Chemical Meningitis and Syndrome of Inappropriate Antidiuretic Hormone Release (SIADH): A Rare Presentation of Pituitary Adenoma Apoplexy.

Pituitary apoplexy is an uncommon condition typically resulting from a sudden haemorrhage within a pituitary adenoma. This bleed can present clinically with a wide array of signs and symptoms. This report documents the case of a 62-year-old male who presented to the Lebanese Hospital Geitaoui University Medical Center with signs and symptoms of meningeal irritation. He was initially thought to have meningitis, and was started on antibiotics; he was then found to have pituitary adenoma apoplexy that was complicated by syndrome of inappropriate antidiuretic hormone release (SIADH). The patient was successfully treated with antibiotics, and fluid restriction and hypertonic saline after ruling out other more common causes for his hyponatraemia, before undergoing a transsphenoidal resection of the pituitary adenoma. A three-month follow-up evaluation of the patient demonstrated the absence of hormonal imbalances and the absence of residual tumours on imaging. LEARNING POINTS: Pituitary apoplexy has as a wide clinical presentationPituitary apoplexy should be ruled out in patients with aseptic chemical meningitis with a history of pituitary adenomasSIADH can complicate chemical meningitis due to pituitary apoplexy.

The combination of immune checkpoint inhibitors and chemotherapy in advanced non-small-cell lung cancer: the rational choice.

Lung cancer is the second most common cancer worldwide and the leading cause of death among cancers. The progressive approvals of immunotherapy as first-line treatment options have helped improve cancer prognosis. However, longer follow-up has confirmed the possibility of acquired resistance to immune checkpoint inhibitors (ICIs) which can lead to late relapses. Chemotherapy can act as a priming therapy to increase a tumor's response to immunotherapy. We aim through this review to explain the mechanism behind ICI resistance and the value of chemotherapy in escaping this resistance. Finally, all US FDA approvals regarding the management of metastatic non-small-cell lung cancer using a combination of ICIs and chemotherapy are summarized.

Radiology residents from learners to teachers: A multi-centric study.

PURPOSE: The teaching role of radiology residents has seldom been evaluated, and little is known about how teaching skills of radiology residents evolve throughout their training in the absence of formal teaching guidance. Our objective is to identify residents' characteristics correlating with better teaching and compare teaching characteristics of junior and senior residents. METHOD: All seven medical schools in Lebanon were involved in this multi-centric study. A self-assessment questionnaire was sent to sixty-nine radiology residents and filled anonymously. Fifty-seven (83 %) responses were received and represent the study population. Data analysis was based on factors correlating with overall teaching effectiveness. A comparison of senior and junior residents' responses was also performed. RESULTS: Overall teaching effectiveness correlated with better knowledge, technical skills, clinical judgment, communication skills, identification and correction of learning problems, and importantly providing and receiving feedback. Senior residents rated themselves significantly better than juniors in "knowledge related to radiology" and in "technical skills" but not in "overall teaching effectiveness". Seniors did not agree on the statement "medical students make my clinical responsibilities easier". Although not reaching statistical significance, seniors showed a trend towards improving teaching skills. CONCLUSIONS: Overall teaching effectiveness is correlated with the adoption of proper skills and techniques. Despite the lack of formal teaching guidance, senior radiology residents are improving their techniques as teachers but still face difficulties in several domains.

A Case of Intermittent Organo-Axial Gastric Volvulus.

Gastric volvulus is defined as twisting of the stomach along its long or short axis, a rare clinical entity that can lead to gastric outlet obstruction. Symptoms are typically acute and include retching, abdominal pain, and vomiting. Chronic intermittent manifestations of this entity present a diagnostic challenge as conclusive imaging findings are only apparent during symptomatic periods. Given the disorder's intermittent nature, a volvulus may resolve before imaging studies can be conducted. We present a rare case of an intermittent organo-axial gastric volvulus that responded to conservative measures.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND: Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated. AIM: To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB. METHODS: This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups. RESULTS: A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2. CONCLUSION: In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

A Phantom of the Large Bowel.

Giant colonic diverticulum (GCD) is a diverticulum that is larger than 4 cm in diameter most commonly arising from the sigmoid colon. Patients with GCD are typically asymptomatic, and clinical manifestations vary from a soft palpable abdominal mass to diarrhea, which is well described in the literature. However, few studies have demonstrated a presentation of GCD with acute diverticulitis. Herein, we report a case of a middle-aged patient presenting with sepsis due to acute diverticulitis as an initial presentation of a GCD.

Peritoneal Tuberculosis: A Forsaken Yet Misleading Diagnosis.

