Use of Plasmapheresis and Immunosuppressants to Treat Diffuse Alveolar Hemorrhage in a Patient with Granulomatosis with Polyangiitis.

Granulomatosis with polyangiitis (GPA) is a systemic granulomatous inflammatory disease characterized by small-to-medium vessel vasculitis due to Central Anti-Neutrophil Cytoplasmic Antibody (C-ANCA). GPA commonly involves the lungs and the kidneys. Among the pulmonary manifestations, diffuse alveolar hemorrhage (DHA) is a rare presentation of GPA that can present with hemoptysis leading to acute onset of anemia and hemodynamic instability. An active diagnostic workup including serologic titer of C-ANCA, imaging, intensive care, and aggressive immunosuppression is the key to DAH management. We report a case of DAH secondary to GPA that presented with hemoptysis leading to severe anemia, initially resuscitated symptomatically and started on plasmapheresis with pulse steroids and cyclophosphamide. Timely diagnosis and management led to a remarkable recovery of the pulmonary symptoms and imaging findings of DAH.

PUBG-related suicides during the COVID-19 pandemic: Three cases from Pakistan.

INTRODUCTION: The present case report presents the most extreme negative aspects of gaming, namely PUBG-related suicide during the coronavirus disease-2019 pandemic in Pakistan. CASE PRESENTATION: Three suicide cases of extreme gamers occurred within a few days of each other in Lahore, Pakistan. All three were young males aged 16-20 years and their suicides appear to be related to PUBG addiction. It is likely that all three individuals experienced other predisposing factors relating to psychological instability. PRACTICAL IMPLICATIONS: For vulnerable groups such as adolescents and emerging adults who have psychological predispositions and/or other comorbidities, engrossing videogames which take up many hours a day such as PUBG may pose a risk which in the most extreme cases may be fatal.

Suicide among adolescents and youths during the COVID-19 pandemic lockdowns: A press media reports-based exploratory study.

PROBLEM: Suicide incidences among adolescents and youths during the Coronavirus Disease 2019 (COVID-19) lockdowns have been reported across the world. However, no studies have been carried out to investigate cumulative nature, patterns, and causative factors of such suicide incidences. METHODS: A purposive sampling of Google news between 15 February and 6 July was performed. After excluding duplicate reports, the final list comprised a total of 37-suicide cases across 11 countries. FINDINGS: More male suicides were reported (21-cases, i.e., 56.76%), and the mean age of the total victims was 16.6 ± 2.7 years (out of a total of 29 cases). About two-thirds of the suicides were from three countries named India (11-cases), UK (8-cases), and the USA (6-cases). Out of 23-student victims, 14 were school-going students. Hanging was the most common suicide method accounting in 51.4% of cases. The most common suicide causalities were related to mental sufferings such as depression, loneliness, psychological distress, and so forth, whereas either online schooling or overwhelming academic distress was placed as the second most suicide stressors followed by TikTok addiction-related psychological distress, and tested with the COVID-19. CONCLUSIONS: The finding of the temporal distribution of suicides concerning lockdowns may help in exploring and evolving public measures to prevent/decrease pandemic-related suicides in young people.

Rhabdomyolysis Induced Acute Kidney Injury in Hyperglycemic Hyperosmolar State Patient With New-Onset Diabetes: A Case Report.

The hyperglycemic hyperosmolar state (HHS) is a serious acute complication of type 2 diabetes mellitus that requires prompt recognition, diagnosis, and treatment. Reversible acute kidney injury is common in hyperglycemic states. However, hyperglycemic emergencies can contribute to the development of rhabdomyolysis, which can further aggravate acute kidney injury and can cause high morbidity and mortality. HHS can be the first clinical presentation of diabetes mellitus in some patients. Here, we present a case of HHS-related rhabdomyolysis and acute kidney injury, which was the first presentation of type 2 diabetes mellitus in this patient. Our case highlights the importance of a rare association between rhabdomyolysis and HHS in diabetic patients.

Maple Syrup Urine Disease Masquerading as Urea Cycle Disorder: A Tale of Two Clinical Mimics.

Maple syrup urine disease, an inherited disorder of metabolism, is characterised by deficient activity of the branched-chain alpha-keto acid dehydrogenase complex (BCKAD) enzyme, resulting in an accumulation of branched-chain amino acids. While it is classically diagnosed by the means of a neonatal screening panel, it can sometimes remain undetected. In such cases, maple syrup urine disease is noted to elicit a constellation of clinical symptoms characterised by a plethora of neurological and respiratory impairments. A prompt diagnosis and management of the disease therefore remains imperative. Due to the remarkable semblance in the clinical symptoms elicited by maple syrup urine disease and urea cycle disorders, both the ailments should be considered in the list of differential diagnosis in patients presenting with elevated serum ammonia levels in the context of the overarching clinical picture. We chronicle the case of a 25-day-old neonate who presented with unabated seizures. An initial diagnosis of a urea cycle disorder was suspected; however, further diagnostic workup divulged an underlying diagnosis of maple syrup urine disease.

