Non-traumatic Thoracic Aortic Dissection in a Healthy Patient.

Aortic dissection (AD) is a serious condition, which typically affects men more than women. Strongly established risk factors include uncontrolled hypertension, connective tissue disorders, advanced age, cocaine use, and aortic injury. We believe it's important to report this case due to the occurrence of Stanford type A AD in a healthy 40-year-old male devoid of genetic, medical, family, and environmental risk factors. This patient presented with a tearing anterior chest pain radiating to the back and was promptly diagnosed and managed with surgical replacement and grafting of the diseased aorta and its involved branches. Therefore, it is imperative to include AD as a differential in atypical case scenarios and case presentations, as missed and delayed diagnosis and management would worsen the clinical outcomes.

Meniscus Tear: Pathology, Incidence, and Management.

Meniscus tears are a common orthopedic pathology and planning a single, effective treatment is challenging. The diagnosis of meniscal tears requires detailed history-taking, physical examinations, special diagnostic tests, and most likely magnetic resonance imaging (MRI) to confirm the lesion. A good understanding of the meniscal structure including vascularity, zones, function, and affected movements with associated symptoms plays a crucial role in establishing an optimal management plan. A careful assessment of the patient's characteristics, comorbidities, post-repair rehabilitation, and patient's overall function and satisfaction are also important for ideal management. While conservative management is commonly implemented and the only option for certain patients, partial meniscectomy remains to be the most performed treatment procedure. However, partial meniscectomy is no longer the first-line therapy due to the limitation of certain patient characteristics and side effects in the long run. Instead, meniscal repair has been shown to have better long-term outcomes and is therefore recommended for all tears, especially for young patients with acute traumatic lesions. Tissue engineering has been of high interest in the current research with promising therapeutic results. This review critically evaluates and compares the management of meniscal tears with surgical versus comprehensive management using the current literature.

Lupus Cerebritis as a Rare Neuropsychiatric Manifestation of Systemic Lupus Erythematosus.

Mixed connective tissue disease (MCTD) is a rare autoimmune condition that shows an overlap of at least two connective tissue diseases (CTD) including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), scleroderma, Sjögren's syndrome, polymyositis, or dermatomyositis. From a laboratory standpoint, MCTD is associated with high titers of anti-U1-RNP antibodies, which makes it difficult to determine whether it is a variant of each of the respective CTDs or a different entity altogether. Our objective is to report the case of a patient with MCTD presenting with status epilepticus who was ultimately diagnosed with lupus cerebritis. The case also highlights the development of complications unrelated to MCTD that made the management even more challenging. Overall, the authors emphasize the rareness of lupus cerebritis as a presentation, the diagnostic challenges faced due to the lack of classical manifestations of SLE, and how the complicated clinical course makes a downhill prognosis more likely.

Bile Cast Nephropathy: A Comprehensive Review.

Bile cast nephropathy (BCN) or cholemic nephropathy (CN) is an acute renal dysfunction, including acute kidney injury (AKI) in the setting of liver injury. It is a common phenomenon in patients with liver disease and is associated with significant morbidity and mortality. CN is characterized by hemodynamic changes in the liver, kidney, systemic circulation, intratubular cast formation, and tubular epithelial cell injury. CN has been overlooked as a differential diagnosis in chronic liver disease patients due to more importance to hepatic injury. However, frequent and considerable reporting of case reports recently has further investigated this topic in the last two decades. This review determines the evidence behind the potential role of bile acids and bilirubin in acute renal dysfunction in liver injury, summarizing the implied pathophysiology risk factors, and incorporating the therapeutic mechanisms and outcomes.

Neurobiology of Schizophrenia: A Comprehensive Review.

Schizophrenia is a debilitating disease that presents with both positive and negative symptoms affecting cognition and emotions. Extensive studies have analyzed the different factors that contribute to the disorder. There is evidence of significant genetic etiology involving multiple genes such as dystrobrevin binding protein 1 (DTNBP1) and neuregulin 1 (NRG1). There is no clear link between neurotransmitter changes and the pathophysiology of schizophrenia; however, studies have shown that subcortical dopamine dysfunction is the key mechanism. Specific regions of gray and white matter changes are observed in patients with schizophrenia; gray matter changes being more significant after the onset of psychosis. These pathological changes may be implicated in the impairment of executive functioning, attention, and working memory. The disease can be managed with pharmacological treatments based on individual patient profile, patient compliance, and disease severity. The challenge of disease management sometimes persists due to the side effects. A better understanding of the pathological processes in schizophrenia may lead to more specific and effective therapies.