In women presenting with an abdominal mass and ascites, the first diagnosis to consider is ovarian cancer. However, clinicians should always consider alternative differentials, namely, peritoneal tuberculosis, especially in the presence of respiratory symptoms and with the increasing prevalence of extrapulmonary tuberculosis. Peritoneal tuberculosis can mimic the clinical presentation of ovarian cancer, and on imaging, it can show similar features of peritoneal carcinomatosis and nodules. Tumor markers can also be elevated in the absence of malignancy. We present the case of a 44-year-old woman with abdominal distension and ascites. Imaging with CT scan, MRI, and PET scan were inconclusive, showing peritoneal nodules. Cytology of ascites was negative. Laparoscopy was done showing Koch bacilli followed by pulmonary sampling showing Mycobacterium tuberculosis. The patient was treated with quadritherapy with resolution of symptoms.

An insight into Clostridium difficile infection: a single-center retrospective case-control study.

BACKGROUND: Clostridium difficile infection (CDI) has become a worldwide health problem in view of its significant incidence and medical and economic impact on the health system. Prior studies have been undergone about risk factors and disease characteristics. We wanted to study the characteristics, prognostic factors associated with CDI at our institute, as well as a new prognostic factor. METHODS: Our study aimed at describing the risk factors, patient characteristics, and outcomes associated with healthcare facility-acquired CDI (HCFA-CDI) and community-acquired CDI (CA-CDI). We intended to identify the factors associated with worse outcomes. We evaluated the characteristics associated with CDI over 3 years. We also evaluated a simple neutrophil-lymphocyte ratio (NLR) and its predictive value for worse outcomes. RESULTS: Six hundred patients were enrolled (333 in a control group; 171 in the HCFA-CDI group and 96 in the CA-CDI group). NLR > 5 predicted increased mortality and intensive care unit transfer in all CDI if done as early as day 2 after CDI diagnosis. In HCFA-CDI, NLR > 5 predicted a higher ICU transfer if done as early as day 1 post-diagnosis and with increased mortality as early as day 2 post-diagnosis. In CA-CDI, NLR > 5 predicted a higher mortality and ICU transfer if done at least 4 days after diagnosis. Moreover, every 10-unit increase in NLR was associated with a significant increase in mortality and ICU transfer in patients with CDI. CONCLUSION: A timely use of NLR can be used as a mean to predict worse outcomes, namely ICU transfer and mortality, in patients with CDI.

A Bleeding Dieulafoy's Lesion in the Anal Canal.

Dieulafoy's lesion (DL) is a dilated aberrant submucosal vessel that erodes through the overlying epithelium in the absence of a primary ulcer. It is a known cause of gastrointestinal (GI) bleeding and commonly located in the lesser curvature of the stomach, but it is rare in the anal canal. We report a unique case of a middle-aged man presenting with lower GI bleeding secondary to an anal DL diagnosed by colonoscopy, managed successfully with endoscopic hemoclips.

Retrograde Jejuno-jejunal Intussusception after Roux-en-Y Gastric Bypass: A Potential à la Mode Complication.

Intussusception is a form of bowel obstruction caused by telescoping of a bowel segment into the adjacent part. Small bowel (SB) intussusception was previously considered a rare long-term complication of Roux-en-Y gastric bypass surgery (REYGB). However, with the rapid increase in the number of bariatric surgeries, the incidence of SB intussusception has been significantly increasing. This condition is potentially life-threatening if not recognized in a timely fashion. Herein, we report a case of retrograde jejuno-jejunal intussusception occurring six years after REYGB.

Granulomatous Diverticulitis: Who Would Have Thought!

Diverticular disease (DD) can have different presentations, including chronic colitis. However, diverticular disease-associated colitis (DAC) is a separate entity that can be associated with a granulomatous inflammation. DAC usually affects the left colon with no involvement of the cecum and the ascending colon. In this setting, Crohn's disease is high in the differential diagnosis. Although granulomatous colitis associated with diverticulosis has been previously described, this is the first case affecting the right colon to be reported in the English literature according to our search of the PubMed database. The patient presented with a tumor-like mass abutting the right colon that was further diagnosed as a granulomatous reaction secondary to DAC.

Hepatitis C Infection Patterns at a Tertiary Care Center in New York: A Cross-Sectional Study.

