Aggressive Management Research Articles

Acute Respiratory Distress Syndrome in a Patient with Myasthenia Gravis and Septic Shock: A Case Report

Introduction: Myasthenia gravis (MG) is an autoimmune disorder characterized by muscle weakness, often affecting respiratory and oropharyngeal muscles. This predisposition to respiratory compromise, coupled with impaired swallowing and the potential need for immunosuppressive therapies, increases the risk of pneumonia and subsequent sepsis in MG patients. Sepsis, in turn, is a significant risk factor for acute respiratory distress syndrome (ARDS), a severe lung condition with high mortality. Case presentation: We present the case of a 47-year-old male with a 4-year history of MG who was admitted to our hospital with progressive dyspnea and dysphagia. His condition deteriorated rapidly, leading to septic shock and respiratory failure necessitating invasive mechanical ventilation. Blood cultures identified Klebsiella pneumoniae with extended-spectrum beta-lactamase (ESBL) production. Despite aggressive treatment, including therapeutic plasma exchange (TPE), the patient's hospital course was complicated. Conclusion: This case underscores the critical importance of vigilant monitoring and early intervention in MG patients presenting with respiratory symptoms or signs of infection. Prompt recognition and aggressive management of sepsis are crucial to mitigate the risk of ARDS and improve outcomes in this vulnerable patient population.

Clinical features and outcomes of paediatric Spitz-type lesions

Introduction and ObjectivesNo definitive management guidelines exist for Spitz-type lesions; recommendations in the UK favour a “safe” approach, with a low threshold for excision. We aim to describe Spitz-type lesions in children to further clarify clinical features and outcomes. MethodsWe conducted a retrospective cohort study in Addenbrooke’s Hospital, Cambridge, UK, reviewing all patients with age ≤18 years with histologically confirmed Spitz-type lesions from November 2014-September 2020. Information collected included patient demographics, lesion details, follow-up, outcomes, and recurrence. Results91 children (male:female 42:49, mean age at diagnosis: 9.4 years, SD: 4.6 years) were identified, consisting of 64 (70.3%) Classic Spitz or Spitzoid naevi, 26 (28.6%) Atypical Spitz Tumours (AST), and one (1.1%) Spitzoid malignant melanoma based on histological features. Assessing clinical features where documented, we found 22.0% (20/91) showed amelanosis, 44.0% (40/91) had a raised bump, 12.1% (11/91) displayed bleeding, 25.0% (20/80) had non-uniform colour, 96.7% (88/91) were de novo lesions, 55.1% (43/78) were evolving in size, and 35.9% (28/78) were evolving in colour. 59 patients (64.8%) were discharged without requiring follow-up, and the other 32 had a median follow-up time of 4 months. We have found no incidences of local recurrence after confirmed excision, no distant metastases, and no mortality in all patients to date. ConclusionsOutcomes for paediatric Spitz-type lesions continue to be exceptionally good, remaining a low-risk lesion which is more likely to be benign in children. Hence, we do not advocate aggressive management policies for paediatric patients with clinically banal Spitz-type lesions.

Whole-Exome Sequencing Identifies Germline BLM Mutation in Ovarian Hepatoid Adenocarcinoma with Favorable Response to Niraparib and Anlotinib Combination Therapy-A Case Report and Literature Review.

