Roux-en-Y Gastric Bypass and the Clinical Manifestations of Vitamin Deficiencies: Case Report and Literature Review.

This case outlines the complications of Roux-en-Y gastric bypass surgery (RYGBS) and demonstrates clinical manifestations of several vitamin deficiencies. We present a 45-year-old female patient who was admitted to our hospital with generalized weakness, anasarca, hypotension, and failure to thrive, a year after she had her RYGBS. After the procedure, she had nausea, vomiting, and diarrhea with progressive inability to tolerate any oral intake. Subsequently, the patient lost over 200 pounds and got bedridden. Initially, after the procedure, the patient had a dilatation of her anastomotic stricture, but after her surgeon moved out of town she was lost to follow up until she presented to our hospital. Upon arrival, the patient was hypotensive, tachycardic, and appeared dehydrated. The exam also revealed several clinical manifestations of vitamin deficiencies including dermatitis concerning Pellagra, follicular hyperkeratosis, and Bitot spots. Laboratory data showed significantly low albumin, protein, acute kidney injury, and several electrolyte abnormalities. The patient had to be admitted to the ICU for pressure support along with colloid and electrolyte replacement. An Esophagogastroduodenoscopy (EGD) was performed which revealed a clean-based ulcer and a 10-mm anastomotic stricture. She was started on Total Parenteral Nutrition (TPN). After the dilatation of the stricture, the patient was able to tolerate oral intake and TPN was subsequently discontinued upon discharge. The patient was educated extensively on the importance of compliance with daily vitamin supplementation and regular follow-up with bariatric physicians at discharge.

Four-Year Follow-Up of a Case of Yellow Nail Syndrome With IgM Deficiency.

Yellow nail syndrome is a rare condition occurring sporadically, with an extremely low prevalence rate. This syndrome classically presents with a triad of lower extremity edema, yellow nails, and mucosal issues such as pleural effusion and/or chronic sinusitis. Two out of the three features are deemed sufficient to diagnose a person with yellow nail syndrome. We present a rare case of yellow nail syndrome that began with chronic leg swelling and later progressed to the development of an asymptomatic pleural effusion and finally discoloration of nails. In our case, the patient did have a significant recent history of a total knee replacement with a titanium implant. Of note was the chronology of events including leg edema and asymptomatic pleural effusion which were present even before the titanium knee implant. The third feature of the hardening and yellow discoloration of the nails was found to have developed following the knee replacement. Interestingly, on further evaluation, he was found to have IgM deficiency.

Non-metastatic Nephrogenic Hepatic Dysfunction (Stauffer Syndrome) and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in a Patient With Renal Cell Carcinoma Coinciding With Liposarcoma.

Stauffer syndrome is a non-metastatic, nephrogenic, hepatic dysfunction syndrome that is linked to extrahepatic paraneoplastic tumors. It manifests with varying clinical signs that include jaundice, anicteric transaminitis, elevated alkaline phosphatase, thrombocytosis, elevated erythrocyte sedimentation rate, prolonged prothrombin time, and, in some cases, hepatosplenomegaly in the absence of hepatobiliary obstruction. Stauffer syndrome is mostly associated with renal cell carcinoma, but research shows other solid malignancies are implicated with this syndrome. Stauffer syndrome is characterized by elevated liver function tests, specifically those that indicate the presence of cholestasis with or without hepatosplenomegaly. The abnormality is not due to tumor infiltration but rather indirect paraneoplastic effects that are poorly understood. Additionally, emerging literature also supports the association of syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to malignancy in the setting of elevated interleukin-6. In this article, we present the case of a 76-year-old patient with SIADH and abnormalities in liver function tests in the context of Stauffer syndrome tied to renal cell carcinoma coinciding with liposarcoma.

Factors That Determine Multiple Primary Cancers in the Adult Population in the United States.

