The Epidemiology and Clinical Presentation of Pancreatic Divisum: A Case Series of 57 Case Reports.

OBJECTIVES: Pancreatic divisum (PD) is the second most common congenital abnormality of the pancreatic duct, which affects 2% to 3% of the population. Most of the population remains asymptomatic, but in people who present with symptoms, it can be a cause of anguish and should be recognized. The main goal of this article was to provide a comprehensive picture of clinical and epidemiological methods of diagnosis and treatment of PD. METHODS: A total of 57 PD case reports were considered in this descriptive analysis with 51 case reports and case series published within the last 25 years. The search strategies include systemic searches using scholarly search engines such as Medscape, Scopus, Cochrane, and PubMed. RESULTS: The 57 cases we studied have an average age of presentation of 42 years, with female sex (58%) predominance. Common presenting symptoms were abdominal pain (87.72%) and radiation to the back (21.6%). Eighty-one percent of the case studies reported pancreatitis, and 63.2% had recurrent pancreatitis. At presentation, laboratory values demonstrated increased amylase, lipase, and liver enzymes. PD was diagnosed using magnetic resonance cholangiopancreatography (28.1%), endoscopic retrograde cholangiopancreatography (57.9%), endoscopic ultrasound (7%), or computed tomography (5.3%) scan of the abdomen. Of significance, biliary duct dilation was found in 70.6% of patients diagnosed as having PD. Incidental masses were found in 66.7% of the patients. The most successful treatment was sphincterotomy with or without stents (47.6%), followed by pancreatoduodenectomy (19%) and pancreaticojejunostomy (10%). CONCLUSIONS: Physicians managing pancreatitis should add PD to their differential diagnoses because it will help improve patient outcomes and avoid unfavorable consequences.

Is cadaveric dissection essential in medical education? A qualitative survey comparing pre-and post-COVID-19 anatomy courses.

CONTEXT: With the surge of the novel coronavirus (SARS-CoV-2 [COVID-19]), the modality of teaching anatomy has shifted from in-person cadaveric dissection to virtual lessons for incoming first-year medical students. As a result, we aim to assess the impact that this curriculum change has on student perspectives. OBJECTIVES: This study aims to understand the relative effect of a virtual anatomy course implemented during the pandemic (2019-2020) on the confidence, skills, and perspectives of first-year medical students compared to medical students who had traditional in-person anatomy at Rowan University School of Osteopathic Medicine (Rowan SOM) in Stratford, New Jersey. METHODS: The authors developed a 14-question survey to target gross anatomy students of the Classes of 2023 and 2024 at Rowan SOM. The Class of 2024 had a virtual anatomy lab compared to the Class of 2023, who had an in-person anatomy lab in their first year of medical school. The responses were analyzed to understand the difference between a hands-on cadaver lab and a virtual anatomy lab utilizing SPSS. RESULTS: The survey was administered to approximately 400 people, from which we received 149 responses (37.3%). Among all responses, 36.2% (n=54) belonged to the Class of 2023 who encountered hands-on cadaver experience, whereas 63.8% (n=95) belonged to the Class of 2024 who gained virtual anatomy lab experience. An independent t-test statistical analysis was utilized. Under the confidence domain, when students were asked about the understanding of trauma after their respective anatomy labs, 64.0% of the Class of 2023 (n=50) showed significantly higher confidence with p<0.001, compared to 15.4% for the Class of 2024 (n=78). Under the skills domain, the Class of 2023 (n=50) felt more comfortable with ultrasound (64.0%), identifying all of the pertinent anatomical structures and their respective locations on imaging (72.0%), and identifying the pathology (90.0%) with respective p values of <0.001, <0.001, and 0.004. Only 36.9% of Class of 2024 respondents shared similar comfort with ultrasound (n=84), 30.9% identifying pertinent anatomical structures (n=84) and 65.4% in identifying pathology (n=84). Under the attitude domain, the Class of 2023 (n=50) had more respect toward the human body with their hands-on cadaver experience (88.0%) than the Class of 2024 (n=89, 33.3%). CONCLUSIONS: Based on current results, it can be established that medical students who had in-person cadaveric dissection had a favorable attitude toward their anatomy course compared to students who had virtual anatomy during the COVID-19 pandemic.

