A Rare Case of Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia: A Case Report.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare pulmonary disease characterized by the diffuse proliferation of neuroendocrine cells in the bronchial epithelium. It is considered a preinvasive precursor to carcinoid tumors and usually presents with obstructive symptoms. We present the case of a 71-year-old female, non-smoker, with a past medical history of asthma, osteoarthritis, allergic rhinitis, and hyperlipidemia who was referred to the pulmonology clinic in view of incidental chest CT findings of multiple pulmonary nodules. Physical examination and labs were unremarkable. CT of the chest showed scattered multiple noncalcified pulmonary nodules with a 10 mm dominant nodule in the inferior right middle lobe and several subcentimeter hypodensities in the left and right lobes of the lung. A PET scan confirmed the CT findings along with no abnormal hypermetabolic activity to suggest malignancy. The patient was followed up in the pulmonology clinic at six months, 12 months, and then 18 months. At 18 months owing to a slight increase in the size of the largest lung nodule, a CT-guided biopsy done was conclusive of a carcinoid. The tumor cells were positive for synaptophysin, chromogranin, insulinoma-associated protein 1 (INSM-1), and thyroid transcription factor 1 (TTF-1). The Ki-67 (Keil) index was <1%. A video-assisted thoracic surgery with right middle lobectomy along with mediastinal lymph node dissection was then done, and the patient was found to have stage pT1aN0 typical carcinoid tumor (1.0 cm), with multiple carcinoid tumors and neuroendocrine hyperplasia, consistent with DIPNECH. She has been under clinical follow-up for over three years at present and continues to be asymptomatic with complete remission following surgery. DIPNECH primarily affects middle-aged, non-smoking females who present with cough and dyspnea, and diagnosis is often delayed due to clinical features overlapping with those of obstructive lung disease. Imaging shows lung nodules, ground-glass opacities, and/or mosaic attenuation. Due to the rarity of the conditions, there are no established clinical trials, and therefore, there is a need to establish guidelines.

Assay Interference Causing Persistently Elevated Vancomycin Levels Leading to Treatment Failure and Fatal Outcome.

In patients receiving vancomycin therapy, serum drug levels are routinely monitored to ensure therapeutic dosing and minimize toxicity. In rare cases, vancomycin levels may be falsely or persistently elevated without any apparent cause. In this case report, we explore a rare case of persistently elevated vancomycin levels despite discontinuation of the drug for days.  This is a case of a 69-year-old female admitted for altered mental status secondary to sepsis from leg cellulitis. Antibiotic therapy included vancomycin. To ensure proper dosing, vancomycin trough levels were collected before the fourth dose, and the result showed a high value of 39 ug/ml. Vancomycin doses were adjusted as per the Bayesian dosing software, and the same remained to be in supratherapeutic levels. The patient eventually deteriorated, and due to persistently high vancomycin levels, the antibiotic regimen was switched to a different antibiotic. Despite normal renal functions, the vancomycin levels remained high, between 27 ug/ml and 32 ug/ml, even in the absence of any further doses. Subsequently, vancomycin serum concentration was determined by another method using high-performance liquid chromatography (HPLC). Blood cultures grew both coagulase-negative Staphylococcus aureus and Achromobacter xylosoxidans. Vancomycin levels remained high a week after discontinuation of the drug. Vancomycin by HPLC assay eventually showed that vancomycin was undetectable in the blood, but, unfortunately, the results came at a time when the patient had already expired. In conclusion, clinicians should maintain a high level of suspicion if persistently higher vancomycin levels cannot be accounted for by renal function or other causes. In patients with persistently high vancomycin levels who continue to clinically deteriorate, it is crucial to consider that assay interference can result in inaccurately elevated vancomycin levels.

Epicardial Adipose Tissue and Development of Atrial Fibrillation (AFIB) and Heart Failure With Preserved Ejection Fraction (HFpEF).

Epicardial adipose tissue (EAT) has been associated with the development of many cardiovascular abnormalities, of which the development of atrial fibrillation (AFIB) in this group of patients is not an uncommon finding. Several mechanisms have been proposed to explain the role of EAT in the development of AFIB. It involves cardiac remodeling owing to the underlying fatty infiltration and the subsequent inflammation and fibrosis. This leads to the formation of ectopic foci that can lead to AFIB. Some studies propose that structural and valvular heart disease and increased hemodynamic stress further augment the development of AFIB in patients with underlying EAT. The degree of development of AFIB is also related to EAT thickness and volume. Therefore, EAT quantification can be used as an imaging technique to predict cardiovascular outcomes in these patients. Obesity also plays an important role in the development of AFIB both as an independent factor and by leading to adipose tissue deposition on the epicardial tissue. Understanding the pathophysiology of EAT is important as it can lead to the development of therapies that can target obesity as a risk factor for preventing AFIB. Some promising therapies have already been investigated for decreasing the risk of AFIB in patients with EAT. Dietary changes and weight loss have been shown to reduce the deposition of fat on epicardial tissue. Antidiabetic drugs and statin therapy have also shown promising results. Bariatric surgery has been shown to decrease EAT volume on echocardiography in obese patients.

An Unusual Case of May-Thurner Syndrome in a Middle-Aged IV Drug Abuser.

May-Thurner syndrome (MTS) is an extrinsic venous compression of the iliocaval venous territory by the arterial system. MTS is common in middle-aged women. Despite its importance, it is uncommonly considered in the differential diagnosis of deep vein thrombosis (DVT), especially in males with other risk factors. Due to the perianal abscess, a 35-year-old male health care worker was abusing IV opioids through his left leg veins. His symptoms included signs and symptoms of cellulitis around the catheter site, followed by recurrent DVTs due to poor response to anticoagulation therapy alone. A comprehensive workup revealed the diagnosis of MTS. The patient eventually required endovenous treatment with stent placement, after which his condition improved dramatically.

