Presentation Of Common Disease Research Articles

Precipitating Factors of Hepatic Encephalopathy in Patients with Cirrhosis of Liver in a Tertiary Care Center of Nepal

Introduction: Chronic liver disease is a common disease presenting in hospitals in Nepal. A large number of cirrhotics present with hepatic encephalopathy. Various precipitating factors are present which precipitate hepatic encephalopathy. This study was intended to identify the precipitating factors of hepatic encephalopathy and to assess whether identifiable precipitating factors of encephalopathy are present. Materials and Methods: This was a hospital-based observational cross-sectional study conducted at the Department of Medicine, Manipal Teaching Hospital, Pokhara. A total of 80 patients were included. The precipitating factors for encephalopathy were documented along with grading. SPSS was used for data analysis. Results: The mean age of the patients was 54.725 ± 11.33 years. There were 55 males (68.8%) and 25 (31.3%) females in the study. All the patients (100%) had a significant amount of alcohol consumption. It was found that hepatic encephalopathy was more severe in the higher Child-Pugh class as compared to a lower one. At least 1 precipitating factor was identified in 81% of patients. The common precipitating factors were increased protein intake, bleeding, infection, diarrhea, and constipation. Conclusions: We conclude that there are different factors that play a key role in precipitating hepatic encephalopathy, with a high protein diet, constipation, bleeding, and infections being predominant. A minor change in dietary habits, regular follow up and timely visits to the health care facility may result in the identification of these common precipitating factors like infections, constipation, and diarrhea.

Exploring Pediatric Dermatology in Skin of Color: Focus on Dermoscopy.

This literature review aims to comprehensively evaluate the clinical and dermoscopic presentations of common pediatric diseases among children with skin of color (SoC) while also addressing potential variations based on racial backgrounds. This review encompasses various conditions, such as nevi subtypes, viral infections, infestations, and inflammatory dermatoses, as well as hair diseases and abnormal vascular formations, occurring in pediatric populations. Overall, we identified 7 studies on nevi subtypes, 24 studies on skin infections, 6 on inflammatory dermatoses, 10 on hair diseases and disorders, and 14 on miscellaneous disorders that also satisfied our SoC- and race-specific criteria. In case of no results, we assumed that dermoscopic findings are similar between SoC adults and children, confirming the hypothesis with our cases of dark-skinned Indian child patients. Inflammatory dermatoses such as psoriasis, eczema, and cutaneous mastocytosis, as well as skin infections like cutaneous leishmaniasis, appear with brownish backgrounds or exhibit dark structures more frequently than the respective dermoscopy images of Caucasian populations. Dermoscopy traits such as erythema in tinea capitis are uncommon or even absent on a dark-colored scalp, while a dark skin tone often obscures many characteristic features, such as dark and yellow dots in alopecia areata and even parts of an intradermal parasite in the case of scabies. Race-specific traits were also observed, such as corkscrew hair in tinea capitis, primarily seen in patients of African origin. Many dermoscopic images are consistent between SoC and non-SoC in various skin lesions, including vascular anomalies, juvenile xanthogranuloma, mastocytoma, and viral skin lesions like molluscum contagiosum, as well as in various hair disorders such as trichotillomania, while tinea capitis displays the most diverse reported dermoscopic features across SoC- and race-specific studies.

Predictive Value of NT-proBNP, FGF21, Galectin-3 and Copeptin in Advanced Heart Failure in Patients with Preserved and Mildly Reduced Ejection Fraction and Type 2 Diabetes Mellitus.

Background and Objectives: Heart failure (HF) is one of the most common initial presentations of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM). There are different cardiac biomarkers related to the pathophysiological mechanisms of HF in T2DM. The current research aims to identify additional biomarkers that could improve the diagnosis and prognosis of HFpEF, which is currently assessed using NT pro-BNP levels. NT pro-BNP is a valuable tool for diagnosing heart failure but may not always correlate with clinical symptom severity or can present normal levels in certain cases, such as obesity. Biomarkers like FGF-21 and galectin-3 could provide greater insight into heart failure severity, especially in diabetic patients. The main objective of the current study is to assess the performance of NT-proBNP, FGF21, Galectin-3 and Copeptin to discriminate between advanced and mild HF. Materials and Methods: A total of 117 patients were enrolled in this study and divided into two groups: 67 patients in NYHA functional class I-II (mild HF) and 50 patients in NYHA III-IV (advanced HF). NT-pro BNP, FGF21, Galectin 3 and Copeptin serum levels were determined with the ELISA method. Receiver operating characteristic (ROC) analysis and binomial logistic regression analysis were used to measure the ability of the studied biomarkers to distinguish between advanced and mild HF patients. Results: In patients with T2DM with advanced HF, serum FGF21 level was significantly positively correlated with eGFR (ρ = 0.35, p = 0.0125) and triglycerides (ρ = 0.28, p = 0.0465) and significantly negatively correlated with serum levels of HDL cholesterol (ρ = -0.29, p = 0.0386) and with RV-RA gradient (ρ = -0.30, p = 0.0358). In patients with mild HF, serum FGF21 level was significantly negatively correlated with NT-proBNP levels (ρ = -0.37, p = 0.0022), E/e' ratio (ρ = -0.29, p = 0.0182), TR velocity (ρ = -0.24, p = 0.0470) and RV-RA gradient (ρ = -0.24, p = 0.0472). FGF21 (AUC = 0.70, 95% CI: 0.60-0.79) and NT-proBNP (AUC = 0.73, 95% CI: 0.63-0.82) demonstrated significant predictive value to discriminate T2DM patients with advanced HF from those with mild HF. Elevated values for FGF21 (≥377.50 ng/mL) or NTproBNP (≥2379 pg/mL) were significantly associated with increased odds of advanced HF after adjusting for demographic and clinical covariates. Conclusions: NTpro-BNP and FGF21 have a similar ability to discriminate T2DM patients with advanced HF from those with mild HF. Univariable and multivariable logistic models showed that, FGF21 and NTproBNP were independent predictors for advanced HF in patients with preserved and mildly reduced ejection fraction and T2DM.

