N-acetyl cysteine versus standard of care for non-acetaminophen induced acute liver injury: a systematic review and meta-analysis.

The role of N-acetylcysteine (NAC) in the treatment of acetaminophen induced acute liver injury (ALI) is well established but its role in non-acetaminophen induced ALI is still elusive. We conducted this meta-analysis to evaluate the role of NAC in non-acetaminophen induced ALI. We searched electronic databases for studies published till Oct 25, 2020. We used RevMan v5.4 software to analyze the data extracted from selected studies by using Covidence systematic review software. Outcome estimation was done using Odds Ratio (OR) with 95% confidence interval (CI). The heterogeneity in various studies was determined using the I2 test. A total of 11 studies were included in quantitative analysis. Use of NAC in non-acetaminophen induced ALI showed 53% reduction in mortality compared to standard of care (OR, 0.47; CI, 0.29-0.75) and reduced mean duration of hospital stay by 6.52 days (95% CI, -12.91 to -0.13). Similarly, the rate of encephalopathy was 59% lower in the treatment group (OR, 0.41; CI, 0.20-0.83). However, the risk of developing nausea and vomiting (OR, 3.99; CI, 1.42-11.19), and the need for mechanical ventilation (OR 3.88; CI, 1.14-13.29) were significantly higher in the treatment group. These findings conclude use of NAC decreases mortality and hepatic encephalopathy compared to standard of care in patients with non-acetaminophen induced ALI. Although there is an increased risk of nausea and vomiting with the use of NAC, the majority of adverse events are transient and minor.

Extramedullary plasmacytoma with associated multiple myeloma as a presentation of the posterior mediastinal mass: a rare clinical encounter.

A plasmacytoma is a single, isolated tumour of abnormal plasma cells. It can develop within the bone, known as solitary plasmacytoma of bone, or outside the bone, referred to as extraosseous (extramedullary) plasmacytoma, without spreading to other parts of the body. Plasmacytoma, an uncommon presentation in the posterior mediastinum, usually arises as solitary or multiple lesions in bone or soft tissues. The standard treatment involves definitive radiotherapy, potentially curative for extramedullary cases. The prognosis varies, being more favourable without concurrent multiple myeloma and worsening with high-risk cytogenetics. The case involves a male in his early 80s with an extensive medical history presenting with difficulty swallowing and dyspnoea. The diagnosis revealed a rare posterior mediastinal plasmacytoma associated with multiple myeloma, emphasising the importance of prompt diagnosis and treatment.

Niraparib Maintenance Therapy for Brain Metastasis in Ovarian Endometrioid Adenocarcinoma With Peritoneal Carcinomatosis: A Comprehensive Case Study and Literature Review.

Brain metastasis is a rare complication of ovarian cancer, always found at the advanced stage. Even though different multimodal approaches are available, including surgical intervention and radiotherapy, there are no official guidelines for handling this serious complication. Poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors are a group of medications initially used for maintenance therapy in platinum-sensitive recurrent ovarian cancer. Niraparib has shown some efficacy in patients with brain metastasis due to its unique properties of penetrating the blood-brain barrier. Here, we present the case of a 51-year-old patient with advanced ovarian cancer with no germline breast cancer susceptibility gene (BRCA) mutations. Despite undergoing surgery and multiple rounds of chemotherapy, the patient's condition worsened, culminating in brain metastasis. Given her neurological issues, radiotherapy was not an option, prompting the initiation of a 300 mg dose of niraparib. To date, only sporadic case reports in the literature have described patients with ovarian cancer treated with niraparib and complicated by brain metastasis. Our case is unique because it is the first case of a patient with the endometrioid type of ovarian cancer.

Waterhouse-Friderichsen syndrome, septic adrenal apoplexy.