A Young Adult With Essential Thrombocythemia Presenting as Myocardial Infarction.

Essential thrombocythemia (ET) is a myeloproliferative neoplasm involving the clonal proliferation of platelets. It is Philadelphia negative and is associated with Janus kinase 2 (JAK2), calreticulin (CALR), or myeloproliferative leukemia virus oncogene (MPL) mutations. The resultant platelets have quantitative and qualitative defects, making them more sticky and prone to thromboembolism. However, ET does not only affect platelet survival, it also has a low leukemogenic potential. It's more common in the elderly, 60 years or more, but can be seen in all age groups, including children. Patients with ET have an increased risk of vascular events like hemorrhage and thromboses like cerebrovascular events, myocardial infarction, superficial thrombophlebitis, deep vein thrombosis, and pulmonary embolism. Cardiovascular risk factors like hypertension, diabetes, and smoking can lead to increased thromboembolism and atherosclerosis. The management of ET focuses primarily on the prevention of thrombosis and hemorrhage. It involves cardiovascular risk management and antiplatelet and cytoreductive therapy according to the risk stratification. Low-risk ET patients are treated with low-dose aspirin, and high-risk ET patients are treated with cytoreductive therapy with hydroxyurea. Interferon (IFN) and anagrelide are reserved for young patients or pregnant women. This case report discusses a 40-year-old male, a known smoker presenting with myocardial infarction and left anterior descending artery (LAD) blockage without any prior history. His high platelets and the relative absence of cardiovascular risk factors helped reach the diagnosis, and bone marrow analysis and mutation analysis confirmed the diagnosis. The patient was started on hydroxyurea, which decreased the total platelet count.

A Rare Presentation of Granulomatosis With Polyangiitis with Multiple Cardiac Valvular Insufficiencies.

Granulomatosis with polyangiitis (GPA), earlier known as Wegener's granulomatosis, is an autoimmune inflammatory disorder that causes necrotizing vasculitis of small- and medium-sized blood vessels. It primarily affects the upper respiratory tract, lungs, and kidneys. Most of the cardiac involvement tends to be subclinical and is often not clinically apparent with involvement of the conduction pathway; myocarditis, pericarditis, or coronary artery involvement are associated with increased morbidity and mortality. These present with the symptoms of shortness of breath, cough, bilateral pedal edema, orthopnea, syncope, and features of heart failure such as elevated jugular venous pressure. We report a rare case of heart involvement with profound valvular deformity involving all four cardiac valves along with renal impairment in a 76-year-old female with recently diagnosed granulomatosis with polyangiitis.

A Case Report of a Prevertebral Mass in an Elderly Male Post Hodgkin's Lymphoma.

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory autoimmune disease characterized by tissue infiltration by dense lymphoplasmacytic infiltrate composed of T cells, activated B-cells, and plasma cells expressing IgG4 and has varied presentations with similar histopathology. It can involve visceral organs, glands, aorta, lymph nodes, and retroperitoneal tissue. In our case, a 68-year-old male with a past history of Hodgkin's lymphoma and in remission presented for investigation of polyclonal gammopathy. Serum electrophoresis showed increased free kappa light chains, free lambda light chains, and kappa lambda ratio; immunoglobulin G (IgG) levels were also increased. A positron emission tomography (PET) scan and magnetic resonance imaging (MRI) thoracic spine suggested a hypermetabolic prevertebral soft tissue density. Biopsy of the mass suggested IgG4-related disease (IgG4-RD). He also had a compression fracture of the T7 vertebra. He was started on intravenous methylprednisolone and rituximab, following which he had a significant decrease in the size of the mass along with a decline in the levels of IgG, kappa, and lambda chains.

Combined Oral Contraceptives Bringing to Light May-Thurner Syndrome.