Hepatoid adenocarcinoma of the ovary represents a rare and malignant extrahepatic tumor that shares morphological and immunophenotypic similarities with hepatocellular carcinoma. Due to the ambiguous histomorphology and aggressive behavior, the diagnosis and management of hepatoid adenocarcinoma of the ovary present unique challenges. Here, we present a 67-year-old woman with massive ascites and disseminated peritoneal implants at initial diagnosis. She was treated with six cycles of neoadjuvant therapy (albumin-bound paclitaxel + nedaplatin + bevacizumab) and a debulking surgery, followed by eight cycles of postoperative adjuvant therapy (albumin-bound paclitaxel + carboplatin + bevacizumab). Elaborate pathology workup found significant involvement of angiogenesis in the tumor and confirmed the diagnosis via immunohistochemistry. Further molecular characterization of the tumor by whole-exome sequencing (WES) revealed a novel heterozygous germline mutation (NM_000057.2, c.1290_1291delinsATCAGGCCTCCATAG, p.Y430fs1) in gene BLM, likely pathogenic, suggesting a potential candidate for Poly (ADP-ribose) polymerase (PARP) inhibitors. For the maintenance therapy, she received a combination of the PARP inhibitor niraparib and the antiangiogenic anlotinib. As of now, the patient has achieved a partial response, with no apparent evidence of disease progression observed nearly 30 months. Our study sheds light on the WES-based profiling in rare cancers to screen for any treatable targets with otherwise no standard therapeutic options. The promising results with the niraparib-anlotinib combination suggest its potential as a maintenance therapy option for hepatoid adenocarcinoma of the ovary, which warrants validation in future larger cohort.

Paediatric idiopathic intracranial hypertension: Epidemiology, clinical features and treatment outcomes in a tertiary care centre in Western Australia.

This retrospective study aims to analyse the epidemiology, clinical and neuroimaging features, treatment modalities, and outcomes of paediatric idiopathic intracranial hypertension (IIH) in a tertiary care centre in Australia. Using the International Classification of Diseases Diagnostic Criteria for IIH, we identified and analysed a cohort of children diagnosed with IIH over a 5-year period (2017-2022). Data on patient demographics, symptomatology, examination findings, investigative results, treatments and outcomes were collected from medical records and electronic health records. A total of 45 cases were analysed. The pre-pubertal group saw a male predominance and the post-pubertal a female one. Increased body mass index was an associated comorbidity in majority of patients. Headaches (89%) and visual symptoms (56%) were the most common symptoms, with tinnitus also seen in 20% of patients. Papilledema was detected in 91% of the cases examined. The commonest neuroimaging features were optic nerve sheath distention (78%) and empty sella (49%). Acetazolamide was the primary treatment, with most patients responding well. Only a minority required surgical intervention. Long-term resolution of headaches was achieved in 89% of patients. The incidence of paediatric IIH in the West Australian population appears relatively high. It presents with subtle symptoms, emphasising the need for increased awareness among health-care providers. Younger children may represent a distinct subgroup with unique clinical features. Timely diagnosis and aggressive medical management lead to favourable outcomes. However, weight loss interventions showed limited effectiveness. This study underscores the importance of early recognition and management of paediatric IIH to optimise patient outcomes.

Healthcare costs and medical utilization patterns associated with painful and severe painful diabetic peripheral neuropathy.

Painful diabetic peripheral neuropathy (DPN) is a common complication in patients with diabetes. It is associated with a poor quality of life and high costs of care. This study investigated the impact of painful DPN on healthcare costs and resource utilization. This was a retrospective analysis of administrative claims of adult patients with diabetes (type 1 or 2) from Optum's de-identified Clinformatics® Data Mart Database. Patients were assigned to four cohorts by presence of DPN and pain severity, based on diagnoses and prescription patterns in a one-year baseline. All-cause and diabetes-associated costs were calculated for the year following the index DPN diagnosis. Risk factors associated with presence of severely painful DPN were evaluated. Relative to those without DPN, patients who had DPN without pain, painful DPN (PDPN), or severe PDPN incurred respective increases of $3,093, $9,349, and $20,887 in average annual all-cause costs. More than half of costs from painful/severe DPN were for prescriptions and inpatient hospitalization. Severe PDPN was associated with elevated odds of diabetic amyotrophy (OR: 8.09; 95% CI: 6.84-9.56), diabetic foot ulcers (OR: 6.54, 95% CI: 6.32-6.76), and loss of mobility (OR: 2.54, 95% CI: 2.48-2.60), among other complications. Painful DPN is associated with higher healthcare costs and resource utilization, and a greater risk of debilitating conditions that limit quality of life. Future research should focus on better treatment options and more aggressive pain management strategies to reduce the negative impacts of DPN.