Waterhouse-Friderichsen syndrome is a rare but potentially fatal disorder of the adrenal gland characterized by bilateral adrenal hemorrhage. It is classically a result of meningococcal sepsis and presents acutely with features of shock, petechial rashes, abdominal pain, and non-specific symptoms such as headache, fatigue, and vomiting. Treatment consists of fluid resuscitation, corticosteroid replacement, and possibly surgery. The prognosis is poor despite treatment. This chapter will review the etiology, pathogenesis, clinical features, and management of the disease.

Impact of Obesity on Breast Cancer Clinicopathological Characteristics in Underserved US Community Safety-Net Hospital: A Retrospective Single-Center Study.

BACKGROUND: Breast cancer continues to pose a significant public health challenge, with its incidence and disproportionate impact on underserved populations in the United States. The relationship between obesity and clinicopathological characteristics at presentation remains a critical area of investigation. Safety-net hospitals caring for underserved communities provide a unique setting to explore these associations. This study seeks to explore a critical gap in knowledge on obesity and breast cancer characteristics in underserved populations in the United States. MATERIALS AND METHODS: In this retrospective study, 927 breast cancer patients were included. Analysis was conducted to assess the association between body mass index (BMI), age of diagnosis, tumor clinicopathologic characteristics, and molecular types stratified by menopausal status at diagnosis. Analysis was performed using the Statistical Package for Social Sciences version 29. RESULTS: A significant association was found between BMI and menopausal status (P < .05). Disease stage at presentation was significantly associated with BMI (P < .05). Further investigation into BMI categories and tumor characteristics revealed a significant correlation in postmenopausal women, with obesity linked to tumor size and lymph node status (P < .05). No significant associations were observed between HER-2 status, ER/PR status, and obesity in either premenopausal or postmenopausal groups. CONCLUSION: This observational retrospective hypothesis-generating study revealed the association between obesity and disease stage and menopause status at diagnosis. In postmenopausal patients, obesity correlated with larger tumor size and advanced lymph node disease involvement. Additionally, ethnic variations were observed, with a higher prevalence of obesity among African American patients.

Partially Reversible Bilateral Papilledema in a Patient Using Anastrozole: A Case Study.

Anastrozole is an endocrine-modifying agent used in the treatment of estrogen-sensitive breast cancer in the postmenopausal breast cancer population. Anastrozole is known for its side effect profile which includes an increased risk of osteoporosis. However, emerging evidence in the literature in the form of case studies demonstrates several potential ocular side effects due to the use of the medication. In our study, a 66-year-old female using anastrozole suffered severe bilateral papilledema that resolved after cessation of the medication. There is a growing body of evidence demonstrating the use of anastrozole and its impact on ocular health leading to deleterious side effects, such as papilledema.

Severe Neurocysticercosis in an Immunocompetent Male Without Travel to an Endemic Region: A Case Report.

Neurocysticercosis is a neglected parasitic cause of seizures in the United States. It can have a wide array of presentations depending on the location and number of cysticercoids. The severity of symptoms varies with the location of the lesion in the brain and to the extent of the number of neurocysticercoids and host immune response. In the severe form of neurocysticercosis, it can present as an acute encephalitic picture. We present a case of severe neurocysticercosis in a patient without any significant travel history. Neurocysticercosis in nonendemic areas can be diagnostically challenging, given the lack of travel history as in our patient. Neurocysticercosis should be kept as a differential in all cases of seizures without prior history of seizure episodes.

Pontine Infarct Resulting in Millard-Gubler Syndrome: A Case Report.

Millard-Gubler syndrome is a crossed brainstem syndrome involving the facial nerve, abducens nerve, and the pyramidal tracts, typically resulting in ipsilateral facial weakness and contralateral hemiparesis. Here we report the case of a 76-year-old female with no pertinent past medical history who presented to the emergency department with acute left-sided facial droop and right upper extremity sensory loss. A pontine infarction was identified on imaging and she was managed medically with complete recovery. Pontine infarction can result in Millard-Gubler syndrome and present with facial weakness and subtle contralateral limb symptoms.

Rare Angina: A Case Report of Ludwig's Angina.

