Monoclonal gammopathy of renal significance (MGRS) is a hemato-nephrological term referring to a heterogeneous group of kidney disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin (MIg) produced by a B cell or plasma cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end stage kidney disease (ESKD). The diagnosis is typically made by nephrologists through a kidney biopsy. Many distinct pathologies have been identified and they are classified based on the site or composition of the deposited Mig, or according to histological and ultrastructural findings. Therapy is directed towards the identified underlying clonal population and treatment decisions should be coordinated between hematologists and nephrologists in a multidisciplinary fashion, depend on the type of MGRS, the degree of kidney function impairment and the risk of progression to ESKD.
Kidney Diseases , Kidney Failure, Chronic , Monoclonal Gammopathy of Undetermined Significance , Paraproteinemias , Humans , Kidney/pathology , Paraproteinemias/pathology , Monoclonal Gammopathy of Undetermined Significance/complications , Monoclonal Gammopathy of Undetermined Significance/pathology
Myxedema coma is an extreme manifestation of hypothyroidism. It is characterized by altered mental status and hypothermia. The most common precipitants of myxedema coma include discontinuation of thyroid supplements and infections. Therefore, the mainstay of treatment is IV glucocorticoids and IV levothyroxine. We describe a case of an 81-year-old woman with myxedema coma who developed acute cardiopulmonary failure with associated pericardial and pleural effusions, which are rare manifestations of myxedema coma.
Coronavirus disease 2019 (COVID-19) is an infection that involves the respiratory tract and is attributed to severe acute respiratory syndrome coronavirus 2. While most people develop mild or uncomplicated illness, approximately 15% develop a severe disease that requires oxygen support, and 5% develop a critical disease. While immunodeficiency is reported as a risk factor for COVID-19, we present a patient with idiopathic CD4+ lymphocytopenia who developed severe COVID-19 with an unexpected clinical course and complete recovery.
Gastric sleeve surgery is a frequently performed procedure. Although it is one of the safest bariatric procedures, it is like any other operation that carries significant risks and complications. Moreover, the hepatic abscess is an infrequent complication of laparoscopic gastric sleeve surgery, the infected late gastric leakage is a rare etiology of the hepatic abscess. We present a case of liver abscess developed one month after sleeve gastrectomy secondary to infected walled-off late-gastric leak. The case highlights this rare complication of gastric sleeve surgery. Moreover, early treatment of liver abscesses with imaging-guided drainage and intravenous antibiotics can prevent life-threatening outcomes.
Peritoneal carcinomatosis is most commonly a rare late-stage manifestation of disseminated ovarian cancer. Women with peritoneal carcinomatosis with no obvious primary tumor are presumptively treated for ovarian cancer. However, less frequently, gastrointestinal cancer disseminates to the peritoneum, which would confer other treatment options. Herein, we present a case of a 68-year-old woman who was managed for peritoneal carcinomatosis of metastatic mucinous adenocarcinoma of lower gastrointestinal origin.
Hyperthyroidism often leads to heart failure when left untreated, specifically high output heart failure and left ventricular (LV) hypertrophy. A very minimal portion of those develop severe LV dysfunction. We report a case of a 65-year-old male who presented with signs and symptoms of heart failure and was found to have hyperthyroidism, severe systolic dysfunction, and severe dilated cardiomyopathy. The patient is a 65-year-old African American male with a history of hypertension (HTN) who presented with complaints of dyspnea on exertion and bilateral lower limb edema of one-week duration. A review of systems revealed paroxysmal nocturnal dyspnea, orthopnea, palpitations, fatigue, and weight loss. Physical exam showed tachycardia but otherwise no exophthalmos, no thyromegaly, no thyroid nodules, clear lungs, normal heart sounds, regular heart rhythm, normal reflexes, and 2+ edema of bilateral lower extremities up to the knees. Labs showed elevated B-natriuretic peptide, severely suppressed thyroid-stimulating hormone, elevated free triiodothyronine (FT3), and free thyroxine (FT4). Electrocardiogram (EKG) revealed sinus tachycardia, incomplete left bundle branch block, and non-specific T wave abnormality. Echocardiography revealed abnormal (LV) structure and function, with moderate to severe dilatation without LV hypertrophy, severe LV systolic dysfunction with ejection fraction (EF) 30-35%, and an abnormal LV diastolic function. The patient was managed with diuresis for acute onset heart failure and with beta-blocker and methimazole for symptomatic hyperthyroidism. Thyroid assessment is an important step in evaluating any patient with suspected heart failure. This case highlights the balance that should exist between treating hyperthyroidism symptoms and managing disease states such as acute heart failure.
