Safety outcomes of anti-platelet therapy post coronary artery bypass graft surgery: A systematic review and network meta-analysis of randomized control trials.

BACKGROUND: Antiplatelet therapy is used to decrease the risk of graft failure post coronary artery bypass graft surgery. We aimed to compare dual antiplatelet therapy (DAPT) with monotherapy along with a comparison of Aspirin, Ticagrelor, Aspirin+Ticagrelor (A+T) and Aspirin+Clopidogrel (A+C) to determine the major and minor bleeding risk, risk of postoperative myocardial infarction (MI), stroke, and all-cause mortality (ACM). METHODS: Randomized Controlled Trials comparing the four groups were included. Odds ratio (OR) and Absolute Risk (AR) were employed to assess the mean and standard deviation (SD) with 95% confidence intervals (CI). The Bayesian random-effects model was used for statistical analysis. Risk difference and Cochran Q tests were used to calculate rank probability (RP) and heterogeneity, respectively. RESULTS: We included 10 trials, consisting of 21 arms and 3926 patients. For the risk of major and minor bleed, A + T and Ticagrelor showed the lowest mean value of 0.040 (0.043) and 0.067 (0.073), respectively, and the highest RP of being the safest group. While a direct comparison between DAPT and monotherapy resulted in an OR of 0.57 [0.34, 0.95] for the risk of minor bleed. A + T was found to have the highest RP and the lowest mean value in terms of ACM, MI, and stroke. CONCLUSION: No significant difference was found between monotherapy or dual-antiplatelet therapy for the major bleeding risk safety outcome, however DAPT was found to have a significantly higher rate of minor bleeding complications post-CABG. DAPT should be considered as the antiplatelet modality of choice post-CABG.

Fluoroquinolones and the risk of aortic aneurysm or aortic dissection: an updated systematic review and meta-analysis including 53,651,283 patients.

INTRODUCTION: The association between fluoroquinolone use and the risk of aortic aneurysm as well as the risk of aortic dissections remains uncertain, primarily due to conflicting findings from observational studies. We sought to conduct a double-systematic review and meta-analysis of all observational studies to assess the existence and extent of both these associations. The aim of our study is to assess the role of Fluoroquinolone on aortic aneurysm and aortic dissection in comparison to other antibiotics. EVIDENCE ACQUISITION: MEDLINE and Cochrane CENTRAL were systematically searched up till June 2021 for observational studies studying the correlation between fluoroquinolone usage and aortic aneurysms and dissections. Random-effects pooling was used to calculate adjusted hazard ratios (HRs) with 95% confidence intervals (CI). To assess publication bias, propensity score matching was conducted, and heterogeneity was evaluated by using I2 statistics. EVIDENCE SYNTHESIS: Of 688 potentially relevant articles, 635 titles were screened. Ten studies were included in the systematic review, and 4 observational studies with 53,651,283 participants were eligible to be included in the meta-analysis. Pooled estimates showed that fluoroquinolone use was associated with a higher risk of aortic aneurysm when compared to other Antibiotics (HR 1.84, 95% CI 1.10-2.48; P<0.00001). However, fluoroquinolones had no significant effect on the risk of developing aortic dissection (HR 1.09, 95% CI 0.96-1.25; P=0.19). CONCLUSIONS: The present analysis suggests that fluoroquinolone usage is more strongly linked to aortic aneurysm than other antibiotics. However, there was no statistically significant link between fluoroquinolone and aortic dissection. As a result, clinicians should exercise caution when administering fluoroquinolone to patients who have a history of or are at risk of aortic disease.

Psychometric performance of the Mental Health Implementation Science Tools (mhIST) across six low- and middle-income countries.

BACKGROUND: Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups-consumers, providers, organization leaders, and policy makers-with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. METHODS: We compiled secondary data from seven studies across six LMIC-Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia-to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. RESULTS: All but one scale within the Provider and Consumer versions had Cronbach's alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. CONCLUSION: We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.

Eosinophilic Asthma Secondary to Adjuvant Anti-PD-1 Immune Checkpoint Inhibitor Treatment in a Melanoma Patient.

