Autoimmune Pancreatitis Mimicking Obstructive Pancreatic Neuroendocrine Tumor.

Autoimmune pancreatitis (AIP), otherwise known as non-alcoholic destructive pancreatitis or sclerosing pancreatitis, is a rare form of chronic pancreatitis that is clinically significant due to its potential to mimic pancreatic cancer. In our case, we present a 64-year-old male with a past medical history of type 2 diabetes and epigastric abdominal pain for one year who presented with worsening epigastric abdominal pain, 12-pound weight loss, and vomiting and was found to have a neuroendocrine tumor on a preliminary pathology report, while official pathology later came back stating AIP. Distinguishing between autoimmune pancreatitis (AIP) and pancreatic cancer is vital, given the stark contrast in their treatment and prognosis. In our case, preliminary pathology suggested a neuroendocrine tumor, prompting consultation with oncology. Utilizing invasive testing like EUS-FNA, we obtained an official diagnosis and prevented the patient from undergoing unnecessary treatments and interventions. Our case shows the importance of further testing when a patient presents with a fast-growing obstructive pancreatic mass. While searching the literature, there are no previously documented cases of an AIP mass as large as our patients and as fast-growing.

Dysautonomia and activity in the early stroke recovery period.

Maintaining cerebral perfusion in the early stages of recovery after stroke is paramount. Autoregulatory function may be impaired during this period leaving cerebral perfusion directly reliant on intravascular volume and blood pressure (BP) with increased risk for expanding cerebral infarction during periods of low BP and hemorrhagic transformation during BP elevations. We suspected that dysautonomia is common during the acute period related to both pre-existing vascular risk factors and potentially independent of such conditions. Thus, we sought to understand the state of the science specific to dysautonomia and acute stroke. The scoping review search included multiple databases and key terms related to acute stroke and dysautonomia. The team employed a rigorous review process to identify, evaluate, and summarize relevant literature. We additionally summarized common clinical approaches used to detect dysautonomia at the bedside. The purpose of this scoping review is to understand the state of the science for the identification, treatment, and impact of dysautonomia on acute stroke patient outcomes. There is a high prevalence of dysautonomia among persons with stroke, though there is significant variability in the type of measures and definitions used to diagnose dysautonomia. While dysautonomia appears to be associated with poor functional outcome and post-stroke complications, there is a paucity of high-quality evidence, and generalizability is limited by heterogenous approaches to these studies. There is a need to establish common definitions, standard measurement tools, and a roadmap for incorporating these measures into clinical practice so that larger studies can be conducted.

Thyroxine Replacement for Subfertile Females With Subclinical Hypothyroidism and Autoimmune Thyroiditis: A Systematic Review.

The second most prevalent endocrine condition affecting women of reproductive age is thyroid disease. The difference between an increased thyroid-stimulating hormone (TSH) concentration and a normal free thyroxine hormone level is used to identify subclinical hypothyroidism. Thyroid autoantibodies, independent of thyroid hormone levels, are used to diagnose autoimmune thyroid disease (ATD). Thyroxine can help infertile women with these two types of thyroid illnesses have better birth outcomes during fertility treatment. We performed a systematic review using PubMed (Medline) as a major database and some other sources EMBASE, the Cochrane Library, Web of Science, Scopus, and Science Direct. We concentrated on four studies, including 806 patients. Our goal is to investigate the efficacy and risks of levothyroxine therapy in infertile women who are receiving fertility treatments and have subclinical hypothyroidism or adequate thyroid function as well as thyroid autoimmunity (euthyroid autoimmune thyroid disorder). Thyroid activity in hypothyroid women should be tracked at pregnancy confirmation and closely monitored during the pregnancy. Early in pregnancy, the dosage of levothyroxine (LT4) can be raised. To ensure optimum TSH levels during breastfeeding, we recommend that patients who are followed in the primary sector have their LT4 dose increased by their general practitioner before their first referral to an endocrinological outpatient clinic. It's important to pay more attention to and track pregnant women with hypothyroidism, who consider pregnancy, to get the best results. LT4 therapy can help subfertile women with subclinical hypothyroidism who are having in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) since it improves embryo growth, implantation rate, and live birth rate.

Non-invasive Positive Pressure Ventilation for Acute Cardiogenic Pulmonary Edema and Chronic Obstructive Pulmonary Disease in Prehospital and Emergency Settings.

