Checkpoint Inhibitor-Related Capillary Leak Syndrome (CLS).

Immune checkpoint inhibitors (ICIs) are now being widely used for the treatment of various malignancies, but they have a distinctive set of side effects due to the overactivation of the immune system, which is important to recognize. Capillary leak syndrome (CLS) is a rare but potentially life-threatening side effect of ICIs that causes a significant increase in the permeability of capillaries, leading to the leakage of plasma-containing proteins from these small vessels. This condition results in several clinical features, including edema, hypotension, hypoalbuminemia, and hemoconcentration. Timely recognition and discontinuation of the offending immunotherapy can optimize outcomes. Treatment is focused on supportive care and prompt initiation of immunosuppressants, such as steroids.

Secondary Hypertension Due to Underlying Takayasu Arteritis.

A young female patient in her early 20s of Hispanic descent presented to the hospital with new-onset chest pain and uncontrolled hypertension. She was found to have blood pressure in the 200s/100s. She was evaluated for causes of secondary hypertension and underwent computed tomography angiography (CTA) of her abdomen to rule out fibromuscular dysplasia, which showed abnormal thickening of lower thoracic and abdominal aorta extending into both renal arteries causing stenosis. This finding led to further investigations, and she was found to have elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Magnetic resonance angiography (MRA) was done, which confirmed the findings of periaortitis in the vessels as described above. A diagnosis of Takayasu arteritis (TA) was made, and the patient was treated with high-dose steroids with significant improvement in her symptoms.

Urinothorax: A Rare Cause of Pleural Effusion.

Urinothorax is a rare cause of pleural effusion, which is seen in patients with obstructive uropathy, blunt trauma, or ureteric injury during abdominal surgical procedures. Clinical symptoms may include dyspnea, chest pain, cough, fever, abdominal pain, and decreased urine output. Diagnosis is made by thoracentesis, which would reveal fluid with a urine-like odor, and pleural fluid analysis, which would show if fluid is transudative in nature with a pH lower than 7.30. Pleural fluid to serum creatine ratio of more than 1 is diagnostic for this condition. In our case, the patient underwent percutaneous nephrolithotripsy with a stent placement three days before presentation to the hospital. She was diagnosed with urinothorax, which led to further investigations, and she was found to have persistent hydronephrosis. Her condition improved after her underlying hydronephrosis was addressed with stent placement. She was discharged home in stable condition.

Cytoplasmic Antineutrophil Cytoplasmic Antibodies (C-ANCA) Vasculitis: An Uncommon Complication After Stem Cell Transplantation.

Granulomatosis with polyangiitis (GPA) is a rare, autoimmune, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis of uncertain etiology. The incidence of autoimmune complications following stem cell transplant is around 2-5%, with autoimmune cytopenia reported most frequently. We present a case of a 65-year-old male patient who presented to the hospital with productive cough, dyspnea, and fever for five months after haploidentical stem cell transplantation. On presentation, he was febrile, tachypneic, and mildly hypoxic. Chest radiograph showed bilateral pulmonary infiltrates. An initial diagnosis of pneumonia was made, and the patient was started on antibiotics. The patient did not respond to initial management, and all his initial infectious workups came back negative. On further evaluation, cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) resulted positive in high titers. The patient was diagnosed with GPA, and IV methylprednisolone and rituximab were started. He responded well to treatment and was eventually discharged home. The classical form of GPA is characterized by the involvement of the upper respiratory tract, sinuses, lungs, and kidneys. Autoimmune disorders may develop secondary to hematopoietic stem cell transplant (HSCT). In our case, the patient was diagnosed with GPA, which is likely one of the autoimmune complications after HSCT.

Bottom-Up Kinetic Chain in Drop Landing among University Athletes with Normal Dynamic Knee Valgus.