Background: Adjuvant immune checkpoint inhibitors are a new standard of care in melanoma. However, the immune related toxicity associated with these agents can be serious, and the long-term implications are yet to be defined especially in the adjuvant setting. We report, to our knowledge, the first case of anti-PD-1-induced eosinophilic asthma in a melanoma patient treated with adjuvant pembrolizumab. Case Presentation. A 72-year-old man commenced pembrolizumab in the adjuvant setting after resection of a stage IIIB cutaneous melanoma. The patient experienced episodes of breathlessness 4 weeks after cycle 1. These episodes were nocturnal and caused acute respiratory distress and cough, occasionally waking him up. The episodes progressed, and he was admitted after cycle 2 with a productive cough, wheeze, and breathlessness. Observations showed saturations on air of 94% and a respiratory rate of 19/min. The only laboratory abnormality was a raised eosinophil count of 1.1 × 109. Spirometry showed a FEV1 of 2.57 (91% predicted), FVC of 4.04 (108% predicted), and ratio of 64%. Peak expiratory flow rate was 94% predicted, and corrected gas transfer was 6.29 (78% predicted) with KCO 1.18 (93% predicted). FeNO was raised at 129 indicating inflammation of his airways, and peak flow was 422 l/min. CT of the chest did not show pneumonitis or other lung pathology. A diagnosis of acute eosinophilic asthma was made. Treatment with steroids and beclometasone dipropionate and formoterol inhaler produced rapid resolution of symptoms and normalisation of the eosinophil count. Pembrolizumab was safely recommenced once steroids had discontinued and symptoms had resolved. Conclusions: Specialist respiratory input was needed for optimal patient management and is ongoing. Although a safe rechallenge with pembrolizumab was possible, treatment in the adjuvant setting is curative in intent and long-term safety follow-up is required to assess for delayed toxicity and long-term health implications. This is likely to require large regional/national/international databases to detect, monitor, and educate the wider medical community as these patients are followed up in primary care following initial specialist follow-up.

Neonatal sepsis and mortality in low-income and middle-income countries from a facility-based birth cohort: an international multisite prospective observational study.

BACKGROUND: Neonatal sepsis is a primary cause of neonatal mortality and is an urgent global health concern, especially within low-income and middle-income countries (LMICs), where 99% of global neonatal mortality occurs. The aims of this study were to determine the incidence and associations with neonatal sepsis and all-cause mortality in facility-born neonates in LMICs. METHODS: The Burden of Antibiotic Resistance in Neonates from Developing Societies (BARNARDS) study recruited mothers and their neonates into a prospective observational cohort study across 12 clinical sites from Bangladesh, Ethiopia, India, Pakistan, Nigeria, Rwanda, and South Africa. Data for sepsis-associated factors in the four domains of health care, maternal, birth and neonatal, and living environment were collected for all mothers and neonates enrolled. Primary outcomes were clinically suspected sepsis, laboratory-confirmed sepsis, and all-cause mortality in neonates during the first 60 days of life. Incidence proportion of livebirths for clinically suspected sepsis and laboratory-confirmed sepsis and incidence rate per 1000 neonate-days for all-cause mortality were calculated. Modified Poisson regression was used to investigate factors associated with neonatal sepsis and parametric survival models for factors associated with all-cause mortality. FINDINGS: Between Nov 12, 2015 and Feb 1, 2018, 29 483 mothers and 30 557 neonates were enrolled. The incidence of clinically suspected sepsis was 166·0 (95% CI 97·69-234·24) per 1000 livebirths, laboratory-confirmed sepsis was 46·9 (19·04-74·79) per 1000 livebirths, and all-cause mortality was 0·83 (0·37-2·00) per 1000 neonate-days. Maternal hypertension, previous maternal hospitalisation within 12 months, average or higher monthly household income, ward size (>11 beds), ward type (neonatal), living in a rural environment, preterm birth, perinatal asphyxia, and multiple births were associated with an increased risk of clinically suspected sepsis, laboratory-confirmed sepsis, and all-cause mortality. The majority (881 [72·5%] of 1215) of laboratory-confirmed sepsis cases occurred within the first 3 days of life. INTERPRETATION: Findings from this study highlight the substantial proportion of neonates who develop neonatal sepsis, and the high mortality rates among neonates with sepsis in LMICs. More efficient and effective identification of neonatal sepsis is needed to target interventions to reduce its incidence and subsequent mortality in LMICs. FUNDING: Bill & Melinda Gates Foundation.

