Point-of-care ultrasonography spotlight: Could venous excess ultrasound serve as a shared language for internists and intensivists?

Point-of-care ultrasonography (POCUS), particularly venous excess ultrasound (VExUS) is emerging as a valuable bedside tool to gain real-time hemodynamic insights. This modality, derived from hepatic vein, portal vein, and intrarenal vessel Doppler patterns, offers a scoring system for dynamic venous congestion assessment. Such an assessment can be crucial in effective management of patients with heart failure exacerbation. It facilitates diagnosis, quantification of congestion, prognostication, and monitoring the efficacy of decongestive therapy. As such, it can effectively help to manage cardiorenal syndromes in various clinical settings. Extended or eVExUS explores additional veins, potentially broadening its applications. While VExUS demonstrates promising outcomes, challenges persist, particularly in cases involving renal and liver parenchymal disease, arrhythmias, and situations of pressure and volume overload overlap. Proficiency in utilizing spectral Doppler is pivotal for clinicians to effectively employ this tool. Hence, the integration of POCUS, especially advanced applications like VExUS, into routine clinical practice necessitates enhanced training across medical specialties.

Hamman Syndrome with a Rare Feature of Pneumorrhachis - An Unusual Complication of Polysubstance abuse and e-vaping.

Hamman syndrome is defined as dissection of air in mediastinum and skin fascia usually due to increased intrathoracic pressure. The air leak tends to make its way into pleural and pericardial layers; however, in rare instances air can also dissect into epidural spaces, regarded as pneumorrhachis. We present a case of a young male with a history of polysubstance abuse and e-vaping, who presented with symptoms of altered mental status. Given the concerning physical examination, a computed tomography of the chest was undertaken, which showed pneumothorax, pneumomediastinum and pneumorrhachis. The patient was closely monitored in the intensive care unit and improved after symptomatic management. The symptoms of pneumorrhachis depend on the volume and location of air in intracranial and intraspinal space. Although asymptomatic in our case, it is crucial for clinicians to be aware that pneumorrhachis with Hamman syndrome can potentially cause neurological deficits and cardiopulmonary arrest in severe cases due to increased intraspinal and intracranial hypertension, emphasising the need for close monitoring. LEARNING POINTS: Elevated intrathoracic pressure generated by deep inhalation of an aerosolised product is one of the triggers of air dissection in pleural, pericardial, and mediastinal regions. In rare instances, air can also translocate into intracranial and intraspinal spaces, which is referred to as pneumorrhachis.Mostly asymptomatic, pneumorrhachis has the potential to develop acute neurological deficits due to increased intracranial and intraspinal pressure, validating the need for acute monitoring.Most cases of pneumorrhachis are managed conservatively. However, severe cases warrant decompression or high concentrations of oxygen administration to facilitate air absorption.

An Uncommon Finding in an Adult: A Case Report of Hypoplastic Left Heart Syndrome and Protein-Losing Enteropathy.

Protein-losing enteropathy (PLE) is a rare disorder with diverse causes, but the treatments are limited and understudied. It is often associated with significant mortality and morbidity. The survival of hypoplastic left heart syndrome (HLHS) in infants without any intervention is usually 4.5 days, and 30-day mortality is 95%. However, with surgical intervention, survival at 20 years is 80%. HLHS can lead to protein-leading enteropathy and is corrected by the three-step procedures (Norwood, Glenn, and Fontan) during infancy. We report a case of Fontan procedure postoperative HLHS associated with PLE and describe its clinical course and outcome. The main intention of reporting this case is to provide awareness among physicians while dealing with refractory cases of hypoproteinemia and appropriate management based on the literature.

Double Negative Is Positive: Anomalous Aortic Origin of the Left Coronary Artery Saved by a Bicuspid Aortic Valve.