Ludwig's angina is the rapidly progressive cellulitis of the soft tissue of the neck and the floor of the mouth. Airway compromise is a frequent and potentially fatal sequela of Ludwig's angina. Here we present a case of a 54-year-old African American male who presented with fever associated with painful swelling of the mouth and anterior neck. He was febrile and hypoxic on presentation. Imaging showed extensive involvement of the neck and mediastinum to the level of the clavicles. The diagnosis of Ludwig's angina of periodontal origin was made, and intubation was performed for airway protection. Management was done by surgical debridement along with a course of broad-spectrum antibiotics. The patient's condition improved, and he was discharged on oral antibiotics with a referral to a dentist. Our case demonstrates that early diagnosis, airway management, treatment with broad-spectrum antibiotics, and surgical intervention are vital for the successful management of severe cases of Ludwig's angina.

Urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) vs. Conventional Approach in Acute Biliary Pancreatitis Without Cholangitis: An Updated Systematic Review and Meta-Analysis.

Gallstone disease is the common cause of acute pancreatitis. The role of early endoscopic retrograde cholangiopancreatography (ERCP) in biliary pancreatitis without cholangitis is not well-established. Thus, this study aims to compare the outcome of early ERCP with conservative management in patients with acute biliary pancreatitis without acute cholangitis. An online search of PubMed, PubMed Central, Embase, Scopus, and Clinicaltrials.gov databases was performed for relevant studies published till December 15, 2020. Statistical analysis was performed using RevMan v 5.4 (The Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen). Odds Ratio (OR) with a 95% confidence interval was used for outcome estimation. Among 2700 studies from the database search, we included four studies in the final analysis. Pooling of data showed no significant reduction in mortality (OR 0.59, 95% CI 0.32 to 1.09; p=0.09); overall complications (OR 0.56, 95% CI 0.30 to 1.01; p=0.05); new-onset organ failure (OR 1.06, 95% CI 0.65 to 1.75; p=0.81); pancreatic necrosis (OR 0.80, 95% CI 0.49 to 1.32; p=0.38); pancreatic pseudo-cyst (OR 0.44, 95% CI 0.16 to 1.24; p=0.12); ICU admission (OR 1.64, 95% CI 0.97 to 2.77; p=0.06); and pneumonia development (OR 0.81, 95% CI 0.40 to 1.65; p=0.56) by urgent ERCP comparing with conventional approach for acute biliary pancreatitis without cholangitis. Henceforth, early ERCP in acute biliary pancreatitis without cholangitis did not reduce mortality, complications, and other adverse outcomes compared to the conservative treatment.

Prevalence and Contributing Factors of Gender-based Violence in SAARC Territories from 2010 to 2020: A Systematic Review and Meta-analysis.

BACKGROUND: Gender-based violence is a key global concern due to the high prevalence and increased socio-economic burden for survivors. However, estimation of the prevalence of gender-based violence is difficult due to differences in study design and underreporting of abuse, especially in developing nations. Therefore, we conducted this study to estimate the prevalence of Gender-based violence among women living in the SAARC region. METHODS: The review protocol was registered in PROSPERO (CRD42020219577). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed throughout the review. A thorough database search was conducted to identify studies done in the SAARC region. Title and abstract screening were done in Covidence, followed by a full-text review. Data were extracted and pooled for analysis using the inclusion and exclusion criteria. Subgroup analysis was done where possible. RESULTS: A total of 76 studies were included in the systematic review and metaanalysis. The community prevalence of domestic violence (DV) was 43.8% (95% CI, 35.1% - 52.9%), GBV prevalence was 34.9% (95% CI, 30.2% - 39.9%) and IPV prevalence was 39.8% (95% CI, 30.7% - 49.6%). GBV prevalence was highest in illiterate women [54.2% (95% CI, 46.8% - 61.5%)] and lowest among women with higher than secondary level education [23.1% (95% CI, 16.2% - 32.0%)]. The prevalence of GBV among women in pregnancy or postpartum period was 32.3% (95% CI, 25.1% - 40.4%, I2: 98.64), while among female sexual workers, the prevalence of Gender-based violence was 42.1% (95% CI, 28.1% - 57.5%, I2: 99.25). CONCLUSIONS: There is a high prevalence of Gender-based violence in the SAARC region. Higher socioeconomic status and educational status are protective factors for Gender-based violence. However, more studies using validated tools are needed to understand the true extent of the problem.

