Urothelial Carcinoma With Bone Metastasis Mimicking Sciatica: A Common Neoplasm With an Uncommon Presentation.

Bone metastasis in urothelial cancer is underreported and not well-researched. A case of urothelial carcinoma (UC) with bone metastasis presenting as musculoskeletal pain is reported. The patient presented with persistent lower back pain associated with right lower extremity pain, numbness, and tingling. Initially, a diagnosis of sciatica was suspected, but the patient did not respond to treatment. An MRI spine was done, which revealed a bright signal mass in the vertebral body suspicious for a metastatic lesion, left hydroureteronephrosis, and a nonspecific cystic focus in the right iliacus muscle. Subsequent imaging revealed an irregular soft tissue mass at the left posterolateral bladder base, resulting in apparent obstruction of the left ureter, highly suggestive of neoplasm, along with numerous lytic bone lesions in the pelvic girdle with associated soft tissue masses, consistent with metastatic disease. The patient underwent an interventional radiology biopsy of the right iliac soft tissue mass to evaluate the lytic bony lesions, which revealed metastatic carcinoma, consistent with UC. A prompt referral was made for urology and oncology consultations. The patient underwent left percutaneous nephrostomy placement for obstruction, but he was not a candidate for any systemic therapy because of his poor performance status, and hospice was recommended as his metastatic disease was not curable and the goal of any kind of treatment was palliative. The optimal treatment for UC with bone metastasis remains divergent, and the management options should be determined as part of a shared decision-making process. This case highlights the importance of having a high suspicion of neoplastic pathology in patients presenting with musculoskeletal pain, like back pain, and not responding to treatment. This should alert the physicians to the potential for serious disease processes.

A Case of Lynch Syndrome-Associated Colorectal Adenocarcinoma in a 19-Year-Old Female Patient.

This case report presents the diagnostic journey and management of a 19-year-old female who was diagnosed with advanced colorectal cancer (CRC) associated with Lynch syndrome (LS), a hereditary nonpolyposis colorectal cancer (HNPCC). The patient initially presented with complaints of persistent abdominal pain, vomiting, and unexplained weight loss, leading to investigations revealing hypochromic microcytic anemia and the presence of an inhomogeneous pelvic mass associated with the sigmoid colon. Subsequent diagnostic procedures, including flexible sigmoidoscopy and pathology reports, confirmed the presence of an advanced rectosigmoid adenocarcinoma with high-grade dysplasia. Molecular testing and immunohistochemical staining revealed a deficiency in mismatch repair proteins, confirming the diagnosis of LS. Despite ineligibility for certain clinical trials due to lymph node infiltration, the patient demonstrated a significant positive response to pembrolizumab immunotherapy, with a notable reduction in tumor size and lymph node involvement. This case underscores the significance of genetic predisposition in the development of early-onset CRC and the potential efficacy of immunotherapy in managing advanced CRC associated with LS in young patients. Additionally, this case provides insights into the evolving landscape of CRC management and the critical role of personalized treatment strategies in optimizing patient outcomes.

Streptococcus pyogenes Pneumonia: A Rare and Severe Presentation in a Patient With Asthma.

Pneumonia is a common respiratory infection typically caused by pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. It is characterized by inflammation and infection in the lung parenchyma, often presenting with symptoms such as cough, fever, and difficulty breathing. Empyema, on the other hand, is a severe complication of pneumonia marked by the accumulation of pus in the pleural cavity. Streptococcus pyogenes (S. pyogenes), also known as group A Streptococcus (GAS), is a bacterium that can cause various infections, including pharyngitis and skin infections. In rare cases, it can lead to community-acquired pneumonia. In our case report, we describe a 32-year-old female with a history of mild persistent asthma who contracted influenza B virus, eventually developing pneumonia caused by GAS, S. pyogenes.

Outcome of tubeless percutaneous nephrolithotomy in elder patients: A single-center experience from a developing country.