Frequency and Predictors of Acute Kidney Injury in Patients With Acute Coronary Syndrome in a Tertiary Care Hospital: A Retrospective Study.

Introduction Acute kidney injury (AKI) is a complex condition marked by rapid deterioration of renal function (within hours or days), with clinical symptoms ranging from a minor rise in serum creatinine to anuric renal failure needing renal replacement therapy. AKI is one of the complications of acute coronary syndrome (ACS). This study aims to determine the frequency of AKI among patients with ACS and identify its predictors. Method This study is a retrospective observational study conducted at the Dow University of Health Sciences, a tertiary care hospital located in Karachi, Pakistan. This study was conducted from January 2020 to June 2021. All patients aged 18-75 years admitted with ACS and admitted for more than 48 hours were included in the study. A pre-set questionnaire was used to collect data from the hospital management information system (HMIS). Results The frequency of AKI among patients with ACS was 24.18%. The factors associated with AKI among patients with ACS on multivariable logistic regression included the age of patients (odds ratio (OR) = 1.04, p-value = 0.018), having diabetes mellitus (OR = 2.33, p-value = 0.031), admission Killip ≥ II (OR = 2.12, p-value = 0.041), previous history of myocardial infarction (MI) (OR = 3.64, p-value = 0.001), baseline glomerular filtration rate (GFR) (OR = 0.94, p-value = 0.001), in-hospital ejection fraction (EF) (OR = 0.93, p-value = 0.001), and serum creatinine at admission (OR = 1.02, p-value = 0.001). Conclusion Age, comorbidities including diabetes mellitus and previous history of MI, admission Killip ≥ II, baseline GFR, in-hospital EF, and serum creatinine level at admission are significant independent predictors of AKI in patients with ACS.

Retraction: Comparison of the Performance of Various Scores in Predicting Mortality Among Patients Hospitalized With COVID-19.

[This retracts the article DOI: 10.7759/cureus.20751.].

Retraction: Frequency and Predictors of Acute Kidney Injury in Patients With Acute Coronary Syndrome in a Tertiary Care Hospital: A Retrospective Study.

[This retracts the article DOI: 10.7759/cureus.21869.].

Comparison of the Performance of Various Scores in Predicting Mortality Among Patients Hospitalized With COVID-19.

Introduction Coronavirus disease 2019 (COVID-19) is a major social and economic challenge, devastating the health care system in several countries around the world. Mortality scores are important as they can help health care professionals to plan treatment as per the patients' condition for proper resource allocation. When it comes to patients, it provides invaluable information for implementing advance directives. The aim of the study is to validate mortality scores for predicting in-hospital mortality in patients with COVID-19. Methodology This was a retrospective cohort study that included data from three tertiary care hospitals in Karachi, Pakistan. Data of patients diagnosed with confirmed COVID-19 infection and hospitalized in Ziauddin Hospital, Aga Khan Hospital, and Liaquat National Hospital were enrolled in the study from November 1, 2020, to April 30, 2021. Data was extracted from the hospital management information system (HMIS) using a structured questionnaire. Results Overall, 835 patients were included in the final analysis. The mean age of patients was 53.29 (SD ± 15.17) years, and 675 patients (80.72%) were males. The sensitivity of the CALL score is highest among all four scores, i.e., 77.25%, and the quick Sequential Organ Failure Assessment (qSOFA) score has the lowest sensitivity (59.79%). However, CALL has the lowest specificity (58.04%), while qSOFA has the highest specificity (73.91%). However, MulBSTA and CRB-65 have a sensitivity of 70.11% and 64.96%, respectively. Conclusion The current study showed that the CALL score had better sensitivity as compared to other mortality scores.

The anti-spasmodic effect of peppermint oil during colonoscopy: a systematic review and meta-analysis.