BACKGROUND: Cancer is a major public health problem worldwide and a leading cause of death in the United States. Multiple primary cancers mean that an individual has more than one cancer in the same or a different organ but does not include instances of metastasis of initial primary cancer. Several factors such as genetics, for example, BRCA1 gene mutations, may predict multiple primary cancers. Factors such as the age at first cancer diagnosis may determine the outcome of multiple primary cancers. This study aims to determine factors that determine multiple primary cancers among the adult population in the United States.  Methods: This study uses data from the Behavioral Risk Factor Surveillance System 2021 dataset. The study included all individuals recently diagnosed with cancer (sample size = 9806). All age groups were included in this study. Measures included the outcome variable number of cancers and a major independent variable: age at first cancer diagnosis. Covariates included race, sex, smoking status, and cancer treatment. Descriptive, bivariate, and multivariate logistic regressions were conducted using a statistical analysis system. It was hypothesized that individuals with age at first diagnosis of cancer at a younger age have higher odds of having multiple primary cancers as compared to individuals diagnosed at an older age.  Results: The age group of 50-64 years had the highest percentage of only one cancer type (35.87%) and of two or more cancers (35.46%). A majority of females had two or more cancers (53.52%) as compared to males (47.48%). The majority of participants with only one cancer type (80.59%) and two or more cancers (88.61%) were of White non-Hispanic ethnicity. At the multivariate level, the age group under 18 years had 9.4% higher odds of having two or more cancers compared to the age group of 18-29 years (adjusted OR (AOR)=1.094, 95%CI=1.026-1.166; p-value=0.0057). The age group 65 years and above had 11.6% lower odds of having multiple primary cancers as compared to the age group of 18-29 years (AOR=0.884; 95%CI=0.859-0910; p-value=<0.0001). The Black non-Hispanic group had 73.8% lower odds of having multiple primary cancers as compared to White non-Hispanic respondents (AOR= 0.262; 95%CI = 0.228-0.301; p-value = <0.0001). Hispanic respondents had 59.8% lower odds of having two or more cancers as compared to the White non-Hispanic group (AOR= 0.402; 95%CI=0.390-0.413; p-value=<0.0001). Current smokers had 9.7% higher odds of having multiple cancers as compared to individuals who never smoked (AOR = 1.097; 95%CI=1.066-1.129; p-value=<0.0001). Former smokers had 24.2% higher odds of having multiple cancers as compared to individuals who never smoked (AOR=1.242; 95%CI=1.224-1.261; p-value=<0.0001). Individuals who were currently on treatment had 2.676 higher odds of having two or more cancers as compared to individuals not on treatment (AOR=2.676; 95%CI=2.629-2.724; p-value=<0.0001).  Conclusion: Multiple primary cancers have been on the increase recently following advancements in anticancer therapy and cancer screening and diagnosis technology. It is important that studies that aim to demonstrate risk factors and predictors of multiple primary cancers such as the age at first diagnosis, smoking status, and cancer treatment are encouraged among public health specialists.

Using Comorbidity Statistical Modeling to Predict Inpatient Mortality: Insights Into the Burden on Hospitalized Patients.

Background The expenditures of the United States for healthcare are the highest in the world. Assessment of inpatient disease classifications associated with death can provide useful information for risk stratification, outcome prediction, and comparative analyses to understand the most resource-intensive chronic illnesses. This project aims to adapt a comorbidity index model to the National Inpatient Sample (NIS) database of 2020 to predict one-year mortality for patients admitted with select International Classification of Diseases, 10th Edition (ICD-10) codes of diagnoses. Methodology A retrospective cohort study analyzed mortality with comorbidity using the Charlson comorbidity index model (CCI) in a sample population of an estimated 5,533,477 adult inpatients (individuals aged ≥18 years) obtained from the National Inpatient Database for 2020. A multivariate logistic regression model was constructed with in-hospital mortality as the outcome variable and identifying predictor variables as defined by the Clinical Classifications Software Refined Variables (CCSR) codes for selected ICD-10 diagnoses. Descriptive statistics and the base logistic regression analyses were conducted using SAS statistical software version 9.4 (SAS Institute, Cary, NC, USA). To avoid overpowering, a subsample (n = 100,000) was randomly selected from the original dataset. The initial CCI assigned weights to ICD-10 diagnoses based on the associated risk of death, and conditions with the greatest collective weights were included in a subsequent backward stepwise logistic regression model. Results The results of the base CCI regression analysis revealed 16 chronic conditions with P-values <0.20. Anemia (1,567,081, 28.32%), pulmonary disease (asthma, chronic obstructive pulmonary disease [COPD], pneumoconiosis; 1,210,892, 21.88%), and diabetes without complications (1,077,239, 19.47%) were the three most prevalent conditions associated with inpatient mortality. Results of the backward stepwise regression analysis revealed that severe liver disease/hepatic failure (adjusted odds ratio [aOR] 10.50; 95% confidence interval [CI] 10.40-10.59), acute myocardial infarction (aOR 2.85; 95% CI 2.83-2.87) and malnutrition (aOR 2.15, 95% CI 2.14-2.16) were three most important risk factors and had the highest impact on inpatient mortality (P-value <0.0001). The concordance statistic (c-statistic) or the area under the curve (AUC) for the final model was 0.752. Conclusions The CCI model proved to be a valuable approach in categorizing morbidity classifications associated with the greatest risk of death using a national sample of hospitalized patients in 2020. Study findings provide an objective approach to compare patient populations that bear important implications for healthcare system improvements, clinician treatment approaches, and ultimately decision decision-makers poised to influence advanced models of care and prevention strategies that limit disease progression and improve patient outcomes.