Background: Percutaneous nephrolithotomy (PCNL) has evolved as a standard procedure to treat large-sized renal stones. A nephrostomy tube is used frequently in this procedure; however, data regarding tubeless PCNL procedures in elder patients is scarce. Aim: The aim of this study was to review the results and outcomes associated with tubeless PCNL procedures in the elderly population. Materials and Methods: A retrospective review of patients aged ≥60 years at our hospital that was treated for renal stones by PCNL procedure. The patients were separated into two groups: Group 1 underwent tubed PCNL procedures and Group 2 received tubeless PCNL procedures. Information regarding variables were recorded in specified pro forma and then processed in Statistical Package for the Social Sciences statistics analyses. Statistical tests were utilized for continuous and categorical variables and a P<0.05 was considered statistically significant. Results: 121 patients with a mean age of 65±5 years were included in the analysis. Mean stone size and body mass index were 3.4±1.5 cm and 26.2±4.3 kg/m2, respectively. Mean operative time was longer in tubed PCNL as compared to the tubeless group. Mean hospital stay was similar among the tubed and tubeless PCNL treated groups. Mean analgesic doses were significantly lower in the tubeless group. The overall stone-free rate was 89/121 patients (74%). Conclusion: Tubeless PCNL can be safely undertaken in geriatric patients and has potential advantages associated with shorter operative times and reduced necessity for analgesia. Relevance for Patients: Tubeless PCNL is considered advantageous as it can reduce post-operative pain and analgesia necessity; shorten hospitalization and lower cost in young patients. However, there is no clear evidence with reference to virtue of tubeless PCNL in the elderly age groups. This study will analyze and review results and outcomes associated with tubeless PCNL in a cohort of elderly patients.

Meta-analysis of incidence and outcomes of life-threatening arrhythmias in takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TC) or stress-induced cardiomyopathy is a transient heart condition that clinically resembles an acute coronary syndrome. This study aims to assess the incidence of life-threatening arrhythmias in patients with Takotsubo cardiomyopathy and evaluate the outcomes of patients with life-threatening arrhythmias (LTAs) in Takotsubo cardiomyopathy compared with those without LTA. METHODS: We comprehensively searched the PubMed, Google Scholar, and Embase databases from inception to February 2021. The primary aim of the study was to determine the incidence of LTAs in TC patients. Other outcomes of interest were the odds of in-hospital, long-term mortality, and cardiogenic shock (CS) in TC patients with LTAs versus those without LTAs. For all statistical analyses, ReviewManager and MedCalc were used. RESULTS: Eighteen studies were included in this study involving 55,557 participants (2,185 with LTAs and 53,372 without LTAs). The pooled incidence of LTAs in the patients of TC was found to be 6.29% (CI: 4.70-8.08%; I2 = 94.67%). There was a statistically significant increased risk of in-hospital mortality (OR = 4.74; CI: 2.24-10.04; I2 = 77%, p < 0.0001) and cardiogenic shock (OR = 5.60; CI: 3.51-8.95; I2 = 0%, p < 0.00001) in the LTA group versus the non-LTA group. LTA was not associated with long-term mortality (OR = 2.23; CI: 0.94-5.28; I2 = 53%, p = 0.07). CONCLUSION: The pooled incidence of life-threatening arrhythmias in the patients of TC was found to be 6.29%. In the group of TC patients with LTAs, the odds of in-hospital mortality and CS, was higher than in the TC patients without LTAs.

Thyroxine Replacement for Subfertile Females With Subclinical Hypothyroidism and Autoimmune Thyroiditis: A Systematic Review.

The second most prevalent endocrine condition affecting women of reproductive age is thyroid disease. The difference between an increased thyroid-stimulating hormone (TSH) concentration and a normal free thyroxine hormone level is used to identify subclinical hypothyroidism. Thyroid autoantibodies, independent of thyroid hormone levels, are used to diagnose autoimmune thyroid disease (ATD). Thyroxine can help infertile women with these two types of thyroid illnesses have better birth outcomes during fertility treatment. We performed a systematic review using PubMed (Medline) as a major database and some other sources EMBASE, the Cochrane Library, Web of Science, Scopus, and Science Direct. We concentrated on four studies, including 806 patients. Our goal is to investigate the efficacy and risks of levothyroxine therapy in infertile women who are receiving fertility treatments and have subclinical hypothyroidism or adequate thyroid function as well as thyroid autoimmunity (euthyroid autoimmune thyroid disorder). Thyroid activity in hypothyroid women should be tracked at pregnancy confirmation and closely monitored during the pregnancy. Early in pregnancy, the dosage of levothyroxine (LT4) can be raised. To ensure optimum TSH levels during breastfeeding, we recommend that patients who are followed in the primary sector have their LT4 dose increased by their general practitioner before their first referral to an endocrinological outpatient clinic. It's important to pay more attention to and track pregnant women with hypothyroidism, who consider pregnancy, to get the best results. LT4 therapy can help subfertile women with subclinical hypothyroidism who are having in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) since it improves embryo growth, implantation rate, and live birth rate.

Non-invasive Positive Pressure Ventilation for Acute Cardiogenic Pulmonary Edema and Chronic Obstructive Pulmonary Disease in Prehospital and Emergency Settings.

