A Case of Concurrence of Clonorchis Sinensis and Pancreatic Adenocarcinoma-A Diagnostic Dilemma.

Clonorchis Sinensis, a common liver fluke, is known to cause biliary disease and can present with a wide array of symptoms. It's mostly found in Asian countries due to consumption of undercooked or raw fish. Although Cholangiocarcinoma is a known serious complication of this disease, Pancreatic neoplasms are rare and have seldom been reported. Here, we report a case of an 80-year-old man who presents with pancreatic adenocarcinoma associated with Clonorchis Sinensis infection.

Syncope Following Treatment of UTI: A Case of Acute Hemolytic Anemia, Methemoglobinemia and Acute Renal Dysfunction Following Phenazopyridine Use in a Patient With G6PD Deficiency.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive genetic disorder which commonly affects males. It is due to a defect in the red blood cell enzyme, G6PD. Lack of G6PD makes the RBCs vulnerable to oxidant stress resulting in hemolysis. The severity of hemolytic anemia varies among individuals with G6PD deficiency. Here we present a case of an 80-year-old man admitted with syncope and jaundice. He was treated with phenazopyridine for a UTI 2 weeks ago. Subsequent investigation revealed G6PD deficiency as well as methemoglobinemia. Historically, phenazopyridine has been associated with causing methemoglobinemia and triggering hemolysis in G6PD deficient individuals. However, only a few cases have been reported in the last 60 years, making it a very rare occurrence.

Third-Degree Heart Block in COVID-19 Pneumonia Complicated by Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia. A Case Report and Review of Literature.

Coronavirus disease 2019 (COVID-19) burden has been identified to cause multiorgan damage. Respiratory compromise is still one of the most common presentations, but cardiac injuries like myocardial injury, ischemia, and conduction abnormalities are also becoming prevalent. We present a case of an 87-year-old male with a history of dementia, type 2 diabetes mellitus, hypertension, chronic kidney disease, and a left kidney transplant hospitalized for respiratory distress and generalized tonic-clonic seizures. He was bradycardic to 27 beats per minute, hypotensive with mean arterial pressure <60 mm Hg. An electrocardiogram (EKG) depicted a high-grade atrioventricular block (AV-block). The transvenous pacemaker was placed via femoral access and tested positive for COVID-19. Work-up was done to rule out possible causes of bradycardia, like hypothyroidism, ischemia, AV nodal blocking agents, and drug-induced bradycardia was negative. His hospital stay got complicated by methicillin-resistant staphylococcus aureus (MRSA) pneumonia leading to empyema and bacteremia. Unfortunately, being critically ill, the family opted for comfort measures, and he passed away. Our clinical vignette signifies cardiovascular complications in COVID-19 patients are associated with poor outcomes if not addressed. The conduction abnormalities in patients with intact cardiac structure and function are becoming more common in the setting of COVID infection. Assessment with serial EKGs and cardiac monitoring might be essential as patients can develop AV blocks at any point of the disease.

Diagnosis of Adrenocortical Carcinoma with Hypercortisolism in a Patient Presenting with Hypokalemic Metabolic Alkalosis.

Adrenocortical carcinoma (ACC) is a rare malignancy with an estimated annual incidence of 0.7-2 cases per million. Most patients present with steroid hormone excess or abdominal mass effects, but 15% of patients with ACC are diagnosed incidentally. A careful history, physical exam, and pertinent lab investigations are necessary to reach the diagnosis. Surgical resection is the cornerstone of treatment in localized ACC; however, systemic chemotherapy with mitotane is preferred in patients with widespread disease or those who are not ideal candidates for surgery.

Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA.

BACKGROUND: Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system. AIM: The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA. METHODS: We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions. RESULTS: A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions. CONCLUSION: Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.

Sublingual Microcirculatory Characteristics of a Case of Profound Chemotherapy-Induced Anemia Treated With a Hemoglobin-Based Oxygen Carrier.

Handheld vital microscopy (HVM) can deepen our understanding of hematologic diseases and therapeutics. However, limited reports have assessed human microcirculation during profound anemia, and response to hemoglobin-based oxygen carriers (HBOCs). A 58-year-old woman presented with constitutional symptoms and was diagnosed with acute myeloblastic leukemia. Subsequently, the patient clinically decompensated and was found to have a hemoglobin of 1.9 g/dL. Human blood product administration was not consistent with her beliefs, and she received supportive care with HBOC-201. Concomitantly, her sublingual microcirculation revealed a markedly low microvascular flow index (2.59±0.26), proportion perfused vessels (66.8±18.8%), perfused vessel density (4.41±0.56 mm/mm2), and total vessel density (6.93±1.91 mm/mm2). HVM imaging is a promising point-of-care device for various hematologic conditions, with the potential to understand tissue-level perfusion in novel clinical scenarios, including profound anemia and HBOC administration, as illustrated in this case report.

Rate, reasons, predictors, and burden of readmissions after transjugular intrahepatic portosystemic shunt placement.