Epidemiology of dengue in SAARC territory: a systematic review and meta-analysis.

BACKGROUND: Dengue is one of the common arboviral infections and is a public health problem in South East Asia. The aim of this systematic review and meta-analysis was to evaluate the prevalence and distribution of dengue in SAARC (South Asian Association for Regional Cooperation) countries. METHODS: The PubMed, PubMed Central, Embase and Scopus databases were searched for relevant studies. Statistical analysis on data extracted from the selected studied was conducted using the Comprehensive Meta-Analysis Software (CMA) version 3 software package. Proportions were used to estimate the outcome with a 95% confidence interval (CI). RESULTS: Across all studies, among cases of suspected dengue, 30.7% were confirmed dengue cases (proportion: 0.307, 95% CI: 0.277-0.339). The seroprevalence of dengue immunoglobulin (Ig)G, IgM or both (IgM and IgG) antibodies and dengue NS1 antigen was 34.6, 34.2, 29.0 and 24.1%, respectively. Among the different strains of dengue, dengue virus (DENV) strains DENV-1, DENV-2, DENV-3 and DENV-4 accounted for 21.8, 41.2, 14.7 and 6.3% of cases, respectively. The prevalence of dengue fever, dengue hemorrhagic fever and dengue shock syndrome was 80.5, 18.2 and 1.5%, respectively. Fever was a commonly reported symptom, and thrombocytopenia was present in 44.7% of cases. Mortality was reported in 1.9% of dengue cases. CONCLUSIONS: Dengue is a common health problem in South East Asia with high seroprevalence. DENV-2 was found to be the most common strain causing infection, and most dengue cases were dengue fever. In addition, thrombocytopenia was reported in almost half of the dengue cases.

Hypothermia versus normothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The current guidelines recommend targeted temperature management (TTM) as part of the post-resuscitation care for comatose patients following out-of-hospital cardiac arrest. These recommendations are based on the weak evidence of benefit seen in the early clinical trials. Recent large multicentered trials have failed to show a meaningful clinical benefit of hypothermia, unlike the earlier studies. Thus, to fully appraise the available data, we sought to perform this systematic review and meta-analysis of randomized controlled trials. METHODS: We searched four databases for randomized controlled trials comparing therapeutic hypothermia (32-34 °C) with normothermia (≥36 °C with control of fever) in adult patients resuscitated after out-of-hospital cardiac arrest. Independent reviewers did the title and abstract screening, full-text screening, and extraction. The primary outcome was mortality six months after cardiac arrest, and secondary outcomes were neurological outcomes and adverse effects. RELEVANCE FOR PATIENTS: Six randomized controlled trials were included in this review. There was no significant difference between the hypothermia and normothermia groups in mortality till 6 months follow up after out-of-hospital cardiac arrest (OR 0.88, 95% CI 0.67-1.16; n = 3243; I2 = 51%), or favorable neurological outcome (OR 1.31, 95% CI 0.93-1.84; n = 3091; I2 = 68%). Rates of arrhythmias were notably higher in the hypothermia group than the normothermia group (OR 1.43, 95% CI 1.20-1.71; n = 3029; I2 = 4%). However, odds for development of pneumonia showed no significant differences across two groups (OR 1.13, 95% CI 0.98-1.31; n = 3056; I2 = 22%). Therefore, targeted hypothermia with a target temperature of 32-34 °C does not provide mortality benefit or better neurological outcome in patients resuscitated after the out-of-hospital cardiac arrest when compared with normothermia.