A novel therapy for spontaneous previable amniotic fluid leak by using intra‐amniotic platelet rich fibrin and plasma: A case report

AbstractIntroductionPreviable premature rupture of membrane (PV‐PROM) is a complex clinical situation posing considerable risks to the foetus. There is an extreme paucity of management options and clear guidelines in the literature for this dismal situation. This is the first report on usage of a novel combination of cellular therapeutic agents in a case of PROM. This study reports the earliest gestational age at which a case of spontaneous PV‐PROM (sPV‐PROM) has been successfully dealt by active management and, the longest period of continuation of pregnancy in a singleton sPV‐PROM for a total of 149 days.ObjectiveTo study the benefit of Intraamniotic Injection of PRF and PRP (IFPRP) in an index case of PV‐PROM.DesignThis is a case report of a 26‐year‐old woman with a recurrent, sPV‐PROM at 14 weeks 2 days with a previous pregnancy loss due to PV‐PROM at 18 weeks managed in a private reproductive health hospital in Mysore, India.MethodsOur subject underwent an elective cervical stitch at 14 weeks. She had confirmed, repeated episodes of leak after 30 h of the procedure. Apart from aggressive management to control infection with vaginal asepsis, an Intraamniotic injection of 9 mL of autologous PRF and 4.5 mL of PRP was done under ultrasound guidance. The pregnancy was monitored closely for signs of infection and foetal wellbeing.ResultsThe amniotic fluid leak stopped immediately after IFPRP for 36 h. After two more bouts of small leak, it stopped completely. She delivered a healthy baby of 3.4 kg at 35 weeks 4 days. The mother and baby did well postnatally.ConclusionOur protocol for fixing the leak is simple, easy to use, and can be done in resource‐poor settings which we consider is a big advantage. Further studies are needed to explore its potential in treating PROM.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for pancreatic cystic lesions: current status and future prospects.

Pancreatic cystic lesions (PCLs) have increased in prevalence due to the increased usage and advancements in cross-sectional abdominal imaging. Current diagnostic techniques cannot distinguish between PCLs requiring surgery, close surveillance, or expectant management. This has increased the morbidity and healthcare costs from inappropriately aggressive and conservative management strategies. Endoscopic ultrasound (EUS) needle-based confocal laser endomicroscopy (nCLE) allows for microscopic examination and delineation of the surface epithelium of PCLs. Landmark studies have identified characteristics distinguishing various types of PCLs, confirmed the high diagnostic yield of EUS-nCLE (especially for PCLs with an equivocal diagnosis), and shown that EUS-nCLE helps to change management and reduce healthcare costs. Refining procedure technique and reducing procedure length have improved the safety of EUS-nCLE. The utilization of artificial intelligence and its combination with other EUS-based advanced diagnostic techniques would further improve the results of EUS-based PCL diagnosis. A structured training program and device improvements to allow more complete mapping of the pancreas cyst epithelium will be crucial for the widespread adoption of this promising technology.

Drug-Resistant Epilepsy in Tuberous Sclerosis Complex Is Associated With TSC2 Genotype: More Findings From the Preventing Epilepsy Using Vigatrin (PREVeNT) Trial

