Beyond the Norm: A Case of Multiorgan Injury Triggered by Ibuprofen.

We report the case of a 71-year-old African American male with a history of chronic obstructive pulmonary disease (COPD), heart failure, vitiligo, penicillin allergy, and cocaine use, who presented with respiratory symptoms and was diagnosed with sepsis, COVID-19 pneumonia, exacerbation of COPD, and acute kidney injury (AKI). Treatment included antibiotics and high-dose steroids. The patient developed thrombocytopenia, autoimmune hemolytic anemia, acute liver failure, and interstitial nephritis associated with prolonged ibuprofen use. High-dose steroids and ibuprofen discontinuation led to significant improvement. This case highlights the rare occurrence of multiorgan injury from ibuprofen use, possibly aggravated by COVID-19, emphasizing the need for cautious non-steroidal anti-inflammatory drug (NSAID) use and close patient monitoring.

Synchronous Bilateral Breast Cancer With Discordant Receptor Status: Treating One Patient but Two Diseases.

The expression of hormone receptors (estrogen and progesterone) and human epidermal growth factor receptor-2 (HER2) has been used for both therapeutic and prognostic purposes in the management of breast cancer. The presence of a discordant receptor status complicates the approach to treatment in patients with synchronous bilateral breast cancer. We describe the case of a 45-year-old female with synchronous bilateral breast cancer with a triple-negative tumor and a contralateral HER2-positive tumor and discussed the impact of this on the approach to therapeutic management.

Improving the Emergency Department Management of Sickle Cell Vaso-Occlusive Pain Crisis: The Role and Options of Sublingual and Intranasally Administered Analgesia.

Vaso-occlusive crisis (VOC), characterized by periods of excruciating pain is the most common clinical manifestation of sickle cell disease (SCD), often resulting in emergency room presentation. These patients often experience long wait times in the emergency department before receiving their first dose of analgesia. This delay results from the complexities of the emergency care system. Using the intranasal or sublingual approach to administering analgesia to SCD patients with VOC offers a fast, safe, noninvasive, atraumatic, and easily accessible route of administration which could reduce the time to first dose of analgesia. With the evolving advances in the development and delivery of analgesic medications, providers should be conversant with the nuances of intranasal and sublingual analgesia in the management of acute vaso-occlusive pain crisis. This review explores the pharmacokinetic profiles, dosages, and administration of intranasal and sublingual analgesics with relevance to the SCD population.

The impact of current therapeutic options on the health-related quality of life of patients with relapse/refractory multiple myeloma: a systematic review of clinical studies.

PURPOSE: Patients with relapse and/or refractory multiple myeloma (RRMM) have a high disease burden with poor health-related quality of life (HRQoL) which worsens with each additional relapse. We aimed to review the impact of triplet, doublet, monotherapies, and salvage autologous stem cell transplantation on the HRQoL of RRMM patients. METHODS: We performed a comprehensive literature search of Medline/PubMed, Wiley Cochrane Library, EMBASE, Scopus, CINAHL, and Clinicaltrials.gov to identify clinical studies in RRMM patients with HRQoL as an outcome measure. The ISOQoL and CONSORT-PRO extension guidelines were used to assess the quality of HRQoL reporting. We synthesized the result using a qualitative analysis. RESULTS: A total of 10,245 RRMM patients enrolled in 28 eligible studies received either a triplet, doublet regimen, monotherapy, or salvage autologous stem cell transplantation. The EORTC QLQ-C30 was the most used questionnaire, and compliance with HRQoL reporting standards is generally poor among studies without an additional HRQoL publication. Most of the current therapeutic options are at best able to maintain HRQoL at baseline but not improve it. The methodological and reporting heterogeneity among the studies complicates generalizations. CONCLUSIONS: Many of the current treatment regimens for RRMM have demonstrated clinical effectiveness in trials. Unlike newly diagnosed MM, these regimens are less likely to result in significant improvement in HRQoL in RRMM. This should be communicated to patients before initiating therapies. IMPLICATIONS FOR CANCER SURVIVORS: Individualized therapeutic approach for RRMM should be chosen based on a shared decision-making process that aligns clinical efficacy with patients' treatment priorities and HRQoL.

Early Intervention With a Curative Intent Through an Intensive Therapy Versus Immunologic Disease Control Using a Minimal Intensity Approach in the Management of High-risk Smoldering Multiple Myeloma: A Systematic Review of Evidence From Clinical Trials.

