute venous thromboembolism.

Primary hyperthyroidism (PHPT) is a relatively uncommon disease and leads to increased calcium levels. Ionized calcium, known as clotting Factor IV, may lead to overt coagulation cascade activation, increasing the risk of venous thromboembolism (VTE). National Inpatient Sample Database was used to sample individuals with primary hyperparathyroidism, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data and age less than 18 were excluded. Moreover, patients with other types of hyperparathyroidism and risk factors for VTE, such as malignancy, thrombophilia, chronic kidney and liver disease, fractures, trauma, oral contraceptive/steroid use, and organ transplant, were excluded. Greedy propensity matching using R was performed to match patients with and without primary hyperparathyroidism on age, race, gender, and 10 other comorbidities, including chronic deep venous thromboembolism. Univariate analysis pre- and post-match were performed. Binary logistic regression was performed after matching to assess whether primary hyperparathyroidism was an independent risk factor for acute VTE. A p-value of < 0.05 was considered statistically significant. Out of 460,529 patients included in the study, 1114 (6.5%) had PHPT. Baseline comorbidities were more common in the PHPT group. On univariate analysis, patients with PHPT were more likely to have acute VTE (2.5% vs. 1.4%; p < 0.001). After 1:1 matching, PHPT patients were twice as likely to have Acute VTE. (OR: 2.1 [1.08-4.1]; p < 0.025). These findings suggest an association between PHPT and VTE, which should be further investigated to prevent the increasing incidence of VTE and its recurrence.

Machine learning: Predicting hospital length of stay in patients admitted for lupus flares.

BACKGROUND: Although rare, severe systemic lupus erythematosus (SLE) flares requiring hospitalization account for most of the direct costs of SLE care. New machine learning (ML) methods may optimize lupus care by predicting which patients will have a prolonged hospital length of stay (LOS). Our study uses a machine learning approach to predict the LOS in patients admitted for lupus flares and assesses which features prolong LOS. METHODS: Our study sampled 5831 patients admitted for lupus flares from the National Inpatient Sample Database 2016-2018 and collected 90 demographics and comorbidity features. Four machine learning (ML) models were built (XGBoost, Linear Support Vector Machines, K Nearest Neighbors, and Logistic Regression) to predict LOS, and their performance was evaluated using multiple metrics, including accuracy, receiver operator area under the curve (ROC-AUC), precision-recall area under the curve (PR- AUC), and F1-score. Using the highest-performing model (XGBoost), we assessed the feature importance of our input features using Shapley value explanations (SHAP) to rank their impact on LOS. RESULTS: Our XGB model performed the best with a ROC-AUC of 0.87, PR-AUC of 0.61, an F1 score of 0.56, and an accuracy of 95%. The features with the most significant impact on the model were "the need for a central line," "acute dialysis," and "acute renal failure." Other top features include those related to renal and infectious comorbidities. CONCLUSION: Our results were consistent with the established literature and showed promise in ML over traditional methods of predictive analyses, even with rare rheumatic events such as lupus flare hospitalizations.

Metastatic melanoma to the lung cured with lobectomy: A case report.

We herein present the case of a 79-year-old female patient who presents with a single asymptomatic pulmonary nodule, melanocytic in nature, later identified as a remote secondary lesion of a primary cutaneous melanoma that was resected 22 years before presentation. Although quite atypical, the patient underwent resection of the affected pulmonary lobe; follow-up imaging did not reveal any local or distant recurrences.

Novel breakthroughs in advanced prostate cancer management.