May-Thurner syndrome (MTS) is a relatively uncommon clinical condition characterized by venous blockage in the left lower leg. Compression of the left common iliac vein by the right common iliac artery and the underlying vertebral body causes obstruction. We report a case of MTS with extensive venous thrombosis in a 44-year-old female who remained clinically silent until she used combined oral contraceptive pills (OCPs) for more than three years.

COVID-19 Infection Related Bowel Perforation.

During an ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel virus, new discoveries about its complications and treatment are made every day. Bowel perforation is another rarely reported complication due to the virus itself leading to ischemia or can be due to the treatment with antiviral drugs that reduces the integrity of epithelial barriers. This makes the bowel more prone to perforation even in patients with no prior history of bowel disease. We report a case of bowel perforation in a 72-year-old male patient with severe COVID-19 infection.

A Unique Case of Exploratory Laparotomy in the Setting of Large Bowel Obstruction Led to the Detection of Pancreatic Carcinoma.

Pancreatic adenocarcinoma is the second most common gastrointestinal cancer after colon cancer. There is a delay in the detection of pancreatic adenocarcinoma as it remains asymptomatic in many individuals until it has metastasized to different parts of the body. We present a case of pancreatic cancer causing a large bowel obstruction in a 78-year-old female, detected during an exploratory laparotomy. Despite the increased incidence of pancreatic cancer, there are no screening guidelines that have been enacted for early detection and cure. Practicing clinicians should keep pancreatic cancer in the differential in high-risk individuals.

A Unique Interaction of Methotrexate and Nitrofurantoin Resulting in Irreversible Pulmonary Fibrosis.

Pulmonary toxicity is the most well-known severe complication related to both methotrexate and nitrofurantoin, which can present as acute, subacute, and chronic. Rheumatoid arthritis is also known to cause pulmonary disease if left untreated. In this report, we present a unique case of a 94-year-old female being treated with methotrexate for several years and then treated with nitrofurantoin in the setting of rheumatoid arthritis and chronic urinary tract infections, resulting in irreversible pulmonary fibrosis, which can further cause more susceptibility to infections and pneumonia. Drug-drug interactions are common in polypharmacy and a patient's history should be analyzed thoroughly before prescribing any new medication that can cause more harm to the patient than good.

Correction: A Young Adult With Essential Thrombocythemia Presenting as Myocardial Infarction.

[This corrects the article DOI: 10.7759/cureus.28883.].

A Rare Case of Pelvic Organ Prolapse in a Nulliparous Female With Autosomal Dominant Polycystic Kidney Disease (ADPKD) and Polycystic Liver Disease (PLD).

Polycystic liver disease (PLD) is a condition that most often occurs in patients with autosomal dominant polycystic kidney disease (ADPKD) and less commonly as isolated liver disease. The presence of both conditions has proven to be a therapeutic challenge. Patients with ADPKD can suffer from significant renal and extra-renal complications and symptoms as a result of space-occupying cysts from polycystic kidney and liver enlargement. We present a case of ADPKD in a 56-year-old Caucasian female who developed pelvic organ prolapse, a rare complication, while also dealing with multiple other complications of ADPKD. Despite the high prevalence of ADPKD, complications such as pelvic organ prolapse have seldom been reported and discussed in the literature. The care team should do a prompt gynecological examination when they realize the burden of cysts becomes so large.

A Rare Case of Delayed Onset Multi-Drug Interaction Resulting in Rhabdomyolysis in a 66-Year-Old Male.

Drug-drug interactions in medications metabolized by cytochrome P450 enzymes can lead to multi-organ complications. An uncommon but serious potential adverse effect of statins is rhabdomyolysis, most commonly triggered by drug interactions. Rhabdomyolysis presents with markedly elevated creatine kinase levels, dark urine, and often myoglobinuria. The breakdown of the muscles during rhabdomyolysis can be toxic to the kidneys, often precipitating acute kidney injury (AKI) and can also damage the liver, causing transaminitis. This study presents a case of a 66-year-old male with delayed onset complex pharmacological interaction between ticagrelor, rosuvastatin, and amiodarone resulting in rhabdomyolysis, AKI, and transaminitis.