A subset of individuals with smoldering myeloma (SMM) are at a high risk of progression to symptomatic myeloma. Current efforts are focused on identifying this high-risk group and intercepting the disease process before its progression. There is no consensus on what the goal of an intervention should be, whether to aim for a cure through a high-intensity intervention or pursue immunologic disease control using the least intense approach. This systematic review summarized current evidence in support of the optimum approach. A database search of Medline/PubMed, Scopus, EMBASE, Web of Science, CINAHL, Wiley Cochrane Library, clinicaltrials.gov, and conference proceedings of ASH, EHA, ASCO, ESMO was performed. Results were presented using narrative synthesis of quantitative data. Of the 2088 identified records, a total of 10 eligible studies made up of 6 minimal-intensity clinical trials, 3 moderate-intensity trials, and 1 high-intensity trial were included in this review with a total demographic population of 588 high-risk SMM patients. Minimal intensity lenalidomide-based regimen demonstrated clinical effectiveness in delaying disease progression and improving overall survival in high-risk SMM. The single-agent monoclonal antibodies did not have any major impact on improving overall survival, although the studies were not powered to do so. There is a marked increase in the depth of response as the intensity of treatment increases without a proportional improvement in overall survival. Moderate- and high-intensity interventions yielded similar minimal residual disease negativity rates and overall survival. The minimal, moderate, and high-intensity approaches all demonstrated clinical benefits in delaying disease progression and improving overall survival in patients with high-risk SMM and increasing intensity of intervention does not necessarily translate to improved overall survival.

Intravenous Fluid Administration and the Risk of Adverse Outcomes in Sickle Cell Disease Patients Hospitalized for Vaso-Occlusive Crisis.

Vaso-occlusive crisis (VOC) is the leading cause of hospitalization in sickle cell disease (SCD). Intravenous fluid (IVF) administration is the usual practice during VOC episodes to slow the sickling process. In the absence of an evidence-based, clear-cut consensus on the optimal choice, route, and rate of fluid administration, there has been a wide variability in the practice of IVF administration in the treatment of VOC. However, there are growing concerns about the safety of this practice. This systematic review summarized the current evidence on the risk of negative outcomes in SCD patients treated for VOC with IVFs. A database search of Medline/PubMed, EMBASE, Scopus, Web of Science, CINAHL, Wiley Cochrane Library, Clinicaltrials.gov, and conference proceedings of the European Hematology Association (EHA) and American Society of Hematology (ASH) were performed. The results were presented using narrative analysis of quantitative data. Of the 2,821 identified records, a total of three eligible retrospective cohort studies with a total demographic population of 549 SCD patients were included in this review. Normal saline, a frequently used IVF for VOC may be associated with adverse outcomes such as poor pain control and volume overload. Volume overload, new oxygen requirement, acute chest syndrome, and acute kidney injury are potential adverse outcomes of inappropriate IVF use in VOC. There is limited evidence supporting the current practice of IVF use in VOC. Randomized controlled trials are required to fully clarify the place and safety of IVF in the management of VOC.

Spontaneous Acute Mesenteric Thrombosis in a Patient With Hemoglobin E Thalassemia.

Acute mesenteric vein thrombosis (MVT) is an uncommon cause of mesenteric ischemia and portal hypertension. The common risk factors for the development of MVT include surgery, acute-intraabdominal inflammatory disorders, malignancies, and other prothrombotic states. However, MVT can occur in the absence of these risk factors. We describe the case of a 40-year-old man with a new diagnosis of hemoglobin E thalassemia and MVT and discuss the relationship between the hemoglobinopathy and thrombosis based on evidence from existing literature. The case emphasizes the importance of a high index of suspicion in the diagnosis of MVT in other to reduce complications and improve overall outcomes.

Second Malignancies Following Primary Cervical Cancer Diagnosis: Analysis of the SEER Database.