The study investigated the influence of ankle strength and its range of motion (ROM) on knee kinematics during drop landing. Fifteen male and fifteen female university athletes with a normal range of dynamic knee valgus (DKV) (knee frontal plane projection angle: men = 3° to 8°, females = 7° to 13°) were recruited. They performed drop landing at height 30 cm and 45 cm with three-dimensional motion capture and analysis. Knee angles were compared at specific landing phases. Isokinetic ankle strength was tested at 60°/s angular velocity while the weight-bearing lunge test was conducted to evaluate ankle ROM. For males, strength for both plantarflexors and dorsiflexors were associated with knee kinematics at both heights (30 cm: r = -0.50, p = 0.03; 45 cm: r = -0.45, p = 0.05) during maximum vertical ground reaction force (MVGRF) phase. For females, ankle invertor strength and knee kinematics were associated at both 30cm (r = 0.53; p = 0.02,) and 45 cm landing heights (r = 0.49, p = 0.03), while plantarflexor strength and knee kinematics showed a significant association during initial contact (r = 0.70, p < 0.01) and MVGRF (r = 0.55, p = 0.02) phases at height 30 cm only. Male and female athletes with normal range of DKV showed a significant relationship between ankle strength and knee kinematics at specific landing phases. These relationships varied with increased landing height.

Calciphylaxis due to metastatic well-differentiated neuroendocrine carcinoma.

A 70-year-old man with history of metastatic well-differentiated neuroendocrine carcinoma was presented to the hospital with a painful left lower extremity ulcer which started around 3 months prior to presentation. He was treated with antibiotics for cellulitis on multiple occasions with no improvement in his symptoms. On initial laboratory evaluation, he was found to have acute kidney injury and a normal calcium level. The patient underwent a skin biopsy and was found to have cellulitis and calciphylaxis of small-sized and medium-sized vessels. Since the patient did not have any underlying risk factors of calciphylaxis, the most likely cause of his calciphylaxis was thought to be his underlying malignancy. Physicians should keep this differential in mind while treating non-healing ulcers in such patients since they are at higher risk of superimposed infections and usually require aggressive wound care.

Cavernous Sinus Thrombosis due to Chronic Bacterial Sinusitis.

The cavernous sinus is the most frequent dural sinus to become infected and thrombosed. Septic cavernous sinus thrombosis has become rare since the advent of antibiotics. We herein present a case of septic cavernous sinus thrombosis caused by chronic bacterial sinusitis.

Gout Due to Tacrolimus in a Liver Transplant Recipient.

Patients taking tacrolimus have an increased predisposition to hyperuricemia. Although literature has widely established the risk of gout in patients taking cyclosporine, the widespread use of tacrolimus in patients following liver transplantation necessitates further investigation into the potential connection between the drug's use and gout. Moreover, hyperuricemia in the context of liver transplants is associated with increased morbidities and mortalities. We describe a case of gout in a liver transplant patient taking the calcineurin inhibitor tacrolimus.

Determining weight-bearing tissue condition using peak reactive hyperemia response trend and ultrasonographic features: Implications for pressure ulcer prevention.

Frequent repositioning is important to prevent pressure ulcer (PU) development, by relieving pressure and recovering damages on skin areas induced by repetitive loading. Although repositioning is the gold standard to prevent PU, there is currently no strategy for determining tissue condition under preventive approaches. In this study, the peak reactive hyperemia (RH) trends and ultrasonographic (US) features are compared with the tissue condition under histopathological examination to determine the potential use of these features in determining the tissue condition noninvasively. Twenty-one male Sprague-Dawley rats (seven per group), with body weight of 385-485 g, were categorized into three groups and subjected to different recovery times, each with three repetitive loading cycles at skin tissues above of right trochanter area. The first, second, and third groups were subjected to short (3 minutes), moderate (10 minutes), and prolonged (40 minutes) recovery, respectively, while applying fixed loading time and pressure (10 minutes and 50 mmHg, respectively), to provide different degree of recovery and tissue conditions (tissue damage and tissue recovery). Peak RH was measured in the three cycles to determine RH trend (increasing, decreasing, and inconsistent). All rat tissues were evaluated using ultrasound at pre- and post-experiment and rated by two raters to categorize the severity of tissue changes (no, mild, moderate, and severe). The tissue condition was also evaluated using histopathological examination to distinguish between normal and abnormal tissues. Most of the samples with increasing RH trend is related to abnormal tissue (71%); while inconsistent RH trends is more related to normal tissue (82%). There is no relationship between the tissue conditions evaluated under ultrasonographic and histopathological examination. Peak RH trend over repetitive loading may serve as a new feature for determining the tissue condition that leading to pressure ulcer.