Atypical aortic origin of coronary artery (AAOCA) is a rare heart condition that has been identified in only a few autopsy cases and in some patients who have undergone angiographic evaluation. AAOCA is known to be closely linked with aortic valve malformations, with the most common type being the bicuspid aortic valve (BAV). A 77-year-old male with a medical history of hypertension and diabetes presented with dyspnea and orthopnea for three days. During the eventual cardiac catheterization, it was noted that the left coronary artery had an anomalous origin from the right side, coursing between the aorta and pulmonary artery. Contrast-enhanced computerized tomography (CECT) also showed a type 2 BAV and a left main coronary artery arising lower at the level of the pulmonary trunk. The dyspnea in this patient was attributed to diastolic dysfunction, and surgical correction of the coronaries was not done. The patient was managed on an outpatient basis for heart failure. In this case, the patient had an anomalous origin of the left coronary artery and type 2 BAV, which posed significant cardiovascular complications. It is unclear if the presence of the concomitant type 2 BAV led to the origin of the anomalous left coronary artery being at a lower level through its effect on the developmental mechanics. This lower origin may have resulted in lower compressive forces on the coronary artery as the inter-arterial pressures would be lower closer to the heart and farther from the lungs. Our case report aims to highlight this complex presentation where the BAV likely provides a benefit in AAOCA cases.

Case Report and Literature Review of an Anomalous Course of the Left Main Coronary Artery (LMCA) Arising From the Right Sinus of Valsalva (RSV) Presenting as Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) mimics myocardial infarction with symptoms like chest pain, electrocardiogram (EKG) changes, and elevated troponin levels, although it typically features normal coronary arteries upon angiography. While often asymptomatic, coronary artery anomalies (CAAs) can cause intermittent vasospasm and endothelial dysfunction, potentially inducing TC. We report the case of a 74-year-old female with a history of hypertension, hyperlipidemia, and peripheral artery disease, who presented with sudden onset chest pain. Initial EKG and elevated troponin suggested myocardial infarction. However, coronary angiography revealed an anomalous left main coronary artery (LMCA) originating from the right coronary artery (RCA), with no significant stenosis. Subsequent transthoracic echocardiography indicated TC, with the left ventricular ejection fraction improving from 35-40% to 60-65% within days. Cardiac computed tomography angiography (CCTA) revealed that the anomalous LMCA originated from the common trunk at the right sinus of Valsalva (RSV), which further continued as a large, dominant RCA. The LMCA branched into a small to moderate left anterior descending artery (LAD) and a non-dominant left circumflex artery (LCx). The LMCA followed a prepulmonic/anterior course, while the LCx took an interarterial course between the aorta and pulmonary artery. The patient was referred for further surgical evaluation. We conclude that the CAA was an incidental finding and was not related to underlying TC. Although rare, this case suggests a possible correlation between CAAs and a predisposition to stress-induced cardiomyopathy, warranting further investigation.

A Rare Case of Adrenal Carcinoma With Isolated Hypercortisolism Mimicking Hyperaldosteronism.

We report a case of a 22-year-old female with pedal edema, hypokalemia, and hypertension. On suspicion of hyperaldosteronism, further workup was pursued, which only revealed a low serum adrenocorticotropic hormone (ACTH) and an inappropriately normal cortisol level after a 1-mg dexamethasone suppression test, suggestive of primary hypercortisolism. CT of the chest, abdomen, and pelvis revealed a left adrenal mass. Based on the clinical findings and biochemical abnormalities, we were expecting this tumor to be aldosterone-secreting, but both serum aldosterone and renin levels were normal in our patient. Eventual surgical resection confirmed initial suspicions of malignancy, as it was found to be adrenal cortical carcinoma. This case highlights the unusual presentation of this rare but aggressive endocrinologic neoplasm and the importance of its prompt diagnosis and treatment.

From Silent to Severe: Gastric Perforation Causing Spontaneous Hydropneumothorax Secondary to a Large Hiatal Hernia.

Hiatal hernias, characterized by the protrusion of internal organs through the diaphragmatic hiatus, are commonly seen in the elderly age group. While surgical management remains debatable for asymptomatic cases, emergent complications necessitate prompt intervention. Here, we present a case of a 69-year-old female with a history of diaphragmatic hernia, who developed acute hypoxic respiratory failure secondary to acute pleural effusion caused by paraesophageal hernia rupture. Despite initial inconclusive imaging, a CT scan revealed the severity, prompting emergent management. The patient underwent esophageal stent placement, video-assisted thoracoscopic surgery-assisted total lung decortication, and three chest tubes placement, followed by antimicrobial therapy. Favorable outcomes were achieved with multidisciplinary intervention, highlighting the importance of timely recognition and comprehensive diagnostic approaches. This case underscores the potential severity of hiatal hernias, particularly paraesophageal types, necessitating vigilance among clinicians for timely intervention. It also emphasizes the effectiveness of combined surgical and medical multidisciplinary approaches in such emergent situations for optimal patient outcomes.