BackgroundChildren with tuberous sclerosis complex (TSC) are at high risk for drug-resistant epilepsy (DRE). The ability to stratify those at highest risk for DRE is important for counseling and prompt, aggressive management, necessary to optimize neurocognitive outcomes. Using the extensively phenotyped PREVeNT cohort, we aimed to characterize whether the TSC genotype was associated with DRE. MethodsThe study group (N = 70) comprised participants with TSC enrolled at age less than or equal to six months with detailed epilepsy and other phenotypic and genotypic data, prospectively collected as part of the PREVeNT trial. Genotype-phenotype correlations of DRE, time to first abnormal electroencephalography, and time to epilepsy onset were compared using Fisher exact test and regression models. ResultsPresence of a TSC2 pathogenic variant was significantly associated with DRE, compared with TSC1 and participants with no pathogenic mutation identified. In fact, all participants with DRE had a TSC2 pathogenic variant. Furthermore, TSC2 variants expected to result in no protein product were associated with higher risk for DRE. Finally, TSC1 pathogenic variants were associated with later-onset epilepsy, on average 21.2 months later than those with other genotypes. ConclusionsUsing a comprehensively phenotyped cohort followed from infancy, this study is the first to delineate genotype-phenotype correlations for epilepsy severity and onset in children with TSC. Patients with TSC2 pathogenic variants, especially TSC2 pathogenic variants predicted to result in lack of TSC2 protein, are at highest risk for DRE, and are likely to have earlier epilepsy onset than those with TSC1. Clinically, these insights can inform counseling, surveillance, and management.

Peer-delivered training of criminal offenders for aggression and distress management: a new approach in social treatment in prisons in Serbia

ABSTRACT Peer-delivered training of criminal offenders for aggression control and distress management was implemented for the first time in Correction Facility in Niš, Serbia. The aim of the manuscript is to present the method of the peer-delivered training and to evaluate the change in the levels of aggression and distress reaction of the participants after completing the program. In the first phase, prison administration chose offenders who completed training for the peer-workers, supervised by engaged professionals. In the second phase, those six convicts trained the sample of 106 fellow prisoners, randomly assigned to the program, through 12 workshops in order to learn and recognize their own dysfunctional reactions and to adapt social desirable behaviour. An independent evaluator compared pre to post-training differences in levels of aggression and distress also presence of psychopathic traits, and socio-demographic characteristics of the subjects, using Buss & Perry Aggression Scale, Psychopathic Personality Traits Scale DS-14 Questionnaire and Socio-demographic Questionnaire. Results indicate increased levels of aggression and decreased levels of distress after the training. Prisoners with longer sentences had increased levels of anger, physical, verbal aggression, psychopathic traits and distress compared to subgroup with sentences shorter than 5 years. Program is beneficial for prisoners with sentences less than 5 years and with high education level.

Risk Factors and Stroke Subtyping in Young Adults: A Study From a Tertiary Care Hospital in South India.

This study aimed to determine the risk factors and stroke subtypes for young ischemic stroke patients and their outcomes at the time of discharge. This is a retrospective cross-sectional study of ischemic stroke patients (n = 264) between the age groups of 18 and 45. The study population was divided into two broad age groups: 18 to 35 years and 36 to 45 years; and compared based on demographics, risk factors, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and outcomes. The outcomes were compared based on the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (MRS) systems at the time of admission and discharge. The mean age of patients was 37.84±6.19 years. The male-to-female ratio was 2.5:1. The most common vascular risk factors identified were diabetes (29.16%), hypertension (49.62%), dyslipidaemia (DLP, 44.4%), and smoking (10.9%). The most common TOAST subtype was large vessel disease (38.63%), followed by the undetermined category (35.6%). The elderly group showed a high proportion of strokes secondary to small vessel disease (14.13%; p = 0.03), while cardioembolic strokes were common in the female subgroup (p = 0.05). The majority of strokes were in the anterior circulation (66.6%) as compared to the posterior (25.75%), and nearly 50% of the patients had intracranial disease. Overall, there was a favourable MRS outcome at discharge. Conventional vascular risk factors are equally prevalent, even among young stroke patients. The benchmark for young stroke age is showing a downward shift as more stroke patients above the age of 35 are showing similar risk factor trends as those of their older counterparts. The majority of stroke burden still falls under the undermined category, which requires aggressive risk factor identification and management.

Is the Diagnosis of fifth Metatarsal Fracture Type Consistent? An Interobserver Reliability Study.