Background: Fibromyalgia (FM), a complex musculoskeletal disorder, can affect individuals from different genders having different genetic and psychosocial backgrounds. The prevalence of FM depends specifically on the age, gender, and level of stress of the individual. Since the university student body tackles high levels of academic and non-academic stress, we aimed to assess the prevalence and characteristics of FM among such a vulnerable population. Methods: A survey was sent to participants from two major English-speaking private universities in Lebanon; the American University of Beirut (AUB) and the Lebanese American University (LAU). The survey included the modified American College of Rheumatology (ACR) 2016 criteria, the widespread pain index (WPI), the symptoms severity score (SSS), and the duration of presence of such FM symptoms. In addition, the survey evaluated the presence of other specific musculoskeletal disorders among participants. Nevertheless, a 12-item general healthy questionnaire (GHQ-12) was used to assess the presence of anxiety, depression, social dysfunction, and loss of confidence among participants. Results: The survey was sent to a total of 2178 students with 184 complete responses (8.45% response rate). The prevalence of FM among the respondents was 13.6%. Students with FM had a significant personal history of a musculoskeletal disorder other than FM and a significant family history of musculoskeletal disorders. The mean SSS score of the target population, including those with FM and those without FM, was 4.5. Patients with FM were significantly in distress and highly symptomatic as measured by GHQ-12 (Unadjusted OR 3.23 [95% CI 1.32-7.95]). Conclusion: Fibromyalgia seems to be prevalent among university students; in particular, those with other musculoskeletal disorders, those with a family history of musculoskeletal disorders, and those with severe depression and anxiety.
Human immunodeficiency virus (HIV)-positive individuals are at an increased risk for kidney diseases, including HIV-associated nephropathy (HIVAN), focal segmental glomerulosclerosis (FSGS), HIV immune complex disease of the kidney (HIVICK), and acute tubular necrosis (ATN). Non-modifiable factors such as age and genetics, as well as modifiable factors such as illicit drug use and compliance, define the progression to renal failure. The patient is a 64-year-old African American male with HIV, treated latent syphilis, chronic kidney disease stage 3a, and cocaine use disorder who presented with shortness of breath, bilateral lower extremities swelling, and fatigue with normal vitals and a physical exam remarkable for bibasilar inspiratory crackles with peripheral edema. Laboratory tests showed creatinine (Cr) of 2.23 mg/dL with a baseline of 1.5 mg/dL, albumin of 1.8, blood natriuretic peptide (BNP) of 667.88, and lipidemia. His urine was remarkable for proteinuria and microalbuminuria in the presence of cocaine. Immunofixation electrophoresis showed a marked increase in IgG and IgM, free lambda, and free kappa/free lambda ratio with HIV viral load of 39,400 copies/ml, absolute CD4 count of 56, and an acute hepatitis B panel. Renal biopsy confirmed HIVAN with FSGS accompanied by collapsing features, HIVICK, and ATN. The patient was subsequently started on highly active antiretroviral therapy (HAART) with prophylactic antibiotics and close monitoring.
PURPOSE: Although studies have examined the effectiveness of telemental health programs, optimal approaches for their evaluation remain unclear. We sought to review the outcomes used to evaluate telemental health programs. METHODS: We conducted a literature search in PubMed and Google Scholar for peer-reviewed studies published between January 2010 until October 2019, and we excluded review articles, opinion papers, presentations, abstracts, and program report without data. RESULTS: 1310 articles were identified, 34 of which were reviewed. Studies used a combination of non-clinical and clinical outcomes, most commonly engagement and impact rates, and standardised clinical measures. Very few studies examined technological feasibility, cost-effectiveness, and qualitative satisfaction reports. CONCLUSIONS: This review is the first to summarise approaches to evaluate telemental health programs. Strengths and weaknesses of the evaluation outcomes are discussed in this review, highlighting essential factors that should be taken into consideration when developing a standardised framework for the evaluation of future telemental health programs.KEY POINTSThe methods used to evaluate telemental health programs are varied and no gold-standard for measurement of success exists.Clinical and non-clinical outcomes are being used to evaluate telemental health programs.More emphasis should be placed on feasibility measures such as cost-effectiveness.Therapeutic alliance should be a crucial part of evaluation of any telemental health program.Longer follow up times and larger sample sizes, as well as more diverse populations, are needed to generalise outcomes.Utilisation of clinical tools to assess success should be limited to standardised measures commonly used in clinical practice.
Mental Health Services/organization & administration , Program Evaluation , Telemedicine , Humans , Outcome Assessment, Health Care