Non-invasive ventilation is an important intervention in treating acute respiratory failure caused by acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (COPD). Although there are studies that give evidence on the efficacy and safety of non-invasive ventilation over standard medical care for COPD and cardiogenic pulmonary edema, less are known about the form of non-invasive ventilation, continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) as an effective intervention for respiratory failure and its efficacy and safety in prehospital settings. We conducted a systematic review by using PubMed and Google Scholar as databases for collecting studies related to the effectiveness of CPAP and BiPAP for cardiogenic pulmonary edema and COPD; the major outcome studied was reducing rates of endotracheal intubation secondary and tertiary outcomes included mortality reduction and shortening length of hospital stay. The study follows the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist 2009. Sixteen studies were identified, including systematic reviews, randomized control trials, and observational studies. Studies published on or after 2010 in a population greater than 40 years old suffering from acute COPD and cardiogenic pulmonary edema were taken for review. Studies that described other respiratory diseases treated with non-invasive ventilation were excluded. Quality appraisal was done using the Cochrane risk bias tool for randomized control trials, Amstar-2 for systematic reviews, and New Castle Ottawa Tool for observational studies. Five studies compared the effectiveness of CPAP and BiPAP with standard medical care in prehospital and emergency settings. Six studies described prehospital intervention. Both forms of non-invasive ventilation were equally significant and effective. Prehospital use had tremendously reduced intubation rates, with not much variability noticed for mortality and hospital stay. Non-invasive ventilation is an effective measure for respiratory failure secondary to COPD and ACPE. Early out of hospital utilization of CPAP and BiPAP reduces the rate of invasive ventilation and reduces complications due to endotracheal intubation. Endotracheal intubation is associated with a considerable incidence of complications like failed intubation, hypotension, or circulatory arrest, even if the emergency physician is well trained, making these forms of non-invasive ventilation safe and effective interventions in the prehospital settings.

Prophylactic Antibiotics, the Mediator of Post-Stroke Infections: A Systematic Review.

Infections frequently complicate an acute stroke and have been associated with an unfavorable prognosis among patients. The use of prophylactic antibiotics seems rational, however, its efficacy has remained obscure. This systematic review aims to offer more clarity to this established dilemma. PubMed and Google Scholar were explored to gain access to studies on post-stroke infection. A systematic review was carried out to analyze how profitable it would be to offer preventive antibiotics immediately after an acute stroke. Five randomized control trials were obtained and analyzed the efficacy of antibiotics in acute stroke according to their intrinsic effects on the infection rate, functionality, and mortality benefits. Based on our findings, we discovered that antibiotics reduce the onset of early infections, especially urinary tract infections, but have absolutely no effect on the functionality and offer no mortality benefit. These results were emphatically shown in two large, open-labeled randomized controlled trials involved in this systematic review. Prophylactic antibiotics provide no additional benefits to the standard of care and should not be used following an acute stroke. They may decrease the incidence of acute infections, especially urinary tract infections, but have no effects on functional outcome and mortality.

Risk of Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis Patient Treated With Natalizumab: A Systematic Review.

Natalizumab, a monoclonal antibody acting on alpha4 integrin receptors, is frequently used to treat multiple sclerosis patients. The biggest downside is the risk of development of progressive multifocal leukoencephalopathy, an immune-related condition affecting mainly the central nervous system. The presence of the John Cunningham virus (JCV) and its reactivation is an important factor in the development of progressive multifocal leukoencephalopathy (PML). This study highlights its different proposed mechanism and risk factors strongly related to natalizumab-induced progressive multifocal leukoencephalopathy. The pieces of literature will also be reviewed to look for a relation between the JCV and natalizumab-induced progressive multifocal leukoencephalopathy in multiple sclerosis treated patients. The articles were searched from three databases and reviewed systematically. The inclusion criteria for this study were patients aged 20-50 years, English language paper, full-text availability, and human studies, whereas articles on patients with AIDS and cancer-related disease prior to natalizumab treatment were excluded. Out of 6531 articles identified after applying the search strategy on three main databases PubMed, Google Scholar, and ResearchGate, a total of 32 articles were finalized for the review. This study follows the guidelines listed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2009. The data collected from these finalized articles were pertaining to the risk factor related to natalizumab induced progressive multifocal leukoencephalopathy and the mechanism related to its pathogenesis.  Natalizumab is known to have the potential to cause progressive multifocal leukoencephalopathy in treated patients; here, we evaluate a close relationship of its related risk factors. The articles studied exhibit a close relationship between the length of natalizumab treatment and the presence of the JCV before infusion of natalizumab. From our analysis, it seems that the mechanism related to natalizumab-induced PML is strongly related to antigen-specific T cells and its effects. The frequency of monitoring and vigilance on the management of patients treated with natalizumab will help detect progressive multifocal leukoencephalopathy.

A Rare Case of Massive Ovarian Mucinous Cystadenoma With Postmenopausal Bleeding.

Mucinous cystadenomas are among the most common benign ovarian neoplasms. They are known for their massive size causing compressive effects ranging from pressure, pain, bloating, and urinary symptoms. Over time, these adnexal masses can lead to fatal complications, such as ovarian torsion or hemorrhage. Incidental findings of these tumors are common as many of these patients are asymptomatic. Pelvic examinations and imaging studies can be used to further diagnose symptomatic patients and aid physicians in developing an appropriate course of treatment. We report a rare case of a large mucinous cystadenoma, with a size of 25 × 25 cm and concurrent management of postmenopausal bleeding. We present the data from the admission of the patient to her discharge, including history and physical examination, diagnostic reports, transabdominal ultrasound, CT scan, surgical evaluation, and surgical-pathology reports. Abdominal pain can present in a variety of different scenarios, and ovarian masses only represent a small portion of the differentials. Mucinous cystadenomas constitute an even smaller percentage of these ovarian growths. As discussed in this case report, a large ovarian mucinous cystadenoma was compressing the surrounding structures resulting in a wide array of symptoms. The case describes the importance of extensive diagnostic evaluation and prompt surgical management of these ovarian tumors. It also brings attention to the significance of diagnosing a medical condition such as postmenopausal bleeding promptly to avoid potential negative outcomes.