Introduction In the United States, 2.7 to 3.9 million patients are infected with the hepatitis C virus (HCV) with 3,500 new cases reported yearly. According to the Centers for Disease Control and Prevention, HCV was the underlying or contributing cause of death of 19,659 patients in 2014. These facts underscore the need for a better understanding of the scope of this disease. Our epidemiologic study aimed at analyzing the pattern of occurrence of HCV infection at Staten Island University Hospital (SIUH) by evaluating the characteristics of newly infected patients with hepatitis C in 2014. The identified features served to better distinguish the targets for preventive health care in our particular population. Methodology A cross-sectional study of all newly diagnosed patients with HCV infections in the year 2014 presenting to SIUH was conducted using International Classification of Disease-9 codes (ICD-9) for hepatitis C. We included all patients with a positive HCV antibody confirmed by polymerase chain reaction testing. Patients were divided into groups according to age to simulate the age groups in the 2013 - 2014 Hepatitis B and C Annual Report of the New York City (NYC) Department of Health and Mental Hygiene published in 2016 (abbreviated to 2014 NYCDOH Report, hereafter). Gender and HCV genotypes were also collected. We compared disease frequency between age groups, gender, and genotype with the results of the 2014 NYCDOH Report. Results A total of 378 newly diagnosed HCV cases were identified; 60.05% were men, and 39.95% were women. The rate of infection with genotype 1a was the highest (36. 5%) followed by 1b (25.9%). In women, genotype 1b was predominant (13.76%) versus genotype 1a as the most common in men. The mean age was 54 years for men and 57 years for women. Most cases fell into the 60 to 69-year age group (32.28%), followed by the 50 to 59-year age group (31.48%). More so, all patients 80 years and older were exclusively women. Conclusions We found most new HCV infections at SIUH were diagnosed in patients aged 60 to 69 years, and the 2014 NYC DOH Report indicates most new HCV infections occur in patients aged 40 to 59 years. Also, all HCV infections detected in patients older than 80 years of age were found in women. These findings provide a better understanding of the patient demographics for appropriate HCV screening policies. Increased awareness and strict adherence to screening policies in baby boomers and high-risk populations are paramount in order to diagnose HCV infection early, offer therapy, and prevent HCV-related mortality and morbidity.

From Bouveret's Syndrome to Gallstone Ileus: The Journey of a Migrating Stone!

Bouveret's syndrome, first described in 1896, is an unusual cause of gastric outlet obstruction secondary to large gallstone impaction in the proximal duodenum after migration through a cholecystoduodenal fistula. Stone migration has been previously described after endoscopic or surgical fragmentation. However, this is the first reported case, in our knowledge, where the stone migrated after oral contrast administration a few days after the onset of symptoms, causing a distal gallstone ileus.

Bouveret's Syndrome: Literature Review.

It was in 1896 that Bouveret's syndrome acquired its name after the French physician Leon Bouveret, who published two case reports in Revue de Medecin. Bouveret's syndrome describes gastric outlet obstruction secondary to an impacted gallstone. The gallstone reaches the small bowel through a bilioenteric fistula as a consequence of chronic inflammation and adherence between the biliary system and the bowels which increase the intraluminal pressure and leads to secondary wall ischemia and wall perforation with gallstone passage into the bowel. Bouveret's syndrome's prevalence is highest among elderly women. Despite the rarity of Bouveret's syndrome, it can cause notable morbidity and mortality rates. We underwent a review of literature about Bouveret syndrome to increase awareness of its occurrence and potentially life-threatening complications.

Diverticular Disease-associated Colitis: What Do We Know? A Review of Literature.

Diverticular disease (DD) is a leading cause of hospitalizations in developed countries affecting 30-50% of individuals older than 60 years. Identified as a distinct entity since 1980, diverticular disease-associated colitis (DAC) describes the occurrence of mucosal inflammation in a colon segment affected with DD with relative sparing of the rectum and proximal colon. Its prevalence is suggested around 1.3-3.8%. Pathogenesis is multifactorial with multiple reports noting clinicopathological overlap between DAC and inflammatory bowel disease (IBD) especially in patients with granulomatous colitis. In this setting, caution should be exercised to avoid an inappropriate diagnosis of IBD. Recurrence rates and long-term outcomes of DAC are not well defined and could range from a benign course to an overt IBD. More studies are needed in order to further characterize this entity.

Wilson's Disease: Expect the Unexpected.

A 64-year-old woman, presented with abdominal distention, jaundice and resting tremor, was found to have liver injury and abnormal liver enzymes. A computed tomography (CT) scan of the abdomen and pelvis showed abdominopelvic ascites and signs of liver cirrhosis. An extensive liver disease workup was performed and came back negative; therefore, a liver biopsy was obtained and showed evidence of cirrhosis with elevated liver copper consistent with Wilson's disease (WD). We report a unique case of late-onset WD in which the ceruloplasmin level and 24-h urinary copper excretion were all normal.