Racial Disparities In In-Hospital Mortality of Children and Adolescents Under 20 Years With Type 1 Diabetes Mellitus.

BACKGROUND: In the United States, racial disparities in health outcomes continue to be a major problem with far-reaching effects on equity in healthcare and public health. Children and teenagers with type 1 diabetes are a disadvantaged demographic that has particular difficulties in managing their condition and getting access to healthcare. Despite improvements in the treatment of diabetes, little study has examined how much racial disparities in in-hospital mortality affect this particular demographic. By examining racial differences in in-hospital mortality rates among children and adolescents with type 1 diabetes in the United States, this study seeks to close this gap. METHODS: This cross-sectional study utilized data from the Healthcare Cost and Utilization Project's (HCUP) Kids' Inpatient Database (KID) for 2012. The KID is a nationally representative sample of pediatric discharges from US hospitals. A total of 20,107 patients who were admitted with type 1 diabetes were included in this study. The primary outcome was the patient's in-hospital mortality status. The primary predictor variable was the race of the patient. Six potential confounders were chosen based on previous literature: age, sex, hospital location, obesity, weight loss, electrolyte disorders status, and median household income. Descriptive statistics and bivariate analyses were done. Multivariate analysis was conducted while controlling for potential confounders. Odd ratios with a 95% confidence interval and probability value were reported. Statistical Analysis System (SAS) version 9.4 for Windows (SAS Institute Inc., Cary, NC, USA) was used for the statistical analysis. RESULTS: A total of 20,107 patients were included in this study. Of the patients included, 78.6%, 5.3%, 5.9%, and 10.2% were of age groups <4, 5-9, 10-14, and 15-18, respectively. Among the patients, 64.3% were female. Whites stood at 54.3%, while Hispanic, Black, and other races accounted for 17.2%, 21.8%, and 6.7% respectively. After adjusting for all other variables, children, and young adults of Asian and Pacific Islanders (OR=1.948; 95% CI 1.015,3.738) had 94% higher odds of in-hospital mortality compared to their White counterparts. Children and young adults aged 5-9 (OR=0.29; 95% CI 0.13,0.649) had 71% lower odds of in-hospital mortality compared to those aged 4 or under. Those aged 10-14 (OR=0.155; 95% CI 0.077,0.313) had 85% lower odds of in-hospital mortality compared to those aged 4 or under, while those aged 15-19 (OR=0.172; 95% CI 0.100,0.296) had 83% lower odds of in-hospital mortality compared to those aged 4 or under. Children and young adults who had weight loss (OR=4.474; 95% CI 2.557,7.826) had almost five times higher odds of in-hospital mortality compared to those without weight loss, while children and young adults who had electrolyte disorders (OR=5.131; 95% CI 3.429,7.679) had five times higher odds of in-hospital mortality compared to those without electrolyte disorders. CONCLUSION: The results show young adults of Asian and Pacific Islanders have higher odds of in-hospital mortality compared to their White counterparts and this study highlights the urgent need for focused measures designed to lessen these inequalities and enhance health equity. The implementation of culturally sensitive healthcare practices, addressing social determinants of health, and enhancing access to high-quality diabetes care should all be priorities.

Cannabis Use and Associated Gastrointestinal Disorders: A Literature Review.

Cannabis, commonly known as marijuana, is used by at least 18% of the United States (US) population, which makes it the most commonly used federally illegal drug in the United States. It is widely used for recreational purposes, while its therapeutic benefits have been extensively explored in the US. For several years, cannabis has been used for the treatment of diverse health conditions, including pain management, anti-inflammatory effects, and spasticity associated with multiple sclerosis and other neurodegenerative diseases. However, cannabis use has been associated with some acute and chronic adverse effects. This review sheds light on gastrointestinal disorders, gastroesophageal reflux disease, pancreatitis, and peptic ulcer disease that have been associated with cannabis use.

Unexplained Hypercalcemia: A Clue to Adrenal Insufficiency.

Hypercalcemia secondary to adrenal insufficiency is a rare condition, but it must be recognized and treated promptly to prevent complications such as kidney damage, bone loss, and cardiac arrhythmias. The co-occurrence of hypercalcemia and adrenal insufficiency can be seen in some rare conditions such as sarcoidosis, however, hypercalcemia as a direct consequence of adrenal insufficiency is well documented in the literature but seldom recognized and often remains underdiagnosed. Symptoms of hypercalcemia in this setting include fatigue, weakness, nausea, vomiting, constipation, abdominal pain, confusion, and dehydration. Treatment typically involves correcting the underlying adrenal insufficiency with hormone replacement therapy, along with measures to lower calcium levels in the blood, such as hydration. In this article, we report the case of a patient presenting with hypercalcemia secondary to adrenal insufficiency.