Treatment pathways of fifth metatarsal fractures are commonly directed based on fracture classification, with particular proximal fractures typically requiring closer observation and possibly more aggressive management. Our aim is to investigate the interobserver reliability of assessment of subtypes of fifth metatarsal fractures. We included all patients referred to our virtual fracture clinic with a suspected or confirmed fifth metatarsal fracture. Plain anteroposterior radiographs were reviewed by 2 novice observers, initially trained on the fifth metatarsal classification identification. Eight different zones were defined based on anatomical location. Patients were excluded from analysis if neither observer could identify a fracture. An interobserver reliability analysis using Cohen κ coefficient was carried out, and degree of observer agreement described using Landis and Koch's description. All data were analyzed using IBM SPSS, version 27. A total of 1360 patients who met the inclusion criteria were identified. The 2 observers had moderate agreement when identifying fractures in all zones, apart from zone 1.2 and distal metaphysis (DM) fractures, which only achieved fair agreement (κ = 0.308 and 0.381 respectively). Zone 3 has slight agreement with zone 2 proximally, and there is an apparent difficulty with distal diaphyseal shaft (DS) fractures, resulting in a lot of crossover with DM, achieving a fair level of agreement (DS 312 vs 196; DM 120 vs 237; κ = .398, P < .001). Reliability of subcategorizing fifth metatarsal fractures using standardized instructions conveys moderate agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow-up during a virtual clinic review, defining fractures of zones 1-3 needs careful consideration. Level III, retrospective cohort study.

Comparative Effectiveness of Therapies in 2665 Elderly Patients with Ruptured Intracranial Aneurysms.

The optimal treatment strategy for elderly patients with ruptured intracranial aneurysms (IAs) remains controversial. We evaluated a national, multihospital database to compare the outcomes of aggressive treatment and medical management for those patients. We performed a retrospective analysis of 2665 elderly patients with ruptured IAs admitted to 11 hospitals in China. Patients were divided into three age groups (60-69, 70-79, and 80 years or older). Multiple logistic regression was used to estimate the odds ratio for favorable and unfavorable outcomes. Patients between 60 and 69 years old undergoing endovascular treatment (EVT) had significantly decreased morbidity (13.7% versus 19.7% and 29.9%), compared to those who underwent clipping and medical management, similar mortality to patients who underwent clipping (3.6% versus 2.6%), and decreased mortality (3.6% versus 8.7%) to patients who underwent medical management. Coiled patients 70 to 79 years old had lower morbidity (21.3% versus 33.8%) and mortality (2.8% versus 11.3%) compared to patients who underwent medical management and similar mortality (21.3% versus 27.2%) and mortality (2.8% versus 4.8%) to patients who underwent clipping. Multivariate logistic regression analysis demonstrated that factors associated with discharge status were age, poor mFisher grade, poor WFNS grade, hypertension, diabetes, smoking, aneurysms 4 mm or larger, and middle cerebral artery aneurysms. Elderly patients treated with EVT had significantly less morbidity and mortality than those treated with clipping and medical management. A comprehensive assessment of the general state of elderly patients and IAs characteristic may help us to predict patients' prognosis.

Bank Competition, Loan Portfolio Concentration and Stock Price Crash Risk: The Role of Tone Ambiguity

AbstractWe examine the association between loan portfolio concentration, competition and stock price crash risk in the US banking industry. We find that during economic downturns, banks with poorly diversified loan portfolios that operate in competitive markets are more likely to crash. Importantly, we show that this link is channelled through aggressive earnings management and ambiguous annual reports. Therefore, managerial ambiguity can serve as an early warning signal of information obfuscation, which can eventually lead to stock price crashes. As a quasi‐natural experiment, we use the passage of the Economic Growth, Regulatory Relief, and Consumer Protection Act in 2018. This policy lowered the regulatory requirements and oversight for a specific group of large banks. The results of a difference‐in‐differences analysis support our baseline findings and add to the ongoing debate on the roots of the 2023 banking crisis. Therefore, our findings can be informative to market participants, regulators and policy makers.

Acute Pancreatitis after EGD: Case Presentation and Literature Review of this Rare Post-Procedure Complication.