The Impact of Inflammatory Bowel Disease on Pregnancy and the Fetus: A Literature Review.

Inflammatory bowel disease (IBD) is a constellation of devastating chronic inflammatory changes in the bowel, either involving the large or small bowel or part of both. As it is widely diagnosed in the fertile age group, this disorder can present itself, very commonly, during pregnancy and thus a better understanding of the disease can be an important factor to influence the maternal and fetal well-being. Medications are what is considered the first line in the management of this disease to control the symptoms or keep the disease in remission. In addition to this, the drugs used to keep the disease in remission can also cause significant adverse effects on the patient and the new nurturing life preparing itself for the outside world. What the fetus gets from the mother will stay for life with the child. We conducted an electronic literature review search which highlights the significance and impact of sustained remission of IBD and the cautious use of various drugs during pregnancy for that purpose. In addition to the influences already mentioned, It is evident that nutritional deficiencies can also prevail with the advancing disease, something to manage as a side note as well. These deficiencies can have a definite effect on the fetus and may cause developmental malformations. In order to avoid this process, a systemic and joint approach should be curtailed. This can reduce the adverse outcomes associated with this ailment during pregnancy.

Women with Epilepsy: Anti-epileptic Drugs and Perinatal Outcomes.

Epilepsy is a chronic neurological condition that requires treatment throughout the pregnancy. Seizures should be well controlled before conception with a specific type of anti-epileptic drug (AED) for each epileptic syndrome. The selection of AED is crucial in women with epilepsy (WWE). AEDs with the lowest malformations rates should be used for treatment during pregnancy. Valproate should be avoided in WWE of childbearing age as it is associated with the highest risk of neurocognitive malformations. However, pregnancy might alter the levels of AEDs, which can lead to an increase in seizure frequency. It is important to monitor AED levels and make necessary dose adjustments to control seizures during pregnancy. WWE should be treated with the lowest possible dose allowed and preferably with a single AED to avoid harmful effects on the developing fetus. Women should be counseled to take folic acid during pregnancy as it reduces the risks for cardiovascular, genitourinary, and neural tube defects. Generally, WWE usually have normal pregnancies and can bear healthy offspring. Pregnant women need continuous follow-up in a coordinated manner with the neurologist and obstetrician to assess for adverse pregnancy and fetal outcomes.

Cancer of Unknown Primary: A Review on Clinical Guidelines in the Development and Targeted Management of Patients with the Unknown Primary Site.

Cancer of unknown primary (CUP) is a malignant widespread metastatic disease without an identifiable primary site after extensive clinical investigation. Recently, a decline is observed in the diagnosis of CUP, mainly due to improvement in detection of the primary tumors, thus decreasing the unknown primaries. Worldwide, CUP is the sixth to eighth most common malignancy, accounting for 2.3% to 5% of a new cancer diagnosis. CUP is third to fourth most common cause of death due to cancer-related mortality. The prognosis of CUP is depressing with the median survival of three to six months in the previous studies, but according to recent studies, median survival is less than one year. High risk for developing CUP is seen in heavy smokers (26 or more cigarettes/day) and individuals with the lowest quartiles of waist circumference. A weak association is observed with the use of alcohol consumption and low level of education. Human papillomavirus DNA plays a role in those with squamous cell carcinoma of unknown primaries in head and neck regions. In the diagnosis of CUP, comprehensive medical history, complete physical examination (including genitourinary, rectal exam, and breast examination in women) and necessary laboratory tests are crucial. Whole-body positron emission tomography-computed tomography (PET/CT) is the investigation of choice to assess the entire body for CUP. Multiparametric 3T-MRI (MP-MRI) is used to examine the local soft tissue status, helps in the staging of the tumor, and to determine the extent of involvement of tissue for medical as well as prognostic purposes. Immunohistochemistry outlines the specific markers, including caudal-related homeobox protein (CDX2), homeobox protein Nkx-3.1 (NKX3-1), paired box gene 8 (PAX8), special AT-rich sequence-binding protein 2 (SATB2), thyroid transcription factor 1 (TTF-1), and splicing factor 1 (SF1) with the focus on the effectiveness of lineage-restricted transcription factors. Patients response to treatment can be evaluated by the gene expression profiling (GEP) test that also predicts tissue of origin (TOO). Tumor identified through gene profiling is sensitive to platinum/taxane therapy, others that are not TOO tumors are resistant to platinum/taxane. The new therapeutic method based on molecular profiling is associated with higher treatment response. In comprehensive genomic profiling, it is observed that there is at least one clinically appropriate genomic alteration in CUP that can influence the targeted therapy. The targeted therapeutic approach will not only improve the disease outcome but will also be cost-effective and save time from finding the primary site.

Drug-induced Reduction of Gamma Carboxylation in Osteocalcin: What is the Fallback?