Non-invasive ventilation is an important intervention in treating acute respiratory failure caused by acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (COPD). Although there are studies that give evidence on the efficacy and safety of non-invasive ventilation over standard medical care for COPD and cardiogenic pulmonary edema, less are known about the form of non-invasive ventilation, continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) as an effective intervention for respiratory failure and its efficacy and safety in prehospital settings. We conducted a systematic review by using PubMed and Google Scholar as databases for collecting studies related to the effectiveness of CPAP and BiPAP for cardiogenic pulmonary edema and COPD; the major outcome studied was reducing rates of endotracheal intubation secondary and tertiary outcomes included mortality reduction and shortening length of hospital stay. The study follows the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist 2009. Sixteen studies were identified, including systematic reviews, randomized control trials, and observational studies. Studies published on or after 2010 in a population greater than 40 years old suffering from acute COPD and cardiogenic pulmonary edema were taken for review. Studies that described other respiratory diseases treated with non-invasive ventilation were excluded. Quality appraisal was done using the Cochrane risk bias tool for randomized control trials, Amstar-2 for systematic reviews, and New Castle Ottawa Tool for observational studies. Five studies compared the effectiveness of CPAP and BiPAP with standard medical care in prehospital and emergency settings. Six studies described prehospital intervention. Both forms of non-invasive ventilation were equally significant and effective. Prehospital use had tremendously reduced intubation rates, with not much variability noticed for mortality and hospital stay. Non-invasive ventilation is an effective measure for respiratory failure secondary to COPD and ACPE. Early out of hospital utilization of CPAP and BiPAP reduces the rate of invasive ventilation and reduces complications due to endotracheal intubation. Endotracheal intubation is associated with a considerable incidence of complications like failed intubation, hypotension, or circulatory arrest, even if the emergency physician is well trained, making these forms of non-invasive ventilation safe and effective interventions in the prehospital settings.

Prophylactic Antibiotics, the Mediator of Post-Stroke Infections: A Systematic Review.

Infections frequently complicate an acute stroke and have been associated with an unfavorable prognosis among patients. The use of prophylactic antibiotics seems rational, however, its efficacy has remained obscure. This systematic review aims to offer more clarity to this established dilemma. PubMed and Google Scholar were explored to gain access to studies on post-stroke infection. A systematic review was carried out to analyze how profitable it would be to offer preventive antibiotics immediately after an acute stroke. Five randomized control trials were obtained and analyzed the efficacy of antibiotics in acute stroke according to their intrinsic effects on the infection rate, functionality, and mortality benefits. Based on our findings, we discovered that antibiotics reduce the onset of early infections, especially urinary tract infections, but have absolutely no effect on the functionality and offer no mortality benefit. These results were emphatically shown in two large, open-labeled randomized controlled trials involved in this systematic review. Prophylactic antibiotics provide no additional benefits to the standard of care and should not be used following an acute stroke. They may decrease the incidence of acute infections, especially urinary tract infections, but have no effects on functional outcome and mortality.

Risk of Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis Patient Treated With Natalizumab: A Systematic Review.

Natalizumab, a monoclonal antibody acting on alpha4 integrin receptors, is frequently used to treat multiple sclerosis patients. The biggest downside is the risk of development of progressive multifocal leukoencephalopathy, an immune-related condition affecting mainly the central nervous system. The presence of the John Cunningham virus (JCV) and its reactivation is an important factor in the development of progressive multifocal leukoencephalopathy (PML). This study highlights its different proposed mechanism and risk factors strongly related to natalizumab-induced progressive multifocal leukoencephalopathy. The pieces of literature will also be reviewed to look for a relation between the JCV and natalizumab-induced progressive multifocal leukoencephalopathy in multiple sclerosis treated patients. The articles were searched from three databases and reviewed systematically. The inclusion criteria for this study were patients aged 20-50 years, English language paper, full-text availability, and human studies, whereas articles on patients with AIDS and cancer-related disease prior to natalizumab treatment were excluded. Out of 6531 articles identified after applying the search strategy on three main databases PubMed, Google Scholar, and ResearchGate, a total of 32 articles were finalized for the review. This study follows the guidelines listed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2009. The data collected from these finalized articles were pertaining to the risk factor related to natalizumab induced progressive multifocal leukoencephalopathy and the mechanism related to its pathogenesis.  Natalizumab is known to have the potential to cause progressive multifocal leukoencephalopathy in treated patients; here, we evaluate a close relationship of its related risk factors. The articles studied exhibit a close relationship between the length of natalizumab treatment and the presence of the JCV before infusion of natalizumab. From our analysis, it seems that the mechanism related to natalizumab-induced PML is strongly related to antigen-specific T cells and its effects. The frequency of monitoring and vigilance on the management of patients treated with natalizumab will help detect progressive multifocal leukoencephalopathy.