INTRODUCTION: Multiple pharmacological agents have been studied in literature with antispasmodic effect during colonoscopy. Peppermint oil, with its relaxing effect on colon has demonstrated varying results. We therefore conducted a systematic review and meta-analysis of the available literature to evaluate its role during colonoscopy. EVIDENCE ACQUISITION: Literature search of the following databases was undertaken: PubMed\Medline, Embase, Cochrane, Web of Science, and CINAHL. Outcomes that were evaluated included incidence of any spasticity, severe spasticity, and peristalsis during examination. Adenoma detection rate (ADR) was evaluated as a quality outcome metric. Risk ratios (RR), risk difference (RD) and mean difference (MD) were calculated using the DerSimonian-Laird method and random effects where applicable. EVIDENCE SYNTHESIS: Overall, six studies (with one abstract) were included in this review. Peppermint oil resulted in overall lower incidence for spasticity (RD: -0.39, P=0.02), severe spasticity (RD: -0.15, P=0.04), and peristalsis (-0.27, P≤0.001) during colonoscopy examination. An improved ADR (RR: 1.31, P=0.01) was also noted, however only two studies evaluated this effect. CONCLUSIONS: Peppermint oil resulted in relaxation of colon during colonoscopy with decrease incidence of spasticity, severe spasticity, peristalsis and improved ADR. These results are encouraging however results are limited due to significant heterogeneity found in the outcomes. Larger studies with standardized dosing are needed to evaluate this effect. Furthermore, studies evaluating additional colonoscopy outcomes such as polyp detection rate, advanced adenoma detection rate, and serrated adenoma detection rate are needed.

United States national trends in comorbidity and outcomes of adult cardiac surgery patients.

BACKGROUND: Comorbidity profiles of cardiac surgery patients are known to have changed over time, but modern national trends in these comorbidities and outcomes are not described. This study describes comorbidity trends over time for common adult cardiac surgery procedures. METHODS: A retrospective, cross-sectional analysis of the National Inpatient Sample was conducted for years 2005-2014. Hospitalizations with coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve repair/replacement (MVRR), as well as combined CABG/valve operations, were identified by ICD-9 procedure codes. Comorbidities were defined based on ICD-9 codes to discriminate between comorbidities and complications. Surgical volume, patient age, in-hospital mortality, and length of stay trends over time were evaluated by linear regression. RESULTS: Incidence increased for AVR, MVRR, and CABG + AVR and declined for CABG and CABG + MVRR (P < .001). The mean number of comorbidities across all surgeries increased from 1.4 to 1.9 (P < .001). Length of stay declined for AVR, CABG + AVR, and CABG + MVRR (P < .001) with an overall decline from 10.1 to 9.7 days (P = .003). In-hospital mortality decreased in all categories over time (P < .001). Overall, in-hospital mortality decreased from 2.9% to 2.3% (P < .001). CONCLUSIONS: Despite increasing comorbidity in cardiac surgery, operations are being conducted with fewer in-hospital mortalities across all types of surgery and decreasing length of stay for most types of surgery, which should inform the frequency of risk model updates and raise questions of the applicability of earlier studies in cardiac surgery to the modern population.

Prevalence and Predictors of the Burnout Syndrome in Medical Students of Karachi, Pakistan.

Objectives Burnout is a psychophysiological syndrome, consisting of a triad of emotional and physical exhaustion, exhibition of impersonal attitude and loss of a sense of achievement for oneself. This study aimed to pinpoint its risk factors, measure its current prevalence in medical students of Karachi, Pakistan and accentuate the areas of focus to benefit the primary care-oriented community as a whole. Methods This cross-sectional study included responses from 600 medical students in Karachi (third to final year). A self-administered questionnaire using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), multi-dimensional mood state questionnaire and perceived stress scale was used, along with a section about burnout prevention assessment. Data were analyzed using SPSS version 24.0 (IBM Corp., Armonk, NY) and chi-square tests used to find significant associations. Results One-fifth (n=109, 18.2%) of our subjects were burned out. The syndrome was significantly observed in those who operated on insufficient sleep (p-value 0.028) and in those having anger management issues and non-dominating temperaments (p-value 0.05). Furthermore, it was statistically significant in those who gave up easily, in those who had no hobbies and had no time to exercise and pray (p-value <0.05). It was more prevalent in pupils of private medical colleges whereas two of its three constitutive factors, Emotional Exhaustion (p-value 0.03) and Personal Achievement (p-value <0.001) were significantly higher in pupils of public sector universities.  Conclusion The deleterious repercussions of burnout syndrome warrant the need for extensive efforts towards the propagation of its awareness.