Spontaneous rupture of thymoma.

We report a case of patient who presented to the hospital due to shoulder pain and was later diagnosed with ruptured thymoma. Shortly after being admitted to the hospital for the work up patient developed respiratory distress and underwent emergent endotracheal intubation. CT scan of the chest showed anterior mediastinal mass with associated right sided hemothorax. He subsequently underwent medial sternotomy with resection of the mass which turned out to be thymoma.

mTORC1 inhibitors rapamycin and metformin affect cardiovascular markers differentially in ZDF rats.

Mammalian target for rapamycin complex 1 (mTORC1) is a common target for the action of immunosuppressant macrolide rapamycin and glucose-lowering metformin. Inhibition of mTORC1 can exert both beneficial and detrimental effects in different pathologies. Here, we investigated the differential effects of rapamycin (1.2 mg/kg per day delivered subcutaneously for 6 weeks) and metformin (300 mg/kg per day delivered orally for 11 weeks) treatments on male Zucker diabetic fatty (ZDF) rats that mimic the cardiorenal pathology of type 2 diabetic patients and progress to insulin insufficiency. Rapamycin and metformin improved proteinuria, and rapamycin also reduced urinary gamma glutamyl transferase (GGT) indicating improvement of tubular health. Metformin reduced food and water intake, and urinary sodium and potassium, whereas rapamycin increased urinary sodium. Metformin reduced plasma alkaline phosphatase, but induced transaminitis as evidenced by significant increases in plasma AST and ALT. Metformin also induced hyperinsulinemia, but did not suppress fasting plasma glucose after ZDF rats reached 17 weeks of age, and worsened lipid profile. Rapamycin also induced mild transaminitis. Additionally, both rapamycin and metformin increased plasma uric acid and creatinine, biomarkers for cardiovascular and renal disease. These observations define how rapamycin and metformin differentially modulate metabolic profiles that regulate cardiorenal pathology in conditions of severe type 2 diabetes.

Case study: survey of patient satisfaction with prosthesis quality and design among below-knee prosthetic leg socket users.

The aim of this case study was to explore patient satisfaction with the quality of prosthetic leg sockets intended for persons with lower limb amputations. A qualitative study based on in-depth interviews, preceded by a questionnaire session, was carried out with patients from the Rehabilitation Center and Hospital in Malaysia. Twelve out-patient and in-patient amputees with lower limb amputations, specifically below-knee amputations, were chosen randomly. The analysis of patients' narratives aimed to identify the functional and esthetic characteristics of currently used prosthetic leg sockets and any problems related to them. The obtained results indicated that out of the 12 participants, 41.7% and 25% were satisfied and somewhat satisfied with their current prosthetic sockets. Durability and comfort were rated by the participants as the most important characteristics of prosthetic sockets, with 83.3%. As regards the esthetic appearance of the socket, 66.7% of the respondents considered that the most important feature was the material from which the socket was fabricated. Thus, we conclude that current satisfaction levels with the quality of prosthetic sockets among amputees in Malaysia are suitable, prosthesis being preferred by many amputees. The results can be used to direct future research on cosmesis and functionality of prosthetic socket design. Implications for Rehabilitation Case study will help participants to get cost effective prosthetic leg socket. Develop prosthetic leg socket comfortable as comparative to existing one. Help Malaysian government to make policy to develop local prosthetic leg socket at affordable price.

An outcome of Surgically Treated Head and Neck Cancer in one of the tertiary Referral Center in the East Coast of Malaysia: A 6-year Retrospective Analysis.