Acute pancreatitis is a common cause of hospitalisation characterised by inflammation of the pancreas. While mechanical, toxic and iatrogenic factors typically cause it, post-oesophagogastroduodenoscopy (EGD) pancreatitis is extremely rare. This report examines a case of acute pancreatitis following EGD, aiming to highlight this rare but significant complication. A 46-year-old woman with a history of breast cancer, anxiety, vitamin D deficiency and gastro-oesophageal reflux disease underwent an EGD, which revealed and led to the removal of duodenal polyps. Six hours post-procedure, she presented with severe abdominal pain radiating to her back, accompanied by nausea. Laboratory results indicated elevated lipase levels, and a computed tomography (CT) scan confirmed acute pancreatitis. The patient was managed with aggressive fluid resuscitation, bowel rest and pain management, leading to an improvement in her condition and subsequent discharge. We believe that the pancreatitis was likely caused by the use of cautery during the endoscopic mucosal resection of duodenal polyps. This case underscores the need for clinicians to recognise acute pancreatitis as a potential complication of EGD, especially in the absence of other common risk factors. Acute pancreatitis following oesophagogastroduodenoscopy (EGD) is an uncommon but significant complication.Possible mechanisms include mechanical trauma, gas insufflation or electrical injury during endoscopic mucosal resection.Clinicians should be aware of this potential complication, especially when no typical aetiological factors for pancreatitis are present.

Linking Diabetic Retinopathy Severity to Coronary Artery Disease Risk Factors in Type 2 Diabetic Patients.

Diabetes mellitus (DM) is a common metabolic disorder characterized by hyperglycemia, leading to chronic complications, notably cardiovascular diseases such as coronary artery disease (CAD). Diabetic retinopathy (DR), a leading cause of blindness, may serve as a non-invasive marker for CAD. This study investigates the correlation between DR and CAD to explore its diagnostic potential in diabetic populations. A cross-sectional study was conducted over one year in a general hospital, involving 100 type 2 DM patients with retinopathy. DR was classified as mild non-proliferative diabetic retinopathy (NPDR), moderate NPDR, severe NPDR, or proliferative retinopathy, based on fundus examinations. Data on age, duration of diabetes, cholesterol levels, glycated hemoglobin (HbA1C), and ECG (electrocardiography) findings were collected. Statistical analysis included frequency analysis, chi-square tests for association between categorical variables, and significance testing with p-values. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp., Armonk, New York, United States). Descriptive statistics were characterized by categorical and continuous variables. The chi-square test determined associations between qualitative variables, with significance set at p<0.05. The mean age of patients was 57.13 ± 8.51 years. Age and duration of diabetes were significant predictors of retinopathy severity (p<0.001). Proliferative retinopathy was found exclusively in patients over 70 years. Lower cholesterol levels (<200 mg/dL) were significantly associated with less severe retinopathy (p=0.033), whereas higher cholesterol levels (>200 mg/dL) did not show a statistically significant association with retinopathy severity (p=0.772). Patients with HbA1C levels between 6.5% and 8.5% predominantly had milder forms of retinopathy, as indicated by the significant p-value (<0.001). In contrast, patients with HbA1C levels above 8.5% are more likely to have severe NPDR or proliferative diabetic retinopathy (PDR), but this association was not statistically significant (p=0.582). ECG abnormalities increased with retinopathy severity (p=0.002). Hypertension was significantly linked to cardiac changes in retinopathy patients (p<0.001), while smoking and family history of CAD were not significant factors.This study's cross-sectional design limits causality inference. The single-center sample of 100 patients may not be broadly generalizable. Reliance on self-reported data introduces potential recall bias, and confounding factors such as diet, physical activity, and additional comorbidities were not accounted for. The lack of a control group further limits comparative analysis. Future longitudinal studies with larger, diverse samples are needed. Retinopathy in DM patients is significantly associated with cardiac changes and other risk factors such as hypertension, dyslipidemia, and poor glycemic control. Aggressive management of these factors is essential. Retinopathy can serve as a predictor of CAD in diabetic patients.