INTRODUCTION: Although PSA screening has been rationalized, prostate cancer continues to have the highest incidence rate in 2021, and alone accounts for 26% of cancer diagnoses in men. A thorough review of the medical literature highlights a vast array of approved and investigational treatments for prostate cancer. Thus, selecting the best treatment option for the appropriate patient at the right time is crucial. Hence, biomarkers help in defining optimal patient stratification, revealing potential processes through which a drug might exert its impact and aid in the tailoring of treatments for efficient personalized medicine. AREAS COVERED: This article is a pragmatic review of novel prostate cancer therapies that can help guide clinicians in tackling prostate cancer with the latest treatments. EXPERT OPINION: Local radiotherapy has proven to be a game changer for low burden, de novo metastatic prostate cancer. Androgen deprivation therapy continues to be the ultimate treatment. Delaying resistance to these agents will undoubtedly be a breakthrough in the treatment of prostate cancer. When it comes to metastatic castrate-resistant disease, treatment options become narrower. PARP inhibitors and N-terminal domain inhibitors offer new hope and have a synergistic effect, with immunotherapy adding promising agents to the therapeutic arsenal.

Gemella endocarditis.

We herein present the case presenting to our facility complaining of a fever of two months duration, who underwent dental procedure. Patient was diagnosed with infective endocarditis secondary to an uncommon bacteria: Gemella haemolysans. Patient was found to have concomitant severe mitral valve regurgitation. Our patient did not have any comorbidity or risk factor beside his dental procedure. Our patient received intravenous antibiotic therapy for six weeks and was scheduled for mitral valve replacement.

Intraparenchymal Hemorrhage: A Fatal Presentation of Undiagnosed Acute Myelogenous Leukemia.

We present the case of a 73-year-old patient who was admitted to the neurocritical care unit with spontaneous intracerebral hemorrhage (ICH). Upon further investigation, she was found to have hyperleukocytosis and thrombocytopenia due to acute myelogenous leukemia (AML), likely resulting in coagulopathy, vessel friability, and consequential intraparenchymal bleed. Prior reports of AML presenting with ICH are scant in the literature. As such, a heightened awareness of such a phenomenon is recommended for rapid detection and appropriate tailored management. This hopefully would, in turn, optimize outcomes.

Endobronchial Chondroma: A Rare Case of Benign Tumor With Atypical High Standardized Uptake Value.

Chondroma is a rare benign tumor of the cartilage and occurs in the tracheobronchial tree, either isolated or as part of the Carney triad. It has been sparsely described in the literature, and some were mislabeled as hamartomas. We herein report a case of a 63-year-old female who was initially treated for community-acquired right middle lobe pneumonia. However, the patient's symptoms persisted warranting further workup, which confirmed the diagnosis of post-obstructive pneumonia. Whole-body positron emission tomography (PET) scan showed a hypermetabolic soft tissue lesion within the middle lobe bronchus, with a standardized uptake value (SUV) of 5.4, which is highly concerning for a primary or a secondary lesion. Since no distant lesions were identified, the patient underwent bronchial sleeve lobectomy of the right middle lobe under the assumption of localized disease. Pathology revealed chondroma, which had an unexpectedly high SUV on the PET scan; follow-up imaging denied any recurrence. Our case presents a rare entity of bronchial tumors with high SUV that presented with post-obstructive pneumonia. The patient's consent for writing this report was obtained.

Duodenocaval Fistula: A Spontaneous Complication of Chemoradiation Therapy in Stage III Ovarian Cancer.

Duodenocaval fistula (DCF) is a rare entity which is sparsely described in the literature. Few etiologies have been listed including chemoradiation therapy. Early recognition may reduce the high mortality rate. We describe the case of a 63-year-old woman with a history of stage III ovarian cancer treated with cytoreductive surgery and adjuvant chemotherapy, including bevacizumab, who presented to the hospital because of fresh blood per rectum. One month earlier, the patient was admitted to the intensive care unit because of hemorrhagic shock secondary to a necrotic duodenal ulcer and was treated with cauterization. The patient was stable when discharged home, however, she was readmitted to the hospital because of hematemesis and hematochezia and was again in hemorrhagic shock for which the patient was urgently transfused. An abdominal computerized tomography (CT) angiography demonstrated locules of air within the intrahepatic and infrahepatic inferior vena cava (IVC), as well as evidence of communication with the duodenal lumen, and a thrombus within the IVC. The patient was evaluated by the surgical oncology and vascular teams, who deemed the patient inoperable. Our case describes ovarian malignancy, treated by radiation, leading to duodenitis, with subsequent ulcer formation. The co-administration of bevacizumab delayed gastric healing and promoted ulcer perforation favoring fistula formation.