Introduction While mortality following primary cervical cancers (PCCs) continues to decline due to advancements in screening and treatment, a small subset of women who developed PCCs will develop second malignancies after their initial diagnosis. Little is known about these women. Objective This study aims to determine the common second malignancies among patients with primary cervical cancers and the factors associated with improved overall survival. Methodology We conducted a retrospective analysis of all PCCs in the SEER database between 1975 and 2016. We identified a subset of patients who subsequently developed secondary malignancies after a primary cervical cancer diagnosis. We then determined the factors associated with a prolonged latency interval, defined as the time between the PCC diagnosis and a subsequent secondary malignancy diagnosis. In a sub-analysis, we also determined the commonest secondary malignancies following a PCC diagnosis. Results A total of 1,494 patients with cervical cancers developed a second malignancy during the study period. The mean age at diagnosis of the PCCs was 56.0 ± 14.0 years. The mean latency interval between PCC and a subsequent secondary malignancy was 9.6 ± 9.3 years. Cytoreductive surgery (odds ratio (OR) = 1.40; 95% confidence interval (CI) = 1.05-1.86) and radiotherapy (OR = 1.52; 95% CI = 1.14-2.03) during the PCC are associated with a prolonged latency interval. Patients who received chemotherapy (OR = 0.23; 95% CI = 0.16-0.33) or those of Hispanic ethnicity (OR = 0.63; 95% CI = 0.44-0.90) were more likely to develop second malignancies within 10 years after a PCC diagnosis. The most common second malignancies were abdominal malignancies with rectal cancers (12.2%), pancreatic cancers (10.1%), stomach cancers (9.2%), cecum cancers (8.4%), and sigmoid colon cancers (8.3%). Conclusion There is a significant association between Hispanic ethnicity and a shorter latency interval among patients with PCC. The findings from this study may help optimize screening for secondary cancers among cervical cancer survivors.

Racial Disparities in Survival Among Non-Hodgkin Lymphoma Patients: An Analysis of the SEER Database (2007-2015).

Introduction Although disparities in cancer survival exist across different races/ethnicity, the underlying factors are not fully understood. Aim To identify the interaction between race/ethnicity and insurance type and how this influences survival among non-Hodgkins lymphoma (NHL) patients. Methods We utilized the SEER (Surveillance, Epidemiology, and End Results) Registry to identify patients with a primary diagnosis of NHL from 2007 to 2015. Our primary outcome of interest was the hazard of death following a diagnosis of NHL. In addition, we utilized the Cox regression model to explore the interaction between race and insurance type and how this influences survival among NHL patients. Results There were 44,609 patients with NHL who fulfilled the study criteria. The mean age at diagnosis was 50.9 ± 10.8 years, with a mean survival of 49.8± 34.5 months. Among these patients, 64.8% were non-Hispanic Whites, 16% were Hispanics, and 10.8% were Blacks. In addition, 76.5% of the study population had private insurance, 16.6% had public insurance, and 6.9% were uninsured. Blacks had the worst survival (HR=1.66; 95% = 1.55-1.78). Patients on private insurance had better survival compared to those with public insurance (HR=2.11; 95% CI=2.00-2.24) Conclusion The racial and socioeconomic disparity in survival outcomes among patients with NHL persisted despite controlling for treatment modalities, age, and disease stage.

Not all lytic bone lesions are malignant: A report of syphilitic osteitis presenting with multiple lytic skull lesions.

Syphilitic osteitis is one of the rare and often under-reported complications of early syphilis. Recognizing this entity is important as it may mimic other conditions like multiple myeloma, lymphoma, or metastatic malignancies. Misdiagnosis and delayed management can lead to irreversible destructive lesions. We herein report a case of calvaria syphilitic osteitis that was initially investigated for possible lymphoma and later diagnosed as secondary syphilis.

B-cell lymphoma-associated hemophagocytic lymphohistiocytosis: A case report.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by an exaggerated but dysregulated immune response resulting in hyperinflammation, with a potential for progression to multiple organ dysfunction and failure. Infectious diseases, inflammatory disorders, malignancies and immunodeficiency syndromes are known triggers of HLH in adults. The present study reported the case of a middle-aged man with HLH triggered by B-cell lymphoma who was successfully treated with dexamethasone; etoposide, prednisone, vincristine, cyclophosphamide, hydroxy-doxorubicin and rituximab chemotherapy; and multiple intrathecal methotrexate with a good outcome.

Global uptake of fertility preservation by women undergoing cancer treatment: An unmet need in low to high-income countries.

Although the incidence of cancers is on the rise globally, mortality has continued to decrease due to advances in early detection and treatment. Cancer treatments such as chemotherapy and radiotherapy can impact the reproductive capacity of survivors by inducing premature ovarian failure and subsequent infertility causing significant psychological distress with decreased quality of life. Despite the increasing need for fertility preservation services for the rising number of cancer survivors and the recent advances in assisted reproductive technology, many women with cancers in low, middle, and to a lesser extent, high-income countries have no access to these services. This article, therefore, presents an overview of the effect of cancer treatment on fertility, options of fertility preservation, and factors influencing fertility preservation utilization by women who had a cancer diagnosis. In addition, we discuss the availability, practices, and outcomes of fertility preservation services in low, middle, and high-income countries and highlight pragmatic steps to improving access to oncofertility care for women with cancers globally.