Investigation and modelling of high rate algal ponds utilising secondary effluent at Western Water, Bacchus Marsh Recycled Water Plant.

There is growing interest in the ability of high rate algal ponds (HRAP) to treat wastewater. This method reduces the costs of algal production while treating the wastewater quicker and more efficiently than standard lagoon practices. Two parallel HRAPs were used in this study to treat secondary effluent. Nitrogen levels were significantly reduced with a mean reduction of 71% for ammonia and 64% for total nitrogen. The use of the HRAPs significantly increased the algal biomass levels compared to the algal growth in the storage lagoons, with a mean increase of 274%. Beneficial use of algae can be used to reduce treatment costs; so being able to predict and optimise the amount of algal biomass produced in HRAPs is vital. However, most models are complicated and require specific, detailed information. In this study, a predictive microalgal growth model was developed for HRAP by adapting two previously established models: the Steele and Monod models. The model could predict algal growth based on temperatures and solar radiation and account for limiting ammonia concentrations in an elevated pH environment with natural variations in the algal community. This model used experimental data that would be readily available to any established HRAP study.

Leveraging Epigenetics to Enhance the Cellular Response to Chemotherapies and Improve Tumor Immunogenicity.

Cancer chemotherapeutic drugs have greatly advanced our ability to successfully treat a variety of human malignancies. The different forms of stress produced by these agents in cancer cells result in both cell autonomous and cell nonautonomous effects. Desirable cell autonomous effects include reduced proliferative potential, cellular senescence, and cell death. More recently recognized cell nonautonomous effects, usually in the form of stimulating an antitumor immune response, have significant roles in therapeutic efficiency for a select number of chemotherapies. Unfortunately, the success of these therapeutics is not universal as not all tumors respond to treatment, and those that do respond will frequently relapse into therapy-resistant disease. Numerous strategies have been developed to sensitize tumors toward chemotherapies as a means to either improve initial responses, or serve as a secondary treatment strategy for therapy-resistant disease. Recently, targeting epigenetic regulators has emerged as a viable method of sensitizing tumors to the effects of chemotherapies, many of which are cytotoxic. In this review, we summarize these strategies and propose a path for future progress.

Impact of Transgenic Brassica napus Harboring the Antifungal Synthetic Chitinase (NiC) Gene on Rhizosphere Microbial Diversity and Enzyme Activities.

Transgenic Brassica napus harboring the synthetic chitinase (NiC) gene exhibits broad-spectrum antifungal resistance. As the rhizosphere microorganisms play an important role in element cycling and nutrient transformation, therefore, biosafety assessment of NiC containing transgenic plants on soil ecosystem is a regulatory requirement. The current study is designed to evaluate the impact of NiC gene on the rhizosphere enzyme activities and microbial community structure. The transgenic lines with the synthetic chitinase gene (NiC) showed resistance to Alternaria brassicicola, a common disease causing fungal pathogen. The rhizosphere enzyme analysis showed no significant difference in the activities of fivesoil enzymes: alkalyine phosphomonoestarase, arylsulphatase, ß-glucosidase, urease and sucrase between the transgenic and non-transgenic lines of B. napus varieties, Durr-e-NIFA (DN) and Abasyne-95 (AB-95). However, varietal differences were observed based on the analysis of molecular variance. Some individual enzymes were significantly different in the transgenic lines from those of non-transgenic but the results were not reproducible in the second trail and thus were considered as environmental effect. Genotypic diversity of soil microbes through 16S-23S rRNA intergenic spacer region amplification was conducted to evaluate the potential impact of the transgene. No significant diversity (4% for bacteria and 12% for fungal) between soil microbes of NiC B. napus and the non-transgenic lines was found. However, significant varietal differences were observed between DN and AB-95 with 79% for bacterial and 54% for fungal diversity. We conclude that the NiC B. napus lines may not affect the microbial enzyme activities and community structure of the rhizosphere soil. Varietal differences might be responsible for minor changes in the tested parameters.

Diverticulitis in the Young Population : Reconsidering Conventional Recommendations.