Osteoporosis is a medical condition in which bone becomes fragile and weak. In this condition, the quality and density of the bone are reduced. Vitamin K is vital for bone mineralization as it plays a vital role in the gamma-carboxylation of osteocalcin. Therefore, if there is a deficiency of vitamin K, it can lead to osteoporosis due to undercarboxylated osteocalcin. Warfarin is the most widely used anticoagulant in the elderly. In this article, we reviewed how Warfarin, an inhibitor of vitamin K, affects bone remodeling and leads to osteoporosis.

Continuous Glucose Monitoring Versus Self-monitoring of Blood Glucose in Type 2 Diabetes Mellitus: A Systematic Review with Meta-analysis.

Every eleventh adult has diabetes, and every third has prediabetes. Over 95% of diabetics are of type 2. It is well established that diabetes doubles the risk of heart disease and stroke apart from increasing the risk of microvascular complications. Hence, strict glycemic control is necessary. However, it increases the risk of hypoglycemia, especially in patients with longstanding diabetes. Continuous glucose monitors (CGM) use a sensor to continuously measure the glucose levels in the interstitial fluid every 10 seconds and gives out mean values every five minutes. CGMs are emerging tools in the management of type 2 diabetes. The prime objective of this review is to find out if there is enough supporting evidence, suggesting that continuous glucose monitoring is more effective than self-monitoring of blood glucose (SMBG) in type 2 diabetes. We conducted a systematic literature search in Medline (PubMed) looking for any studies addressing our objective. It is observed that there is a varying level of evidence supporting that employing a CGM can reduce glycated hemoglobin (HbA1c), hypoglycemic events, and increase patient satisfaction. However, some studies reported no significant benefits. This systematic review with meta-analysis concludes that the use of CGM in type 2 diabetes mellitus (T2DM) is beneficial, as it significantly reduces HbA1c compared to the usual method of SMBG. The pooled mean difference in HbA1c was -0.25 (-0.45, -0.06) and statistically significant (at p = 0.01) when comparing CGM to SMBG.

Efficacy and Safety of Stem Cell Therapy in Advanced Heart Failure Patients: A Systematic Review with a Meta-analysis of Recent Trials Between 2017 and 2019.

Objective The effects of stem cell therapy in patients with advanced heart failure is an ongoing debate. This study aimed to assess the effectiveness and safety of stem cell therapy plus the standard of care as compared to the placebo plus the standard of care in advanced heart failure patients. Methods A comprehensive keyword search of PubMed between 2017 and 2019 was performed to extract trials conducted with stem cell therapy controlled with placebo in advanced heart failure. We included randomized controlled trials (RCTs) with data on safety and efficacy in patients with advanced heart failure after stem cell transplantation. Results Six RCTs, consisting of 569 patients, were selected. Three-hundred sixty-seven (367) out of 369 participants from the eligible four out of six RCTs were included for efficacy analysis, as we lost two patients from the final analysis due to early death. Five-hundred twenty-six (526) out of 527 participants from the eligible five out of six RCTs were included for safety analysis, as we lost one patient from the final analysis for not being able to receive the intervention. Stem cell transplantation significantly improved left ventricular ejection fraction (LVEF) by 4.58% (95% CI: 3.73-5.43%; p = 0.00001), improved left ventricular end-systolic volume (LVESV) by -5.18 ml (95% CI: -9.74 to -0.63 ml; p =0.03), and there was no difference in the risk of all-cause mortality (OR 0.97; 95% CI: 0.52 to 1.78%; p = 0.91). The above results correlate with the previous meta-analysis data conducted in 2016. Conclusions This meta-analysis provided the cumulative efficacy and safety results of stem cell transplantation in advanced heart failure based on recent RCTs. The above results suggest that stem cell therapy was associated with a moderate improvement in LVEF, and the safety analysis indicates no increased risk of mortality in patients with advanced heart failure. This meta-analysis recommends conducting more RCTs comparing stem cell transplantation and placebo with a larger patient population and longer follow-up.

Pulmonary Involvement in Crohn's Disease: A Rare Case Report.

Crohn's disease (CD) is a granulomatous inflammatory disease that can involve any part of the gastrointestinal tract, from mouth to anus. In most cases, it remits and relapses in the terminal ileum, requiring treatment via steroid boluses. In rare cases, however, CD can involve the pulmonary system presenting as dyspnea on exertion and dry cough. We present a case of a 38-year-old man who developed shortness of breath, cough, and wheezing for one month after a colectomy procedure due to recurrent toxic megacolon. He recovered and tolerated extubation successfully and was prescribed mesalamine as maintenance therapy for CD. His pulmonary symptoms after the colectomy, along with his imaging and pulmonary function tests, indicated pulmonary involvement in the lungs as a progression of the primary inflammatory bowel disease. After confirming this diagnosis, he was treated with oral high-dose steroids after successful diagnosis, and the patient's symptoms improved dramatically. This case highlights often overlooked CD bronchopulmonary involvement in the postoperative period.