Comprehensive review of statin-intolerance and the practical application of Bempedoic Acid.

Statin-intolerance (SI) has prevalence between 8.0 % and 10 %, and muscular complaints are the most common reason for discontinuation. Bempedoic acid (BA), an ATP citrate lyase inhibitor, decreases hepatic generation of cholesterol, upregulates low-density lipoprotein (LDL) receptor expression in the liver, and eventually clears circulating LDL-cholesterol from the blood. Multiple randomized clinical trials studying BA demonstrate a reduction in LDL levels by 17-28 % in SI. The CLEAR OUTCOME trial established significant cardiovascular benefits with BA. A dose of 180 mg/day of BA showed promising results. BA alone or in combination with ezetimibe is US Food and Drug Administration-approved for use in adults with heterozygous familial hypercholesterolemia and/or established atherosclerotic cardiovascular disease. BA reduced HbA1c by 0.12 % (p < 0.0001) in patients with diabetes. Adverse events of BA include myalgia (4.7 %), anemia (3.4 %), and increased aminotransferases (0.3 %). BA can cause up to four times higher risk of gout in those with a previous gout diagnosis or high serum uric acid levels. Reports of increased blood urea nitrogen and serum creatinine were noted. Current evidence does not demonstrate a reduction in deaths from cardiovascular causes. More studies that include a diverse population and patients with both high and low LDL levels should be conducted. We recommend that providers consider BA as an adjunct to statin therapy in patients with a maximally tolerated dosage to specifically target LDL levels.

The Outcome of Aplastic Anaemia Associated with Terbinafine Therapy.

Onychomycosis (OM), a widespread fungus that affects the toenails and/or fingernails, causes a large amount of morbidity and is very frequent in the general population. The best treatment is systemic antifungals. Terbinafine is a potent antifungal drug that works by targeting the keratin and lipids found in fungi. In the United States, the prevalence of this nail ailment ranges from 2% to 14%; it is 5.5% globally. Here, we describe a case of aplastic anaemia linked to oral terbinafine use. Clinicians should be aware of this rare adverse effect and early discontinuation of the treatment is required to prevent significant morbidity and mortality. LEARNING POINTS: Aplastic anaemia is a rare side effect of terbinafine.Patients should be advised about this, and serial laboratory testing can be helpful for those who are on a long-term course of terbinafine.Early diagnosis and start of treatment can lead to a favourable outcome.

Autoimmune diabetes from pembrolizumab: A case report and review of literature.

BACKGROUND: Immunotherapy, specifically the use of checkpoint inhibitors such as pembrolizumab, has become an important tool in personalized cancer therapy. These inhibitors target proteins on T-cells that regulate the immune response against tumor cells. Pembrolizumab, which targets the programmed cell death 1 receptor on T-cells, has been approved for the treatment of metastatic melanoma and non-small cell lung cancer. However, it can also lead to immune-related side effects, including pneumonitis, colitis, thyroid abnormalities, and rare cases of type 1 diabetes. CASE SUMMARY: The case presented involves an adult patient in 30s with breast cancer who developed hyperglycemia after receiving pembrolizumab treatment. The patient was diagnosed with diabetic ketoacidosis and further investigations were performed to evaluate for new-onset type 1 diabetes. The patient had a history of hypothyroidism and a family history of breast cancer. Treatment for diabetic ketoacidosis was initiated, and the patient was discharged for close follow-up with an endocrinologist. CONCLUSION: This literature review highlights the occurrence of diabetic ketoacidosis and new-onset type 1 diabetes in patients receiving pembrolizumab treatment for different types of cancer. Overall, the article emphasizes the therapeutic benefits of immunotherapy in cancer treatment, particularly pembrolizumab, while also highlighting the potential side effect of immune-related diabetes that can occur in a small percentage of patients. Here we present a case where pembrolizumab lead to development of diabetes after a few cycles highlighting one of the rare yet a serious toxicity of the drug.

Calcitriol induced hypercalcemia - a rare phenomenon in lung cancer: A case report.