Use of Tocilizumab May Avoid the Need of Invasive Ventilation.

Coronavirus disease 2019 (COVID-19) is an illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Increased pro-inflammatory cytokines including interleukin 6 (IL-6) are associated with severe forms of illnesses. The severe cases of COVID-19 require a high amount of oxygen supplementation and might even require endotracheal intubation with ventilator support. A blockade of inflammatory cascade with the use of tocilizumab has been shown to decrease the need for intubation and ventilator requirement.

Recurrent Pneumothorax in an Adult Male With Bilateral COVID-19 Pneumonia.

Pneumothorax is defined as the condition in which air is collected between the visceral and parietal pleura. Pneumothorax as a complication of coronavirus disease 2019 (COVID-19) infection has been reported in relatively few cases and recurrent pneumothorax is even rarer. We present a case of a 50-year-old critically ill patient who required mechanical ventilation for 55 days and developed recurrent bilateral pneumothorax. The patient initially presented with shortness of breath and cough. He was found to be COVID-19 positive on the polymerase chain reaction (PCR) test. Subsequently, his oxygen demand increased, and he ultimately needed mechanical ventilation. He developed four episodes of pneumothorax. The patient was managed in all four episodes with intercostal tube insertion. To prevent subsequent episodes, pleurodesis was performed after the fourth episode of pneumothorax.

May-Thurner Syndrome: An Anatomic Predisposition to Deep Vein Thrombosis.

May-Thurner syndrome (MTS) is a rare clinical condition caused by extrinsic compression of the left common iliac vein by the right common iliac artery, leading to venous stasis and predisposing to thrombus formation. Here, we present the case of a 39-year-old female with no obviously known other risk factors predisposing to thrombosis who presented with severe left leg pain and swelling for a week. The international normalized ratio was elevated and the venous Doppler study showed extensive thrombosis extending from the left common iliac vein to the common femoral vein and the popliteal vein. She was diagnosed with MTS and treated with catheter-directed mechanical thrombolysis and thrombectomy, along with angioplasty of the left common iliac vein and external iliac vein, with near-complete resolution post-treatment. MTS should be suspected in patients who present with unilateral limb thrombosis regardless of the presence of predisposing factors. Timely management with endovascular procedures is necessary to help prevent other potential life-threatening complications.

Central Pontine Myelinolysis Secondary to Hyperglycemia in a Young Patient.

Central pontine myelinolysis (CPM) is a neurological disorder typically caused by rapid correction of severe chronic hyponatremia. Conditions causing a hyperosmolar state can also cause CPM, but it is rarely seen in diabetes. Here we describe a case of a 34-year-old female with longstanding uncontrolled diabetes mellitus who presented with bilateral upper and lower limb weakness and dysphagia. Examination showed decreased muscle strength, and laboratory investigations showed high HbA1c, high blood glucose, increased serum osmolality, and normal sodium. A diagnosis of CPM was made after MRI showed restricted diffusion in the bilateral pons and CT showed pontine hypodensities. The patient was started on insulin therapy, and she showed clinical improvement with improving blood glucose levels. After five days of hospital stay, she was discharged home with appointments to neurology and endocrinology clinics. This case shows that CPM is a potential complication of uncontrolled diabetes mellitus in the presence of normal serum sodium. Timely treatment of hyperglycemia can lead to improvement of symptoms, but it is a potentially fatal condition. Thus, a diagnosis of CPM should be considered in diabetic patients who present with neurological symptoms and hyperglycemia.

D-dimer as a biomarker for assessment of COVID-19 prognosis: D-dimer levels on admission and its role in predicting disease outcome in hospitalized patients with COVID-19.