BACKGROUND: Surgical management of head and neck cancer is undoubtedly challenging, and we would like to see the outcome of managing such cases at one of the tertiary referral center in the East Coast of Malaysia. METHODS: A 6-year retrospective analysis of surgically treated head and neck cancer cases in Hospital Tengku Ampuan Afzan (HTAA) Kuantan, Pahang was conducted. RESULTS: The total number of patients reviewed was 55 and mean age of the patients was 59 years (SD 12). The larynx was the most common surgically treated site (29.1%), followed by the oral cavity (16.4%) and the paranasal sinuses (14.5%). Majority of the patients presented with stage III (32.8%) and stage IV (41.8%) cancer. Post-operative local complications (23.6%) and wound breakdown was identified as the most common cause (20%). Low hemoglobin level prior to surgery was associated with anemia after surgery (P = 0.007) and prolonged hospital stay (P = 0.030). Tumor recurrence was observed in 21.8% of the cases. Advanced stage tumor had more percentage of positive margin than early stage tumor i.e., 23% in early stage versus 58% in advanced stage (P = 0.050). CONCLUSION: Surgical management of head and neck cancer in this center has an acceptable outcome.

An outcome of Surgically Treated Head and Neck Cancer in one of the tertiary Referral Center in the East Coast of Malaysia: A 6-year Retrospective Analysis

Background: Surgical management of head and neck cancer is undoubtedly challenging, and we would like to see the outcome of managing such cases at one of the tertiary referral center in the East Coast of Malaysia. Methods: A 6-year retrospective analysis of surgically treated head and neck cancer cases in Hospital Tengku Ampuan Afzan (HTAA) Kuantan, Pahang was conducted. Results: The total number of patients reviewed was 55 and mean age of the patients was 59 years (SD 12). The larynx was the most common surgically treated site (29.1%), followed by the oral cavity (16.4%) and the paranasal sinuses (14.5%). Majority of the patients presented with stage III (32.8%) and stage IV (41.8%) cancer. Post-operative local complications (23.6%) and wound breakdown was identified as the most common cause (20%). Low hemoglobin level prior to surgery was associated with anemia after surgery (P = 0.007) and prolonged hospital stay (P = 0.030). Tumor recurrence was observed in 21.8% of the cases. Advanced stage tumor had more percentage of positive margin than early stage tumor i.e., 23% in early stage versus 58% in advanced stage (P = 0.050). Conclusion: Surgical management of head and neck cancer in this center has an acceptable outcome.

Oncologic outcome in surgical management of jugular paraganglioma and factors influencing outcomes.

BACKGROUND: The purpose of this study was to identify the factors that may influence the management outcome in patients with jugular paragangliomas. METHODS: The surgical records of 121 cases of jugular paraganglioma (Fisch classifications C and D) were reviewed. RESULTS: The average follow-up was 88 months. Intracranial extension (ICE; Fisch classification De and Di) constitutes 55.4% of the cases. Two cases had a malignant jugular paraganglioma. Complete tumor resection was achieved in 81.8% of the cases, and there was evidence of recurrence in 4.0% from this group. Surgical tumor control was achieved in 96% of cases. Perioperative complications consisted mainly of cerebrospinal fluid leakage in 1.6% of the cases. The lower cranial nerve (CN) was preserved in 63% of the patients mainly in the cases without ICE. CONCLUSION: The infratemporal fossa approach type A allows for complete tumor resection with low perioperative morbidity and recurrence rates. The significant influential factors were the severity of ICE and internal carotid artery involvement.

The association between sleep apnea and young adults with hypertension.

OBJECTIVES/HYPOTHESIS: To study the association between sleep apnea and hypertension in a younger age group than previously studied, adding upper airway sizes at endoscopy as important compounding variables not often included in the past. STUDY DESIGN: Case control. METHODS: We analyzed data on sleep-disordered breathing (based on polysomnography tests), body mass index (BMI), neck circumference, upper airway endoscopy sizes, and habitus and health history in 120 hypertensive and 120 nonhypertensive participants in a clinic-based setting. Independent t test, χ(2) , multivariate analysis, and binary logistic regression models were used for case-control comparison. RESULTS: The mean age of the participants was 27 years; 67.5% were male. The incidence and severity of sleep apnea were significantly higher in the hypertensive than the control subjects. Persons with hypertension had an OR of 2.7 times of having comorbid sleep apnea than patients without hypertension (95% confidence interval [CI] 1.2-6.1). Persons with sleep apnea (AHI [apnea-hypopnea index] ≥ 5) had an OR of 2.76 (95% CI 1.57-4.86), and persons with severe sleep apnea (AHI ≥ 30) had an OR 7.94 (95% CI 4.21-15.33) for having hypertension than did persons without sleep apnea. Although adjustments for the compounding factors, particularly BMI, decreased the OR to a large degree, subjects with severe sleep apnea were still 72% more likely to have hypertension than subjects without sleep apnea. CONCLUSIONS: Sleep apnea is related to hypertension in young adults aged 18 to 40 years. The association was more pronounced with the increasing severity of sleep apnea. Screening for sleep apnea should be considered in young adults with hypertension.