Indigenously adapted cognitive-behavioral therapy for excessive smartphone use (IACBT-ESU): A randomized controlled trial.

This study aims to assess whether 12 sessions of indigenously adapted cognitive-behavioral therapy for excessive smartphone use (IACBT-ESU) would reduce excessive smartphone use. A single-blind randomized controlled trial was conducted in students (12 to 19 years of age) to examine the potential beneficial effects of IACBT-ESU (n = 62) compared with brief educational data alone (n = 62). Symptoms of depression, anxiety, stress, and peer relations were also compared between the two groups. The IACBT-ESU group demonstrated significant reductions in excessive smartphone use, with reduced symptoms of depression, anxiety, stress, hyperactivity, and emotional difficulties at both trial end and at 3-month follow-up (p < .01) compared with control participants. IACBT-ESU was associated with reduced excessive smartphone use and improved psychological well-being, with beneficial findings maintained 3 months after the trial's end. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Prevalence of Acute Coronary Syndrome and Various Risk Factors in Acute Stroke Patients.

Background Stroke is the second leading cause of death worldwide after acute coronary syndrome (ACS). Both diseases share many risk factors such as hypertension, diabetes, dyslipidemia, and smoking. Patients who experience acute coronary syndrome are at heightened risk of recurrent ischemic events such as ischemic strokes, one of the most feared cardiovascular events because of the risk of long-term disability. We tried to estimate the prevalence of underlying ACS among patients with acute stroke. Methods This cross-sectional study was done at the CPE Institute of Cardiology, Pakistan, and Nishtar Medical University and Hospital, Pakistan. A total of 160 acute stroke cases were selected by consecutive sampling technique and questionnaire forms were filled. Detailed history, investigations, and physical examinations were done. The primary outcome was the prevalence of ACS and secondary outcomes were the prevalence of hypertension, smoking, dyslipidemia, diabetes mellitus, and previous history of stroke in stroke patients. Results Most of the patients that presented to us were above 50 years of age with the mean age of 62 years (SD = 9.23 years). Male predominance was seen with a total of 115 (72%) cases. Out of 160 patients, 91 (57%, p < 0.05) had underlying ACS, with 45 cases (49%) with unstable angina, 20 (22%) with non-ST-elevation myocardial infarction (NSTEMI), and 26 (29%) with ST-elevation myocardial infarction (STEMI). Prevalence of risk factors in 160 cases were, hypertension (101, 63%), lack of exercise (91, 57%), smoking (70, 44%), diabetes mellitus (61, 38%), dyslipidemia (50, 31%). All these results were statistically significant (p < 0.05). Prevalence of obesity (35, 22%) and previous stroke history (19, 12%) was statistically insignificant (p > 0.05). Conclusion Acute coronary syndrome is still frequently present in patients with acute stroke. The need of the hour is to manage ACS efficiently so that its deadly complications such as stroke can be prevented.

Atypical Descending Paralysis in Miller Fisher Syndrome: A Rare Variant of Guillain-Barre Syndrome.

Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome (GBS) which usually presents with descending paralysis. Common symptoms are ophthalmoplegia, ataxia, and areflexia. Our case presented with an atypical presentation. A 52-year old lady presented to the neurology outpatient department with frequent falls, blurring and doubling of vision and difficulty swallowing. These symptoms followed mild non-bloody diarrhea for two weeks ago. She had bilateral ptosis, lateral gaze palsy in both eyes, absent gag and cough reflex; she was unable to walk in a straight line and had right-hand grip weakness. Other motor and sensory examination were normal. She was admitted, kept under observation and investigated accordingly. Cerebrospinal fluid (CSF) analysis showed albuminocytologic dissociation. Nerve conduction studies showed slowed conduction in abducent, glossopharyngeal, vagus, and the right ulnar nerve. Blood analysis showed antiganglioside GQ1b antibodies; hence, the diagnosis of MFS, a variant of GBS, was made. Empirically plasmapheresis and then after confirmation intravenous immunoglobulins (IVIG) were used as treatment options. She recovered gradually within four weeks.

Dehydration related abdominal pain (DRAP).

OBJECTIVE: To describe the frequency of dehydration as a medical cause of acute abdomen. DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: The study was conducted at Combined Military Hospital, Malir Cantonment Karachi between March 1, 2000 to March 1, 2002. SUBJECTS AND METHODS: All the patients reporting with abdominal pain to the surgical outpatient department or the emergency department, were reviewed in the study. The clinical findings in all these cases were studied along with the mode of their management and outcome. RESULTS: Of all the patients presenting with abdominal pain, 303% (n=68) were suffering from dehydration related abdominal pain. They were predominantly males in a ratio of 8.7:1, mostly in the 2nd and 3rd decades of their lives. All these cases were suffering from acute or chronic dehydration were provisionally diagnosed by general practitioners as 'acute abdomen' and referred for surgical consultation. Associated symptoms included vomiting in 42.6% backache in 91.2%, headache in 95.6%, and pain in lower limbs in 97.1% of the cases. 83.8% required indoor management with intravenous fluids. All the patients became asymptomatic with rehydration therapy. CONCLUSION: Dehydration is a possible cause of severe abdominal pain. There is a need to educate the general public about the benefits of adequate fluid intake.