BACKGROUND: Calcitriol-induced hypercalcemia has been rarely reported in cases of lung cancer; however, it is frequently reported in cases of lymphoid malignancy and granulomatous disease. We present a rare case of hypercalcemia associated with squamous cell cancer of the lung with elevated calcitriol level. CASE SUMMARY: A 61-year-old Caucasian female with severe hypercalcemia of 15 mg/dL, which led to a new diagnosis of metastatic lung cancer. Since the parathyroid hormone-related peptide (PTHrP) level was minimally elevated at 2.1 pmol/L, we believe excessive calcitriol production by tumor cells was the underlying mechanism for hypercalcemia. Calcitriol was significantly elevated at 130 pg/mL with a low 25-hydroxyvitamin D level of 25.9 ng/mL and suppressed PTH level of 8 pg/mL. Corticosteroids are generally used to treat calcitriol-induced hypercalcemia, but we successfully treated our patient with bisphosphonate, highlighting the further utility of bisphosphonates in hypercalcemia treatment. CONCLUSION: We believe that the underlying cause of hypercalcemia, in this case of metastatic squamous cell lung carcinoma, was elevated calcitriol, which was likely produced by the tumor cells. In addition to PTHrP, calcitriol levels should be included in the workup for hypercalcemia in cases of lung cancer. However, the pathophysiology and prognostic significance of dysregulated calcitriol production in solid tumors remain unclear and warrant further research. Bisphosphonate may be used as a steroid-sparing therapy even in cases of calcitriol-induced hypercalcemia and warrants further investigation.

Hemophagocytic Lymphohistiocytosis and Pancreatic Cancer: A Rare Association.

Introduction: Hemophagocytic lymphohistiocytosis (HLH) or hemophagocytic syndrome (HPS) is a life-threatening and relatively rare condition that usually presents as a multisystem febrile illness. It is associated with excessive activation of the immune system and hypercytokinemia, leading to an unregulated aggregation of macrophages and lymphocytes. Here, we present the first likely case of HLH with metastatic pancreatic carcinoma being the underlying etiology. Case: A 44-year-old male with past medical history significant for heart transplant for which he was on tacrolimus, End-Stage Renal Disease (ESRD) on hemodialysis, recently treated CMV viremia, and necrotizing pancreatitis presented to the emergency with complaints of chills, decreased appetite, worsening non-bloody emesis, and dull left upper quadrant abdominal pain with radiation to the back for four days. No shortness of breath, fever, diarrhea, or blood in the stool was reported. Vitals on admission were blood pressure of 90/61 mmHg, a heart rate of 110 beats per minute, temperature of 98.1 °F, and respiratory rate of 18 per minute. Physical exam was significant for scleral icterus, decreased bibasilar breath sounds, moderate abdominal tenderness in the left flank and left upper abdominal quadrant without any palpable mass, and 1+ bilateral pedal edema. The remainder of the physical examination was benign. Electrocardiogram (EKG) showed sinus tachycardia without any ischemic changes, and chest x-ray showed mild pulmonary edema. Initial blood workup revealed WBC at 8.3 k/uL, hemoglobin of 10.2 g/dL, platelet count of 90 k/uL, and BUN/creatinine of 45/5.8 (baseline 40/5.0). Cardiac workup showed an elevated high sensitivity troponin level of 2479 pg/mL and brain natriuretic peptide (BNP) of 600 (0-100 pg/mL). The hepatobiliary profile showed an aspartate transaminase (AST) level of 2645 U/L, an alanine transaminase (ALT) of 2935 U/L, alkaline phosphatase (ALP) of 106 U/L, and lipase of 61 U/L, with total and conjugated bilirubin of 3.5 mg/dL and 2.1 mg/dL, respectively. Transthoracic echocardiogram (TTE) showed reduced left ventricular size with hyperdynamic systolic function. Computerized tomography (CT) scan of the abdomen (Fig. 1) revealed numerous new pulmonary nodules, ring-enhancing lesions within the liver, hyperenhancement of the pancreas with walled-off necrosis, and splenomegaly. Microbiological work-up was positive for cytomegalovirus (CMV) serologies (IgM and IgG) but absent viral load on Polymerase Chain Reaction (PCR). The initial diagnosis was systemic inflammatory respiratory syndrome (SIRS), likely septic versus distributive in the setting of pancreatitis, demand mediated non-ST segment elevation myocardial infarction (NSTEMI), and shock liver. Tacrolimus was held, and the patient was started on broad-spectrum antibiotics including vancomycin and cefepime for sepsis of unknown origin along with vasopressors for hypotension, requiring admission to the medical intensive care unit. Blood and urine cultures were collected on admission which remained negative throughout the course of hospital. CA19-9 levels were found elevated at 5587 U/mL. Liver biopsy was consistent with poorly differentiated adenocarcinoma of pancreatic origin. Both Infectious Disease and Hematology were consulted due to broad differential diagnoses. Due to the patient's continued hemodynamic instability and nonresponsiveness to the antibiotics, HLH was suspected with supporting labs as follows: ferritin 55,740 ng/mL (22-322 ng/mL), triglycerides 177 mg/dL (30-150 mg/dL), and fibrinogen 244 mg/dL (173-454 mg/dL), thus conferring 70-80% probability of HPS based on H-score. Soluble IL-2 R levels came out at 19,188 pg/mL (ref range 175-858 pg/mL). The patient couldn't be started on HLH treatment due to initial concerns of underlying infection and the delay in results of soluble IL-2 Receptor (IL-2 R) levels. The infection as a possible etiology was ruled out due to negative blood and urine cultures and HLH was attributed to pancreatic cancer. A marrow biopsy couldn't be pursued as the patient died within a week of hospitalization. An autopsy was not performed as per family's request. Conclusion: HLH can occur secondary to solid cell malignancies including those from the pancreas and should be kept high in the differential in critically ill cancer patients who are nonresponsive to antibiotics. H-score has been reported to be a more sensitive tool compared to the HLH protocol, especially if used earlier during the presentation. Further research is needed to compare diagnostic efficacy for HLH protocol verses H-score especially in critically ill patients as they might benefit from steroid trial.

Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal.

According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.

Tracheoesophageal Prosthesis Malfunction - A Case Report.

Tracheoesophageal prosthesis (TEP) is an artificial connection between the trachea and esophagus allowing air into the upper esophagus from the trachea thereby vibrating it. TEPs give patients who lose their vocal cords to laryngectomies a tracheoesophageal voice. A potential complication of this is silent aspiration of gastric content. We present a case of a 69-year-old female with a TEP placed after a laryngectomy for laryngeal cancer who presented to the hospital with shortness of breath and hypoxia. She was initially treated for a presumed diagnosis of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations but continued to be hypoxic despite aggressive medical management. Further evaluation revealed silent aspirations as a consequence of TEP malfunction. Through our case report we urge clinicians to consider this differential diagnosis, as the clinical presentation of silent aspiration among patients with a TEP can be easily mistaken for a COPD exacerbation. A large number of patients with TEPs are smokers with underlying COPD. LEARNING POINTS: TEPs give patients who lose their vocal cords to laryngectomies a tracheoesophageal voice.A potential complication of TEPs is silent aspiration around or through the TEP, causing coughing and even recurrent aspiration pneumonitis or pneumonia.Patients with TEPs typically have extensive smoking histories and underlying COPD or CHF which can have exacerbations that are similar in presentation.

Impact of Obesity on In-Hospital Morbidity and Mortality Among Patients Admitted for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD).

Background Obesity has been considered to be a risk factor for increased morbidity and mortality among patients with cardiopulmonary diseases. The burden of chronic obstructive pulmonary disease (COPD) and obesity is very high in the United States. We aimed to use the National Inpatient Sample (NIS) to evaluate the impact of obesity on the outcomes of patients hospitalized with COPD exacerbation. Materials & Methods This is a retrospective cohort study from the NIS database involving adult patients hospitalized for COPD exacerbation in the year 2019 obtained using the international classification of diseases, 10th revision coding system (ICD-10). Obese and morbidly obese subgroups were identified. Statistical analyses were done using the Stata software, and regression analysis was performed to calculate odds ratios. Adjusted odds ratios (aOR) were calculated after adjusting for potential confounders. Results Among patients hospitalized for COPD exacerbations, mortality rates were lower among obese and morbidly obese patients; aOR 0.72 [0.65, 0.80] and aOR 0.88 [0.77-0.99], respectively. Obese and morbidly obese were more likely to require non-invasive ventilation aOR 1.63 [1.55, 1.7] and aOR 1.93 [1.85-2.05], respectively, and were more likely to require mechanical ventilation aOR 1.25 [1.19, 1.31], and aOR 1.53 [1.44-1.62], respectively. The tracheostomy rate was 1.17%, 0.83%, and 0.38% among patients with morbid obesity, obesity, and nonobese patients, respectively. Obese (aOR 1.11 [1.07-1.14]) and morbidly obese patients (aOR 1.21 [1.16-1.26]) had higher odds of being discharged on home oxygen and to a skilled nursing facility (SNF), aOR 1.32[1.27-1.38] and aOR 1.37 [1.3-1.43], respectively. Average hospital charges and length of hospitalization were significantly higher for morbidly obese and obese patients as compared to non-obese patients (p < 0.01). Conclusions Among admissions for COPD exacerbation, the rates of non-invasive ventilation, mechanical ventilation, tracheostomy, discharge with supplemental oxygen, length of hospitalization, hospitalization charges, and discharge to an SNF were higher among obese patients representing a higher morbidity and healthcare utilization in this group. This, however, did not translate into increased mortality among obese patients admitted with COPD exacerbations, and further randomized controlled trials are required to confirm our findings.