Diagnosing Frailty in Primary Care Practice.

Frailty is a complex age-related clinical condition with increased vulnerability to negative health outcomes that manifest as a multidimensional syndrome and hence, a challenge to identify at-risk populations. We aim to summarize the implementation of strategies to diagnose fragility in family practice using current evidence. We searched the PubMed and Google Scholar databases for relevant articles, using the Medical Subject Headings (MeSH) terms "Frailty," "Frailty Scales," and "Primary Health Care." All original research articles on the elderly population (65 years of age or older) published in English and the last five years were included. Frailty diagnosis has resulted in positive outcomes in the overall literature. Recent hospital admission may indicate a health problem that can end up in a negative outcome and has been often described as associated with frailty. It was also shown to affect the intensive care units' mortality, in-hospital mortality, and long-term mortality. However, multiple screening instruments have been developed and validated to improve feasibility in clinical practice. The frequent lack of agreement between frailty instruments has slowed the broad implementation of these tools. The impacts of frailty warrant an upstream, proactive, holistic, interprofessional primary care approach to its identification, assessment, and management. It is a preventable disorder; identifying elderly patients at risk in primary care can help shape appropriate care processes tailored to their needs. This literature review aims to demonstrate the importance and strategies in identifying frailty in primary care settings and assess its impact on several outcomes.

A Rare Case of Three Distinct Gastrointestinal Neoplasms Occurring Simultaneously in an Elderly Patient.

Duodenal adenocarcinoma (DA), gastrointestinal stromal tumor (GIST), and pancreatic neuroendocrine tumor (PNET) are a set of rare gastrointestinal (GI) cancers characterized by nonspecific symptoms such as anemia, weight loss, and abdominal pain. We report an interesting case of DA, GIST, and PNET in a 79-year-old African American male who presented to the emergency department with syncope. The patient was tachycardic and found to have severe anemia. Further computed tomography (CT) of the abdomen and pelvis with contrast revealed a mass within the duodenal bulb along with a pancreatic cystic lesion. The patient underwent gastroduodenectomy and distal pancreatectomy with incidental findings of GIST in the posterior gastric wall. The patient after surgical removal of all tumors no longer experienced abdominal pain and had hematocrit and hemoglobin (H&H) level of 9.1/31.7 postoperation day (POD) 14. The case unfolds a rare presentation of three neoplasms that were moderate to well-differentiated with no metastases. It highlights the importance of assessment of rare GI neoplasms concurrently with colorectal cancer when geriatric patients present with nonspecific GI symptoms.

Central Nervous System Toxoplasmosis and Cytomegalovirus Colitis in an Asymptomatic HIV Positive Patient.

Human immunodeficiency virus (HIV) associated opportunistic infections are complications of patients with advanced HIV infection who are unaware of their disease or non-compliant with antiretroviral therapy. HIV patients with low CD4 count, generally less than 200 cells/µL, are at risk of developing opportunistic infections. We report a case of a 53-year-old male diagnosed with opportunistic infections, Toxoplasma gondii and cytomegalovirus (CMV). His initial presentation was central nervous system Toxoplasmosis and he later developed CMV colitis. Both are consequences of his undiagnosed advanced HIV status. The patient was promptly treated with appropriate medications for both conditions. The patient's HIV status is well controlled with highly active antiretroviral therapy (HAART) and his CD4 count is improving. It further exhibits the significance of adequate screening protocols and the importance of early treatment for HIV patients.

Diffuse Nickel Hypersensitivity Reaction Post-cholecystectomy in a Young Female.

Nickel, a silvery-hard metallic element used in corrosion-resistant alloys, is widely used in the medical field. Nickel has aided in medical advancements; however, it has been known to cause hypersensitivity reactions. Retained foreign bodies due to surgical procedures may cause postoperative complications such as allergic reactions. This case involves a 30-year-old female presenting with non-specific symptoms involving multiple organ systems, notably with abdominal pain. Due to chronic symptoms, the patient was tested for metal allergies and diagnosed with hypersensitivity reactions to nickel surgical clips that were previously inserted during cholecystectomy. Subsequently, the patient had surgical removal of the foreign bodies, which led to significant improvement of her symptoms immediately. This case demonstrates a delayed hypersensitivity reaction to a foreign body involving multiple body systems and vague symptoms making the diagnosis challenging. It is important to carefully evaluate the patient's past medical history including history of any allergies. It also brings attention to the necessity of performing metal skin patch tests preoperatively for individuals with a history of any type of allergies.