Pulmonary Embolism and Chronic Superior Vena Cava Occlusion Complicating Central Line-Associated Venous Thromboembolism in a Sickle Cell Disease Patient.

Sickle cell disease (SCD), the most common genetic disorder globally, is often associated with an increased risk of venous thromboembolic events (VTE). Many of these patients have central lines placed for the purposes of repeated medication administration, blood transfusions, and blood draw, further increasing the risk of VTE. Given the non-specific presentation of VTE and pulmonary embolism, as well as the risk of mortality if interventions are delayed, a high index of suspicion is required for early diagnosis of the condition. We report the case of a 35-year-old woman with SCD and a port-a-cath in place who presented with extensive upper extremity and intrathoracic VTE with associated pulmonary embolism and chronic superior vena cava (SVC) occlusion. We also discuss the peculiarities of the clinical manifestations and management of VTE and pulmonary embolism in the setting of SCD based on the evidence from existing literature.

The effect of intervention versus watchful waiting on disease progression and overall survival in smoldering multiple myeloma: a systematic review of randomized controlled trials.

BACKGROUND: Smoldering multiple myeloma (SMM) is an intermediate pre-malignant condition with individuals having a distinct risk of progression to overt myeloma. The optimal management option has remained controversial due to the heterogeneous nature of the condition in which progression to overt diseases is variable. The question of who, when, and what to use for the treatment of SMM remains equivocal. We performed a systematic review of randomized controlled trials and summarized the current evidence supporting the best approach to the management of SMM. METHODS: A comprehensive literature search of Medline/PubMed, PubMed Central, Embase, Scopus, Web of Science, Wiley Cochrane Library, CINAHL, clinicaltrial.gov, and conference proceedings of ASCO, ASH, EHA, and ESMO was performed on October 25, 2020. Synthesis of the result was done using narrative analysis. RESULT: Of the total 1560 identified records, 10 eligible studies involving 1157 patients made up of 580 in the intervention group and 577 in the control group were included in this review. Three early trials of melphalan and prednisone fail to demonstrate any significant impact on disease progression with major toxicities reported. Three trials on bisphosphonate monotherapy show reduced skeletal-related events without any clinical effect on disease progression. Lenalidomide monotherapy or as part of a combination therapy demonstrates superiority in delaying disease progression over observation. Only Lenalidomide and dexamethasone combination demonstrated superior overall survival over observation across the trials. CONCLUSION: Trials of lenalidomide in a less intensive approach has shown promise in delaying disease progression and should be investigated further in clinical trials.

Neuromyelitis optica spectrum disorder in Africa: What is the current state of knowledge?

BACKGROUND: Neuromyelitis optica spectrum disorder (NMOSD) is a chronic autoimmune inflammatory disease of the central nervous system, usually involving the optic nerve, brain, and spinal cord. While the disease is believed to be more common among individuals of African descent, the disease landscape across the continent has not been systematically explored. In this study, we carried out a systematic scoping review by synthesizing original studies on NMOSD from Africa. METHODS: A comprehensive literature search of PubMed (MEDLINE), Scopus, Embase, and Web of Science databases with the search terms 'neuromyelitis optica' and 'Africa' was performed on June 17, 2020. Synthesis of the result was done using narrative analysis. RESULT: Of the total 133 identified records, 14 eligible studies from Africa were included. Most of the studies were from North African countries (n = 8; 57%); predominantly retrospective descriptive (n = 8; 57%), or case series (n = 3; 21%); and published within the last two decades (n = 13; 93%). The total number of cases in the studies is 332, with a reported female to male ratio of 4:1 and an age range of 12-88 years at disease onset (average of <40 years in 50% of reports). Aquaporin-4 antibodies was tested in 214 cases and found in 61.7%. Three cases had Myelin Oligodendrocyte Glycoprotein antibody test with one of the cases testing positive and was associated with severe optic neuritis. Autoimmune disorders were reported in 23 out of 93 cases from three studies, while a few studies reported infectious disease associations. IV methylprednisolone was the rule during acute attacks from all the studies, while the choice of medication for maintenance varies, possibly depending on availability and cost. CONCLUSION: The research landscape on NMOSD in Africa, though limited, provides significant insight into the epidemiology, etiology, and clinical characteristics of the disease. Gaps still exist in the knowledge of disease management. Further research focusing on the African context is needed to provide customized evidence-based care to patients with NMOSD.

Acute Ischemic Stroke in COVID-19: Putative Mechanisms, Clinical Characteristics, and Management.