Comparative Analysis of C-reactive Protein and Procalcitonin as Biomarkers for Prognostic Assessment in Pediatric Sepsis.

Background Sepsis poses a critical medical challenge due to its profound systemic inflammatory response, which frequently results in organ dysfunction and high mortality rates, especially in pediatric patients. The condition requires prompt recognition and aggressive management to mitigate its severe outcomes. Methods This prospective study enrolled 248 pediatric patients admitted with sepsis to the pediatric intensive care unit (PICU) at our tertiary care center. Patients were randomly assigned to either the C-reactive protein (CRP) or procalcitonin (PCT) groups, with biomarker levels measured upon admission (hour zero) and again at 72 hours post-admission. Clinical parameters such as the need for ionotropic support, use of steroids, incidence of acute kidney injury (AKI), requirement for invasive ventilation, patient outcomes, and changes in antibiotic management were assessed based on these biomarker levels. Results Procalcitonin-positive sepsis cases demonstrated notable clinical severity compared to their C-reactive protein counterparts, showing significantly lower systolic blood pressure (p = 0.012), heightened need for ionotropic support (p < 0.0001), and more pronounced liver and renal dysfunction as indicated by elevated serum bilirubin (p = 0.001) and creatinine levels (p = 0.0058). The incidence of AKIwas also higher in procalcitonin-positive cases. Despite these severe clinical parameters, there were no significant differences in the length of the PICU stay or in patient outcomes concerning discharge and mortality rates. Procalcitonin levels effectively guided antibiotic management, resulting in therapy adjustments in a substantial proportion of cases, with 67 (54%) experiencing downgrades and 33 (27%) requiring upgrades based on procalcitonin levels measured 72 hours post-admission. Conclusion Procalcitonin proves to be a valuable biomarker in assessing the severity and management of sepsis in pediatric patients. It correlates significantly with clinical parameters such as blood pressure, the need for ionotropic support, and markers of organ dysfunction.

Expert Panel Opinion on Nutritional Management of Sarcopenia in Cancer Patients

Sarcopenia is a widely prevalent skeletal muscle condition that progresses over time and is associated with adverse outcomes. It is characterized by an accelerated loss of muscle mass and functional ability. Proposed causes of sarcopenia include aging, physical inactivity, malnutrition, hormonal disturbances, inflammation, and neurodegenerative changes. According to the IAPEN INDIA (India Association for Parenteral and Enteral Nutrition), nutritional management should be integrated into the diagnostic process for all chronic diseases, including cancer. Studies recommend aggressive nutritional management, providing an energy intake of &gt;30 kcal/kg/day and protein intake of &gt;1.2g/kg/day for patients with sarcopenia. Published literature suggests that adequate intake of antioxidants, such as vitamin D, E, and C, along with Omega-3 fatty acids, creatine, and L-carnitine, might be beneficial for preserving and improving sarcopenia, and functional outcomes. In summary, nutritional management complemented with resistance exercise, under strict supervision, is key to preventing and treating sarcopenia in cancer patients.

Prognostic significance of non-thyroidal illness syndrome in sepsis

Background and objectives. Sepsis is a common diagnosis among ICU patients. Therefore, the present study aimed at assessing the prognostic significance of non-thyroidal illness syndrome (NTIS) in sepsis. Materials and methods. The study was done as a retrospective analysis on adult patients of age greater than 18 years who were admitted with sepsis to an urban tertiary care ICU at Saveetha Medical College and Hospital. Results. The study found that NTIS can manifest as a fall in T3 alone, T4 alone, or both T3 and T4. A combined fall in T3 and T4 strongly correlates with poor primary outcomes (28-day mortality) compared to a fall in either hormone alone. Advancing age in septic patients leads to a greater combined fall in T3 and T4 values and an increased mortality rate, especially among females. The overall mortality rate in this series was 55%, with severe infections and high APACHE II scores contributing to lower hormone levels and higher severity. Conclusion. NTIS should be considered an indicator of poor prognosis in septic patients, necessitating aggressive management. It underscores the importance of assessing TSH alongside T3 and T4 in critically ill patients, although treating NTIS was beyond the scope of this study.