Acute Limb Ischemia Complicated by Heparin-Induced Thrombocytopenia in an Asymptomatic COVID-19 Patient.

Acute limb ischemia (ALI) is the sudden decrease in limb perfusion caused by embolism secondary to many blood stasis conditions. Treatment commences with intravenous (IV) unfractionated heparin infusion. Individuals can have an immune-mediated reaction to heparin products which results in heparin-induced thrombocytopenia (HIT). Coronavirus disease 2019 (COVID-19) has added to the difficulty of treating patients with ALI due to increasing the likelihood of HIT via the virus's ability to manipulate the coagulation parameters. We present a case of ALI complicated by HIT in a 49-year-old male with a confirmed asymptomatic COVID-19. The patient initially presented with progressive pain, coldness, and tingling in the right foot. He was treated with a tissue plasminogen activator (TPA) and a heparin drip. The occlusion persisted despite medical intervention leading to right below-knee amputation. The patient returned to the emergency department (ED) 13 days later with massive intracranial hemorrhage and subsequently expired. This case study demonstrates the significance of COVID-19 diagnostic testing due to the possibility of developing blood clots and potential complications, including HIT.

Revision Laparoscopic Adjustable Gastric Band as a Successful Alternative Over Sleeve Gastrectomy After Failed Initial Weight Loss Therapies.

Bariatric surgery is one of the most successful treatment options for morbid obesity and related comorbidities that is reserved for patients when lifestyle modifications and medical treatments fail. Bariatric surgeries are proven to result in weight reduction and improve obesity-related complications; however, there still are some reported failures. We report the case of a 35-year-old woman with morbid obesity and diabetes mellitus who had failed laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG) when done individually. The patient finally had a successful weight loss after undergoing revision LAGB over LSG. Although the present literature reports LAGB being an unsuccessful weight loss procedure, this case highlights the significance of LAGB as an effective bariatric surgery compared to other procedures. Our patient not only lost her weight successfully but also resolved her comorbid conditions and mental illness following the LAGB.

Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers.

Diabetic ketoacidosis (DKA) is an acute and significant life-threatening complication of diabetes. The association of sodium-glucose cotransporter-2 inhibitors (SGLT2i) with euglycemic diabetic ketoacidosis (EDKA) has been well reported. This literature review was conducted to understand the mechanism of EDKA and identify the potential risk factors and precipitants for patients taking SGLT2i. After reviewing the published literature between 2010 and 2020, 32 articles are included in the final review. The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.

Delayed Titanium Hypersensitivity and Retained Foreign Body Causing Late Abdominal Complications.

Titanium is a known metal used widely in the medical field and can cause allergic reactions with complications. Our case is about a 28-year-old female presenting with a spectrum of abdominal symptoms with a complicated medical history. The abdominal pain is associated with titanium allergy reaction from previously inserted titanium-based surgical clips. This patient is concurrently found to have a retained pigtail catheter in the cecum discovered incidentally through radiology. We discuss the presentation, investigations, and treatment of this unusual case. The case also unfolds rare differential diagnoses to keep in mind when encountering a patient with abdominal pain and associated nonspecific symptoms.

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.

Massive Leiomyomata and Severe Endometriosis Resulting in a Frozen Pelvis in an Asymptomatic Patient.

Leiomyomas, also known as uterine fibroids, are the most common benign uterine tumors in women. The most frequently reported symptoms are uterine bleeding and abdominal and/or pelvic pressure; however, most cases are asymptomatic and may be found incidentally. Endometriosis is a condition where the endometrium proliferates outside of the uterine cavity. Extrauterine endometrial implants are usually found in the ovaries, pelvis, and peritoneum, but can extend anywhere throughout the body. Women with endometriosis may exhibit dysmenorrhea, dyspareunia, dyschezia, and infertility. Inflammation caused by endometriosis may lead to fibrosis, scarring, and adhesions. We report a case of an asymptomatic 36-year-old African-American woman with increasing abdominal girth, consistent with a 28-week gestation, presenting to her obstetrician/gynecologist for her annual exam, who on further investigation is found to have multiple large fibroids, bilateral ovarian cysts, and widespread endometriosis with several adhesions ultimately leading to a frozen pelvis.