INTRODUCTION: Coronavirus Disease 2019 is a primarily respiratory illness that can cause thrombotic disorders. Elevation of D-dimer is a potential biomarker for poor prognosis in COVID-19, though optimal cutoff value for D-dimer to predict mortality has not yet been established. This study aims to assess the accuracy of admission D-dimer in the prognosis of COVID-19 and to establish the optimal cutoff D-dimer value to predict hospital mortality. METHODS: Clinical and laboratory parameters and outcomes of confirmed COVID-19 cases admitted to four hospitals in Kathmandu were retrospectively analyzed. Admitted COVID-19 cases with recorded D-dimer and definitive outcomes were included consecutively. D-dimer was measured using immunofluorescence assay and reported in Fibrinogen Equivalent Unit (µg/ml). The receiver operating characteristic curve was used to determine the accuracy of D-dimer in predicting mortality, and to calculate the optimal cutoff value, based on which patients were divided into two groups and predictive value of D-dimer for mortality was measured. RESULTS: 182 patients were included in the study out of which 34(18.7%) died during the hospital stay. The mean admission D-dimer among surviving patients was 1.067 µg/ml (±1.705 µg/ml), whereas that among patients who died was 3.208 µg/ml (±2.613 µg/ml). ROC curve for D-dimer and mortality gave an area under the curve of 0.807 (95% CI 0.728-0.886, p<0.001). Optimal cutoff value for D-dimer was 1.5 µg/ml (sensitivity 70.6%, specificity 78.4%). On Cox proportional hazards regression analysis, the unadjusted hazard ratio for high D-dimer was 6.809 (95% CI 3.249-14.268, p<0.001), and 5.862 (95% CI 2.751-12.489, p<0.001) when adjusted for age. CONCLUSION: D-dimer value on admission is an accurate biomarker for predicting mortality in patients with COVID-19. 1.5 µg/ml is the optimal cutoff value of admission D-dimer for predicting mortality in COVID-19 patients.

Premenstrual Syndrome in Students of a Teaching Hospital.

BACKGROUND: Premenstrual syndrome is group of psychosomatic symptoms which occurs during second half of menstrual cycle. Significant number of reproductive aged females suffer from it with its impact on their daily activities. This study was conducted to assess the prevalence, severity and impacts of Premenstrual syndrome on female students of a teaching hospital of Kathmandu, Nepal. METHODS: This cross-sectional study was conducted among female students of a teaching hospital from Kathmandu over a period of three months. Premenstrual Symptom Screening Tool was used to quantify the symptoms severity and their effect in activities. In addition; patient profile, socioeconomic status were recorded. The obtained information was entered in Statistical Package for Social Sciences and analyzed. Findings were then interpreted using chi-square test. RESULTS: Out of the 285 respondents, 206 (72.3%) reported at least one premenstrual syndrome symptom of moderate to severe intensity among which 74 (25.9%) had at least one severe symptom. Six individuals (2.1%) fulfilled all criteria for Pre-Menstrual Dysphoric Disorder and 49 (17.2%) fulfilled the criteria for moderate to severe premenstrual syndrome and rest (80.7%) were having no or mild premenstrual syndrome with isolated symptoms. PMS was found to have significant association to menstrual bleeding (p?0.001) and severity of dysmenorrhea (p?0.001), family history of premenstrual syndrome (p=0.019) and physical activity (p=0.021). CONCLUSIONS: Premenstrual syndrome is common in female and has a considerable impact on day to day activities activities although its severe form Pre-Menstrual Dysphoric Disorder is less common.

ACR Appropriateness Criteria® Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass.

An acute scrotum is defined as testicular swelling with acute pain and can reflect multiple etiologies including epididymitis or epididymo-orchitis, torsion of the spermatic cord, or torsion of the testicular appendages. Quick and accurate diagnosis of acute scrotum and its etiology with imaging is necessary because a delayed diagnosis of torsion for as little as 6 hours can cause irreparable testicular damage. Ultrasound duplex Doppler of the scrotum is usually appropriate as the initial imaging for the acute onset of scrotal pain without trauma or antecedent mass in an adult or child. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.