When the Pleural Fluid Appears in an Unexpected Color: A Bilothorax Case

Abstract Background: Bilothorax, or cholethorax, is a rare cause of exudative pleural effusion characterized by the presence of bile in the pleural space. Recognizing this condition is essential to prevent severe complications such as empyema and acute respiratory distress syndrome. Case: This report presents a 70-year-old male patient who developed right-sided bilothorax following multiple biliary tract interventions. The patient presented with symptoms of jaundice, fever, and abdominal pain. Clinical and radiological evaluations revealed right-sided pleural effusion, and thoracentesis yielded dark yellow-green fluid. The diagnosis of bilothorax was confirmed by a pleural fluid/serum total bilirubin ratio &gt;1.0. Early intervention was performed using a cystofix to drain the pleural fluid. However, despite all interventions, the sepsis condition could not be controlled, and the patient unfortunately passed away. Discussion: Bilothorax is generally associated with hepatobiliary procedures and is mostly observed on the right side due to anatomical proximity. Diagnosis requires a high index of suspicion, especially in patients with relevant clinical histories and characteristic pleural fluid appearance. Rapid thoracentesis and pleural fluid analysis are crucial for diagnosis. Treatment typically involves pleural drainage and early administration of broad-spectrum antibiotics. Conclusion: Bilothorax is a life-threatening condition requiring urgent diagnosis and intervention. This case highlights the importance of recognizing this rare condition and the necessity for early aggressive management in patients with a history of hepatobiliary procedures.

MASLD-related HCC: Multicenter study comparing patients with and without cirrhosis

Background and AimsDespite its growing incidence, hepatocellular carcinoma (HCC) related to metabolic dysfunction-associated steatotic liver disease (MASLD) in non-cirrhotic liver remains poorly characterized. We compared the characteristics, management, survival, and trends of MASLD-related HCC in patients with or without underlying cirrhosis in a large multicenter cohort. Methods354 patients with MASLD-related HCC presented at the liver tumor meetings of four French university hospitals between 2007 and 2018, were included in the study. Data were extracted from the meetings’ databases and from the French Birth and Death Registry. Results35% of HCC cases occurred in the absence of cirrhosis. HCC was diagnosed through screening in 60% of patients with cirrhosis, and incidentally in 72% of patients without it. Non-cirrhotic patients were older, had a greater tumor burden, but also better liver function than cirrhotic patients. Non-cirrhotic patients showed better overall survival than those with cirrhosis (p=0.043). However, cirrhosis was not independently associated with overall survival, the independent predictors were age, liver function, tumor burden and BCLC classification. Non-cirrhotic patients underwent surgery more frequently than cirrhotic patients did (41% versus 11%, p<0.001), even in cases where the largest tumors were ≥5 cm (42% versus 14%, p=0.002) or there were four or more lesions (19% versus 2%, p=0.024). Among the cirrhotic and non-cirrhotic patients who underwent surgery, survival was not significantly different. The cirrhosis / no cirrhosis ratio remained stable over the study period. ConclusionsIn MASLD-related HCC, non-cirrhotic patients account for 35% of cases and have poor prognostic factors (higher age and larger tumors) but also better liver function, resulting in more aggressive management of advanced tumors and better survival compared to cirrhotic patients. Impact and implicationsThe incidence of hepatocellular carcinoma related to MASLD is projected to increase by 47% to 130% by year 2030 with one third occurring in non cirrhotic livers, making them inaccessible to screening with tumors more advanced at diagnosis. Our study shows that survival in MASLD patients with hepatocellular carcinoma relies on age, tumor burden and underlying liver function and the preserved liver function of these non-cirrhotic patients allows them to be managed surgically. A better understanding of the pathophysiological processes driving HCC occurrence in non-cirrhotic MASLD patients to screen and early management of these patients.