BACKGROUND AND AIM: Nationwide data on readmissions after the transjugular intrahepatic portosystemic shunt (TIPS) procedure are lacking. We aimed to investigate the 30-day readmission rate after TIPS procedure, reasons, and predictors for readmissions and its impact on resource utilization and mortality in the USA. METHODS: We identified all adults who underwent an inpatient TIPS procedure between 2010 and 2014 using the National Readmission Database. Outcomes included all-cause 30-day readmission rate, reasons and predictors of readmissions, mortality rate, and mean hospitalization charges. RESULTS: Out of a total of 31 230 hospitalizations with TIPS procedure, 28 021 patients met the study criteria and were finally included. The mean age of patients was 56.90 years, and 63.84% were men. All-cause 30-day readmission rate was 27.81%. Hepatic encephalopathy with or without coma was the most common reason for readmissions in at least 36.43% patients. The in-hospital mortality for index hospitalization and 30-day readmission was 10.69% and 5.85%, respectively. The mean hospitalization charges for index hospitalization and readmissions were $153 357 and $45 751, respectively. Advanced age, Medicaid insurance, higher Charlson comorbidy index, ascites as indication of TIPS, and nonspecific or hepatitis C cirrhosis etiologies for cirrhosis were found to be independent predictors of 30-day readmissions after a TIPS procedure. CONCLUSIONS: Our study found a high rate of readmission for patients undergoing TIPS procedure, and the majority of these readmissions were related to hepatic encephalopathy. Further studies highlighting areas for improvement, particularly for patient selection and post-discharge care, are needed to reduce readmissions.

Relation of total bilirubin and QT interval prolongation (from the Third National Health and Nutrition Examination Survey).

OBJECTIVE: The association of bilirubin with cardiovascular disease (CVD) is controversial. We sought to explore the association of total bilirubin (TB) levels with QT interval in a multiracial cohort. METHODS: A total of 6,627 participants (59.0 ± 13.3 years; 52.6% women, 49.7% Non-Hispanic Whites) without CVD from the Third National Health and Nutrition Examination Survey were included in this analysis. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. A multivariable logistic regression model was used to examine the cross-sectional association between tertiles of TB and prolonged QT interval (≥450 ms in men and ≥460 ms in women). RESULTS: The prevalence of prolonged QT was higher among those with higher levels of TB (prolonged QT prevalence was 4.7%, 6.8%, and 7.0% across TB lower (0-0.4 mg/dl), middle (0.5-1.6 mg/dl), and higher (0.70-4.30 mg/dl) tertiles, respectively). In a model adjusted for potential confounders, participants within the highest TB tertile had significantly greater odds of the prolonged QT interval (Odds ratios [95% confidence interval] 1.53 [1.16-2.02]) compared to those with bilirubin levels in the first tertile. Each 0.29 mg/dl increase in TB levels was associated with a 12% (p-value <.0001) increase in the prevalence of prolonged QT interval. This association was stronger in men than in women (interaction p-value = .04). CONCLUSION: Elevated bilirubin levels are associated with a prolonged QT interval. This finding extends our current knowledge on the relationship between serum bilirubin and CVD by demonstrating a link between higher TB and abnormal cardiac repolarization.

Current Trends of Drug Resistance Patterns of Acinetobacter baumannii Infection in Blood Transfusion-dependent Thalassemia Patients.

OBJECTIVE: The present study aimed to evaluate the current trends of drug resistance patterns of Acinetobacter baumannii infection in blood transfusion-dependent thalassemia patients. STUDY DESIGN: This study was a cross sectional study, conducted at the Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad, Sindh, Pakistan from October 2014 to January 2016. SUBJECTS AND METHODS: Of 921 blood samples, A. baumannii strains were isolated from 100 blood samples. Blood samples were processed for the isolation, identification, and drugs sensitivity as per the Clinical and Laboratory Standards Institute. A. baumannii strains were identified by microbiological methods and Gram's staining. API 20 E kit (Biomeriuex, USA) was also used for identification. Data were analyzed on Statisti × 8.1 (USA). RESULTS: Mean ± standard deviation age was 11.5 ± 2.8 years. Nearly 70% were male and 30% were female (P = 0.0001). Of 921 blood transfusion-dependent thalassemia patients, 100 (10.8%) patients showed growth of A. baumannii. Drug resistance was observed against the ceftazidime, cefixime, cefepime, imipenem, meropenem, amikacin, minocycline, tigecycline, and tazocin except for the colistin. CONCLUSION: The present study reports drug-resistant A. baumannii in blood transfusion-dependent thalassemia patients. National multicenter studies are recommended to estimate the size of the problem.

Combined Interatrial and Intrapulmonary Shunting in Orthodeoxia Detected by Transesophageal Echocardiography.

Contrast transesophageal echocardiography was found useful in diagnosing combined interatrial and intrapulmonary right-to-left shunts in a patient presenting with orthodeoxia. This was done by separately examining the pulmonary veins and the interatrial septum during intravenous normal saline injections.