When Hormones are Being Difficult: A Rare Case and the Literature Review of Pembrolizumab-Induced Polyendocrinopathy.

Immune Checkpoint inhibitors (ICIs) such as nivolumab, pembrolizumab, and ipilimumab are monoclonal antibodies against cytotoxic T lymphocyte antigen 4 (CTLA4) or program death (PD)1 and its ligand PDL1. Agents targeting PD1, such as pembrolizumab, have shown widespread efficacy in the past and are also associated with a wide range of immune-related adverse events (irAEs), including endocrine toxicities. A 31-year-old female with a medical history significant for Stage IIb Breast cancer on chemo and immunotherapy (pembrolizumab) presented with nausea, vomiting, and generalized abdominal pain. Laboratory studies showed a blood glucose level of 356 mg/dl, elevated Anion gap 18 meq/L, beta-hydroxybutyrate 46 mg/d, and low C-peptide levels <0.10 ng/ml. The patient was treated for Diabetic Ketoacidosis (DKA). Further testing revealed high Thyroid Stimulating Hormone (TSH) levels along with elevated thyroid peroxidase levels of 38 IU/L. After discharge from the hospital on insulin and levothyroxine therapy, the patient reported increasing fatigue and further testing revealed low cortisol levels <0.5 mcg/dl with elevated ACTH consistent with primary adrenal insufficiency. The patient was started on hydrocortisone therapy with improvement in symptoms. Endocrine toxicities are not uncommon in patients receiving pembrolizumab, but polyendocrinopathy in a relatively rare side effect of pembrolizumab. Only a few cases of pembrolizumab-induced polyendocrinopathy have been reported so far which we have mentioned in this article. While patients are on immunotherapy, close monitoring for clinical signs & symptoms can lead to an early diagnosis, substantially improving morbidity and mortality.

HCAHPS: having constant communication augments hospital and patient satisfaction.

BACKGROUND AND AIM: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has become a standardised instrument to measure hospitalised patients' perception of care. Our hospital's HCAHPS scores for the 'communication with doctors' domain in medical service were suboptimal when compared with peer groups in December 2020. Our goal was to improve performance in the 'communication with doctors' domain to at least 50% from baseline over a 6-month period. INTERVENTION: Orientation of house staff, nurses and attendings on the Acknowledge, Introduce, Duration, Explain, Thank you (AIDET) approach. Implementation of the afternoon rounds (with documentation) along with the morning rounds to summarise the plan and discuss updates throughout the day to enhance doctor-patient communication. DATA ANALYSIS: HCAHPS domain scores for 'communication with doctors' with each subcategory were tracked monthly as well as the number of PM notes written as a measure of afternoon rounds. RESULTS: 'Communication with doctor' domain improved from 8% percentile rank in December to as high as 78%. 'Doctors treat you with courtesy/respect' improved from 24% percentile rank in December to as high as 90%. 'Doctors listen carefully to you' improved from 13% percentile rank in December to as high as 88%. 'Doctors explain in a way you understand' improved from 2% percentile rank in December to as high as 72%. CONCLUSIONS: Our results suggest that HCAHPS scores in the 'communication with doctors' domain can be improved when employing the AIDET approach with each patient encounter and the addition of afternoon rounds. Sustainability is vital to the success of these interventions, as we observed in our results that there is a direct proportional correlation with the number of afternoon rounds performed with higher scores.