Rate of recurrent vestibular schwannoma after total removal via different surgical approaches.

OBJECTIVES: The objective of this study was to assess the differences in the recurrence rates of vestibular schwannoma (VS) after total tumor removal through enlarged translabyrinthine (ETL), retrosigmoid (RS), and middle cranial fossa (MCF) approaches. Our results were compared with previously published data, and literature reviews were done to identify the possible causes for the recurrence of VS. METHODS: We performed a retrospective analysis of 2,400 cases of VS that underwent removal at the Gruppo Otologico, Piacenza, Italy, from 1983 until 2010. The minimum postoperative follow-up was 12 months. We also reviewed the previously published data on recurrence rates of VS after ETL, RS, and MCF approaches. RESULTS: Total tumor removal was achieved in 2,252 cases (93.8%). The recurrence rate was 0.05% for the ETL approach, 0.7% for the RS approach, and 1.8% for the MCF approach. Literature reviews of 3 previously published case series utilizing the translabyrinthine approach showed that none of the primary tumors were less than 2.0 cm in size. Recurrences were seen between 1 and 13 years after the initial surgery. CONCLUSIONS: The rate of VS recurrence after total removal is exceptionally low in experienced hands. Undetected microscopic deposits left on crucial points such as the facial nerve, the preserved cochlea nerve, or the fundus of the internal auditory canal could be possible causes for the recurrence. A definite advantage of an ETL approach is the excellent internal auditory canal exposure, resulting in an extremely low rate of VS recurrence. The patients should be followed up to 15 years with gadolinium-enhanced magnetic resonance imaging (with fat suppression sequence in ETL approach cases). Recurrent VS may exhibit a faster growth rate than primary VS.

Bilateral vocal cord palsy as the sole presentation of acquired syphilis.

Bilateral vocal cord palsy is almost always caused by neck surgery, particularly surgery of the thyroid. We report a case of bilateral vocal cord palsy requiring emergency surgery to relieve the airway obstruction as the sole presentation of acquired syphilis. As the incidence of syphilis worldwide is rising, this unusual presentation may give clinicians a different perspective on the disease.

Two cases of congenital vallecular cyst: a reminder of the potentially fatal cause of upper airway obstruction in infants.

Vallecular cyst, a benign yet rare laryngeal lesion, may cause stridor and even life-threatening upper airway obstruction in infants. It can cause apnoea and poor feeding habits, thus reducing the chance of survival. Although laryngomalacia remains the most common cause of stridor in this age group, awareness and a high level of suspicion for this condition can help lead to early management and intervention. Direct laryngoscopy is accepted as the gold standard for diagnostic purposes, and marsupialisation of the cyst is the preferred treatment. We describe 2 cases of vallecular cysts in infants admitted to our hospital where timely diagnoses led to appropriate treatment.

Two Cases of Congenital Vallecular Cyst: A Reminder of the Potentially Fatal Cause of Upper Airway Obstruction in Infants

Vallecular cyst, a benign yet rare laryngeal lesion, may cause stridor and even life-threatening upper airway obstruction in infants. It can cause apnoea and poor feeding habits, thus reducing the chance of survival. Although laryngomalacia remains the most common cause of stridor in this age group, awareness and a high level of suspicion for this condition can help lead to early management and intervention. Direct laryngoscopy is accepted as the gold standard for diagnostic purposes, and marsupialisation of the cyst is the preferred treatment. We describe 2 cases of vallecular cysts in infants admitted to our hospital where timely diagnoses led to appropriate treatment.