Nativity Status Predicts Tobacco Use: A Comparative Analysis of US-Born and Foreign-Born Adults From the Health Information National Trends Survey (HINTS).

Introduction Tobacco smoking remains one of the leading causes of morbidity and mortality globally and in the United States (USA). We hypothesize that US-born naturals have higher odds of tobacco smoking compared to their foreign-born counterparts, and our study aims to assess the relationship between nativity status and odds of tobacco smoking using a nationally representative sample. Methods We utilized the Health Information National Trends Survey (HINTS) 5 Cycle 1 (2017) and Cycle 2 (2018) for this study. Our main outcome variable was smoking status divided as ever smoker and never smoker. The main predictor was US birth status. We controlled for sociodemographic characteristics such as age, race, gender, educational status, and marital status. We performed weighted descriptive statistics and bivariate analysis with chi-square for our variables. Unadjusted and adjusted logistic regression was used to ascertain the odds of our outcome given our predictor. Significance was set at 95% confidence, and the alpha level was set to 0.05. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Results Our final sample consisted of 5,677 individuals (weighted: 429,613,693). Of our sample, 36.89% were ever smokers, females were 50.73%, and the majority (57.90%) were high school graduates. In terms of nativity status, those born in the USA were 85.65%, while the non-US-born population was 14.35%. After adjusting for confounders, we found that non-US-born respondents had 42% lower odds of being ever smokers compared to their US-born counterparts (adjusted odds ratio (AOR) = 0.576; 95% confidence interval (CI) = 0.388-0.854; P = 0.0062). Females were 24% less likely to be ever smokers compared to males (AOR = 0.758; 95% CI = 0.644-0.893; P = 0.0010). Having a bachelor's degree or a graduate degree was associated with 42% and 53% lower odds of being ever smokers compared to high school graduates (AOR = 0.583; 95% CI = 0.474-0.717; P < 0.0001) (AOR = 0.471; 95% CI = 0.377-0.588; P < 0.0001). Whites had 97% higher odds of being ever smokers compared to Hispanics (AOR = 1.977; 95% CI = 1.459-2.679; P < 0.0001). Conclusion Our finding of lower odds of tobacco use among foreign-born nationals compared to US-born nationals is consistent with previous studies and suggests the need for equity in tobacco use prevention between the two populations assessed in our study. This is poised to improve overall tobacco use burden, morbidity, and mortality.

A Case Report of Losartan Induced Angioedema.

Angiotensin-converting-enzyme inhibitors (ACEI) and Angiotensin Receptor Blockers (ARBs) are commonly used to manage hypertension and cardiovascular diseases. Although angioedema due to ACEI is a well-known side effect, only a few cases are associated with ARBs, such as losartan. Medication-induced angioedema has been known for many years; however, the mechanism by which many medications cause angioedema is not clearly understood. Here we present the case of angioedema in a 50-year-old male taking losartan after he developed acute kidney disease.

Liver Hydatid Cyst Masquerading as a Liver Abscess.

Hydatid cyst of the liver is a rare zoonotic disease in the United States. It is caused by Echinococcus granulosus. This disease is mainly seen among immigrants from countries where this parasite is endemic. Differential diagnoses of such lesions can include pyogenic or amebic abscesses, in addition to other benign or malignant lesions. We report the case of a 47-year-old woman who presented with symptoms of abdominal pain and was diagnosed with a hydatid cyst of the liver masquerading as a liver abscess. Microscopic and parasitological tests confirmed this diagnosis. The patient was treated and discharged without further complications during follow-up.

Fibrillary Glomerulonephritis in a Patient With Vulvar Squamous Cell Carcinoma.

Fibrillary glomerulonephritis is a rare condition characterized by glomerular accumulation of non-branching fibrils, leading to hematuria, proteinuria, and hypertension. It is often associated with malignancy but has no known cause. A 66-year-old Caucasian female with a history of vulvar squamous cell carcinoma presented with one month of painless hematuria in the setting of new-onset progressive renal dysfunction and nephrotic range proteinuria. Comprehensive evaluation, including renal biopsy with staining for DnaJ heat shock protein family member B9 (DNAJB9), provided a definitive diagnosis of fibrillary glomerulonephritis. The patient initially received rituximab and prednisone therapy. Unfortunately, her renal function continued to decline over the next month, requiring re-hospitalization with initiation of hemodialysis. To our knowledge, this is the first case describing an association between vulvar squamous cell carcinoma and fibrillary glomerulonephritis.