Epidemiology and Determinants of Survival for Primary Intestinal Non-Hodgkin Lymphoma: A Population-Based Study.

Background: Gastrointestinal tract is the most common site of extranodal non-Hodgkin lymphoma (EN-NHL). Most of the published data have been on gastric NHL with limited studies on primary intestinal non-Hodgkin lymphoma (PI-NHL) considering rare incidence. We performed epidemiological and survival analysis for PI-NHL from the Surveillance, Epidemiology, and End Results (SEER) 18 database. Methods: A total of 9,143 PI-NHL cases of age ≥ 18 years were identified from the SEER 18 database for the period 2000 - 2015. Totally, 8,568 patients were included for survival analysis. Cause-specific survival (CSS) and overall survival (OS) analysis were done for PI-NHL and PI-diffuse large B-cell lymphoma (PI-DLBCL) using sex, age of onset, treatment, histology, stage, and year of diagnosis. Survival analysis was done by using Cox proportional hazard model and Kaplan-Meier plot with log-rank test. Results: The percentage of PI-NHL of all the intestinal cancers and EN-NHL were 1.35%, and 10.52%, respectively. The age-adjusted incidence was 0.9145/100,000 population for the study population. PI-NHL was more common among patients aged ≥ 60 years, male and non-Hispanics Whites. Majority of patients were diagnosed at stage 1 and 2 (74%), and DLBCL (44.8%) was the most common histology. Overall median survival was 111 (95% confidence interval (CI): 105 - 117) months. In OS analysis, significant increased risk of mortality was seen with T-cell NHLs vs. DLBCL (hazard ratio (HR): 2.56), patients aged ≥ 60 vs. < 60 years (HR: 2.87), stage 4 vs. stage 1 (HR: 1.93), male vs. female (HR: 1.17), with best outcome seen in patient treated with combination of chemotherapy and surgery vs. none (HR: 0.45). Similar results were seen in CSS and for PI-DLBCL as well. Significant improvement in outcomes was observed for PI-DLBCL patients receiving chemotherapy with/without surgery. Conclusions: Findings from our large, population-based study reveal PI-NHL is a rare type of intestinal malignancy with significant difference in survival based on histological and epidemiological characteristics.

A Signet Cell Carcinoma of the Ileum: A Rare Differential Diagnosis of Intestinal Pathology with Fistula Mimicking Crohn's Disease.

Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death in the USA. Primary signet ring cell carcinoma (SRCC) of the colon and rectum is extremely rare with a reported incidence of less than 1%. Here we present the case of a 41-year-old man who presented with abdominal pain, severe microcytic anaemia and a negative faecal occult blood test (FOBT). A CT scan of the abdomen revealed thickening of the terminal ileum and proximal right colon with extensive lymphadenopathy and a fistula tract extending from the terminal ileum to the right buttock. Endoscopic features like cobblestoning of the ileocolic junction along with elevated blood and stool inflammatory markers raised suspicion of Crohn's disease (CD). However, histopathological study surprisingly revealed primary colorectal signet cell carcinoma (PCRSCC) with no evidence of CD. Cases of simultaneous PCRSCC and CD have been reported, but no clear association has been established. Our case is unique in that it presented with classic clinical features of CD, but PCRSCC without any histological evidence of underlying CD was found on histology. LEARNING POINTS: A rare case of primary colorectal signet cell carcinoma of the colon is described.Primary signet cell carcinoma of the colon can present with severe microcytic anaemia and abdominal pain.Signet cell carcinoma can mimic Crohn's disease on radiological and endoscopic findings, including the presence of a fistula tract.

Cerebral Venous Sinus Thrombosis in COVID-19: An Unusual Presentation.

Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has been associated with a significantly increased risk of venous and arterial thromboembolism, particularly in severely sick patients. Recently, cerebral venous sinus thrombosis (CVST) cases have been reported in the context of coronavirus disease-2019 (COVID-19). These cases either had an active COVID infection with a positive reverse transcription-polymerase chain reaction (RT-PCR) or were symptomatic (fever, respiratory symptoms, myalgia) during the presentation. We present here a 41-year-old male with CVST who had negative RT-PCR and positive immunoglobulin G (IgG) COVID-19 antibodies. He was neither diagnosed nor had a flu-like illness before admission. This case highlights that CVST can be a late sequela of previously undiagnosed asymptomatic COVID-19 infection.