The emergence and spread of the highly contagious novel coronavirus disease (COVID-19) have triggered the greatest public health challenge of the last century. Aside from being a primary respiratory disease, acute ischemic stroke has emerged as a complication of the disease. While current evidence shows COVID-19 could cause ischemic stroke especially in severe disease, there are similarities in the risk factors for severe COVID-19 as well as ischemic stroke, underscoring the complex relationship between these two conditions. The pandemic has created challenges for acute stroke care. Rapid assessment and time-sensitive interventions required for optimum outcomes in acute stroke care have been complicated by COVID-19 due to the need for disease transmission preventive measures. The purpose of this article is to explore the putative mechanisms of ischemic stroke in COVID-19 and the clinical characteristics of COVID-19 patients who develop ischemic stroke. In addition, we discuss the challenges of managing acute ischemic stroke in the setting of COVID-19 and review current management guidelines. We also highlighted potential areas for future research.

Risk of Gallstone Formation in Aberrant Extrahepatic Biliary Tract Anatomy: A Review of Literature.

The age-long mnemonic of '5Fs' (fat, female, fertile, forty, and fair) has traditionally been used in medical school instructions to describe the risk factors for gallstone disease. However, evidence suggests that aberrant extrahepatic biliary tract (EHBT) anatomy may contribute significantly to the risk of gallstone disease. This review explores the anatomy and embryological bases of EHBT variations as well as the prevalence of these variations. Also, we discuss the risk factors for gallstone formation in the relationship between gallstone disease and aberrant EHBT anatomy.

Pancreatic Duct Variations and the Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic procedure in the management of biliary and pancreatic disorders. Despite advances in ERCP facilities and techniques, pancreatitis remains the most common and feared complication of this procedure. The technical challenges of ERCP could be further compounded by variations in the configuration of the pancreatic ductal system. As a result, the knowledge of these variations and their potential role in the development of post-ERCP pancreatitis (PEP) is essential to any successful risk reduction strategy. This review provides an overview of the anatomy and embryological basis of pancreatic duct variations, as well as explore the different types and prevalence of these variations. Also, we discuss the mechanisms of PEP and provide evidence supporting a link between the variations and PEP using published data.

Pulmonary Fibrosis in COVID-19 Survivors: Predictive Factors and Risk Reduction Strategies.

Although pulmonary fibrosis can occur in the absence of a clear-cut inciting agent, and without a clinically clear initial acute inflammatory phase, it is more commonly associated with severe lung injury. This may be due to respiratory infections, chronic granulomatous diseases, medications, and connective tissue disorders. Pulmonary fibrosis is associated with permanent pulmonary architectural distortion and irreversible lung dysfunction. Available clinical, radiographic, and autopsy data has indicated that pulmonary fibrosis is central to severe acute respiratory distress syndrome (SARS) and MERS pathology, and current evidence suggests that pulmonary fibrosis could also complicate infection by SARS-CoV-2. The aim of this review is to explore the current literature on the pathogenesis of lung injury in COVID-19 infection. We evaluate the evidence in support of the putative risk factors for the development of lung fibrosis in the disease and propose risk mitigation strategies. We conclude that, from the available literature, the predictors of pulmonary fibrosis in COVID-19 infection are advanced age, illness severity, length of ICU stay and mechanical ventilation, smoking and chronic alcoholism. With no proven effective targeted therapy against pulmonary fibrosis, risk reduction measures should be directed at limiting the severity of the disease and protecting the lungs from other incidental injuries.

Chest Computed Tomography Findings in COVID-19 and Influenza: A Narrative Review.

OBJECTIVE: The COVID-19 pandemic and annual influenza epidemic are responsible for thousands of deaths globally. With a similarity in clinical as well as laboratory findings, there is a need to differentiate these two conditions on chest CT scan. This paper attempts to use existing literature to draw out differences in chest CT findings in COVID-19 and influenza. METHODS: A search was conducted using PubMed. 17 original studies on chest CT findings in COVID-19 and influenza were identified for full-text review and data analysis. Findings. COVID-19 and influenza share similar chest CT findings. The differences found show that COVID-19 ground-glass opacities are usually peripherally located with the lower lobes being commonly involved, while influenza has a central, peripheral, or random distribution usually affecting the five lobes. Vascular engorgement, pleural thickening, and subpleural lines were reported in COVID-19 patients. In contrast, pneumomediastinum and pneumothorax were reported only in studies on influenza. Conclusion and Relevance. COVID-19 and influenza have overlapping chest CT features with few differences which can assist in telling apart the two pathologies. Additional studies are needed to further define the differences and degree between COVID-19 and influenza.