A Case of Primary Sternomanubrial Osteomyelitis With Oxacillin-Resistant Staphylococcus aureus (ORSA) Bacteremia.

We herein report the case of a previously healthy 26-year-old male patient who presented to our hospital with chest pain and fevers. Investigations revealed oxacillin-resistant Staphylococcus aureus (ORSA) osteomyelitis of the manubrium, for which no inciting event or background was identified, classifying it as primary sternomanubrial osteomyelitis (PSO). The patient was appropriately treated with intravenous antibiotics, resulting in clinical improvement. The sternomanubrial site without trauma has rarely been described in the literature.

HER2 in gastric adenocarcinoma: where do we stand today?

Aim:HER2 is a proto-oncogene expressed in 10-30% of gastric adenocarcinomas and is an ideal target for inhibition in malignancy with high recurrence and dismal survival rates. Materials & methods: A systematic search was conducted via PubMed, Google Scholar and the clinicaltrials.gov database to report the results of ongoing and past studies investigating HER2 inhibitors in gastric cancer. Results: Twenty-five studies were included; ToGA trial is the pivotal trial approving the use of trastuzumab in metastatic gastric cancer, followed by more studies investigating other HER2 inhibitors in this setting, as well as in local and locoregional malignancy. Conclusion: Anti-HER2 molecules are proving efficacy and safety in gastric cancer; the evidence is growing and association with other cancer agents is under investigation.

Lay abstract Targeted therapies are experiencing tremendous growth. HER2 is a receptor that sometimes can be present on the surface of malignant cells; when activated, it favors their proliferation and tumor growth. Thus, inactivating this receptor would be an ideal target, inhibitors are widely approved for breast cancer. The indication of the same drugs is expanding in gastric cancer, first in metastatic cancer, and growing in the localized and locoregional setting. This article highlights the studies investigating HER2 inhibitors in gastric cancer, proving their efficacy and convenience.

Spontaneous Pneumothorax: A Tale of Two Unique Cases.

We herein present two cases of spontaneous pneumothorax. The first one is occurring in an elderly female who has an extensive history of smoking and an underlying chronic obstructive lung disease, whereas the second case represents a congenital bleb in a male patient who has no other underlying pulmonary disorder. Both cases presented to our facility with a spontaneous pneumothorax following pulmonary bleb rupture. Both patients underwent thoracoscopic surgery with subsequent partial pleurectomy and pleurodesis.

Checkpoint inhibitors in BCG-unresponsive nonmuscle invasive bladder cancer: can they help spare the bladder?

Intravesical BCG therapy has been for years, the standard of care in nonmuscle-invasive bladder cancer. But upon recurrence/relapse, radical cystectomy is imposed, due to the paucity of other therapeutic options. Immunotherapy has been revolutionizing cancer treatment, and its indications continue to broaden. It has been approved for the treatment of advanced urothelial cancer of the bladder, mainly as a second-line therapy. Its activity is being studied in nonmuscle-invasive bladder cancer that is not responsive to BCG; we herein report the trials investigating these checkpoint inhibitors (pembrolizumab, nivolumab, atezolizumab, durvalumab and avelumab) in this particular setting.

Lay abstract Administration of BCG vaccine inside the bladder has, for a long time, been the treatment of bladder cancer that has not invaded the layers of this organ, or at least has not arrived at the muscle of the bladder. However, when this cancer recurs or has not responded to this type of treatment, radical cystectomy (i.e., complete removal of the bladder) is imposed. While the latter is associated with significant decrease in quality of life, and when immunotherapy (therapy that relies on immune white blood cells combatting tumor cells) has shown promising results in metastatic bladder cancer, trials are ongoing to prove the potential benefits of this novel therapy in confined, but not responsive to BCG, bladder cancer. In this article, we report these studies, highlighting the most important ones that are, if not already, leading to approval of immunotherapy in this setting.