BACKGROUND: In the past diverticulitis was believed to be uncommon in the young population. However, there is growing concern suggesting that these patients develop more severe clinical symptoms and may require more frequent intervention. METHOD: We performed a retrospective chart review of patients with diverticulitis in individuals with age less than 40 years over an 8 year period (2007-2015). Diagnosis was confirmed with a CT scan. In addition to age we took into consideration race, gender, anemia (hematocrit< 41), leukocytosis (WBC > 12), BMI and whether it was an initial episode or recurrence. Our outcome variables were complications (abscess, fistula, and perforation, results of colonoscopy (polyps or colon cancer)) and whether the patient required surgery. RESULTS: We identified 123 patients who were less than 40 years old with the diagnosis of diverticulitis. There was greater than a 3:1 ratio of males to females (77% males and 23% females) with an average age of 32.6 year. The race of the patients was nearly entirely Hispanic (88.6%). With regards to the outcome variables, 18.7% had abscesses as a complication. Perforations were observed in 26% of the patients, of which one was complicated by a fistula. A total of 25 (20%) patients went to surgery. Of these, 21 had an abscess, perforation, or tubular adenomatous polyps (TAP). Follow-up colonoscopy post-diverticulitis results were available for 42 patients. Of those patients, 9 had hyperplastic polyps and 3 had TAP. The remaining 30 patients had no polyps. No colon cancer or villous polyps were found in the entire cohort. CONCLUSION: Our study highlights that young patients who have an index case of uncomplicated diverticulitis with no other risk factors or complications may not gain further benefit from routine colonoscopy as once traditionally thought. (Acta gastroenterol. belg., 2016, 79, 435-439).

The Short-term Effects of Insulin, Metformin and Insulin-Metformin Combination on the Liver Morphology in High Fat Diet / Streptozotocin Induced Diabetic Albino Rats.

OBJECTIVE: To evaluate the histological effects of insulin, metformin and insulin-metformin combination on liver morphology in high fat diet (HFD) / Streptozotocin (STZ) induced diabetic albino rats. STUDY DESIGN: Experimental and comparative study. PLACE AND DURATION OF STUDY: Institute of Basic Medical Sciences (IBMS), Dow University of Health Sciences (DUHS), Ojha Campus, Karachi, from January to August 2012. METHODOLOGY: The study was conducted on 50 HFD/STZ induced diabetic albino wistar rats which were randomized into 5 groups. One of the groups was treated with insulin, one with metformin, and the other group with insulin-metformin combination for 4 weeks. One of the groups was left untreated. One group was control group. After the treatment period, the rats were sacrificed and livers were isolated, weighed, processed and stained to analyse the difference in hepatic morphology in each treated and untreated groups, then the results were compared with control rats. RESULTS: Statistically significant difference (p < 0.0001) was seen between the groups by using Kruskill Wallis Test. To further investigate the effectiveness of insulin, metformin and insulin-metformin combination, Mann-Whitney U-test was applied. Statistically significant difference was noticed when diabetic rats were given insulin-metformin combination (p < 0.0001). CONCLUSION: The combination therapy was observed to have better effects on liver morphology than insulin and metformin used separately.

Should prostate cancer be considered as a differential diagnosis in patients with osteolytic bone lesions?

OBJECTIVE: Prostate cancer is the most frequently diagnosed cancer in men, as well as the second leading cause of death among cancers after lung cancer. In the United States, it is more prevalent in African-American men than in Caucasian men. Prostate cancer frequently metastasizes to the bone, with most of the reported lesions appearing to be osteoblastic on radiographs. Here, we describe an unusual presentation of metastatic prostate cancer with diffuse osteolytic bone lesions. CASE PRESENTATION: An 80-year-old previously healthy Hispanic man presented with worsening back pain, difficulty with ambulation, and bladder outlet obstruction. Physical examination was significant for spinal tenderness in the thoracic and lumbar region. Digital rectal examination was remarkable for asymmetric enlargement of the prostate with nodularity and firmness. Imaging studies revealed diffuse osteolytic lesions. His prostate-specific antigen was 562.8 ng/mL (normal 0-4). Prostate biopsy and imaging studies confirmed a diagnosis of metastatic prostate cancer. CONCLUSIONS: This case demonstrates that bone metastases of prostate cancer are not purely osteoblastic although most of the reported bone metastases in prostate cancer have been osteoblastic in nature. Therefore, clinicians are to consider metastatic prostate cancer as a differential diagnosis for patients with osteolytic bone lesions.