Patterns of disease presentation and outcome during the 2024 Al-Sha’abania mass gathering event in Karbala, Iraq

IntroductionMass gatherings can be defined as spontaneous or planned gatherings of many individuals that lead to an increased burden on local healthcare services. This study was conducted to estimate the prevalence of common disease presentations to temporary healthcare outlets during Al-Sha’abania mass gathering events to improve public health preparedness for future events. MethodA cross-sectional study was conducted during the Al-Sha’abania religious mass gathering in Karbala between February 24 and February 26, 2024, including seven healthcare outlets distributed around Imam Hussein and Imam Abbas Holy Shrines. ResultWe retrieved the records of 6799 patients who attended the temporary healthcare outlets during the data collection period; 3919 (57.6 %) were males. Females (62.0 %) and individuals above the age of 50 (52.7 %) constituted a higher proportion of emergency presentations. The most common cause of attendance was non-communicable conditions in both cold (66.7 %) and emergency cases (49.4 %). However, accidents/injuries were more common in emergency presentations (18.8 % vs. 2.7 %). The highest overall cause of attendance across all categories was joint/bone conditions (1192, 19.26 %) for cold cases and hypertension for emergency cases (84, 13.75 %). Out of the 611 patients with emergency presentation, only 8 (1.3 %) required referral to secondary and tertiary healthcare centers. ConclusionDifferences in the number of cases presented to different healthcare outlets require careful resource allocation during future mass gathering events in Karbala. Additionally, the importance of managing chronic conditions should be emphasized to reduce the burden of non-communicable conditions during mass gathering events.

Incorporating genetic testing into a routine kidney clinic.

Incorporating genetic testing in routine outpatient nephrology clinic can improve on chronic kidney disease (CKD) diagnosis and utilization of precision medicine. We sent a genetic test on patients with atypical presentation of common kidney diseases, electrolytes derangements, and cystic kidney diseases. We were able to identify a gene variant contributing to patients' kidney disease in more than half of our cohort. We then showed that patients with ApoL1 risk allele have likely worse kidney disease, and we were able to confirm genetic focal segmental glomerulosclerosis (FSGS) in 2 patients and avoid unnecessary immunosuppression. Genetic testing has also improved our operation to establish a polycystic kidney disease excellence center by confirming our diagnosis, especially in patients without a well-defined family history. In conclusion, utilizing genetic testing in a routine outpatient renal clinic did not cause any burden to either patients or nephrologists, with minimal administrative effort and no financial cost to our patients. We expect that genetic testing in the right setting should become routine in nephrology to achieve a patient-centered precision medicine with less invasive means of kidney disease diagnosis.

Evaluation of ChatGPT-Generated Differential Diagnosis for Common Diseases With Atypical Presentation: Descriptive Research.

The persistence of diagnostic errors, despite advances in medical knowledge and diagnostics, highlights the importance of understanding atypical disease presentations and their contribution to mortality and morbidity. Artificial intelligence (AI), particularly generative pre-trained transformers like GPT-4, holds promise for improving diagnostic accuracy, but requires further exploration in handling atypical presentations. This study aimed to assess the diagnostic accuracy of ChatGPT in generating differential diagnoses for atypical presentations of common diseases, with a focus on the model's reliance on patient history during the diagnostic process. We used 25 clinical vignettes from the Journal of Generalist Medicine characterizing atypical manifestations of common diseases. Two general medicine physicians categorized the cases based on atypicality. ChatGPT was then used to generate differential diagnoses based on the clinical information provided. The concordance between AI-generated and final diagnoses was measured, with a focus on the top-ranked disease (top 1) and the top 5 differential diagnoses (top 5). ChatGPT's diagnostic accuracy decreased with an increase in atypical presentation. For category 1 (C1) cases, the concordance rates were 17% (n=1) for the top 1 and 67% (n=4) for the top 5. Categories 3 (C3) and 4 (C4) showed a 0% concordance for top 1 and markedly lower rates for the top 5, indicating difficulties in handling highly atypical cases. The χ2 test revealed no significant difference in the top 1 differential diagnosis accuracy between less atypical (C1+C2) and more atypical (C3+C4) groups (χ²1=2.07; n=25; P=.13). However, a significant difference was found in the top 5 analyses, with less atypical cases showing higher accuracy (χ²1=4.01; n=25; P=.048). ChatGPT-4 demonstrates potential as an auxiliary tool for diagnosing typical and mildly atypical presentations of common diseases. However, its performance declines with greater atypicality. The study findings underscore the need for AI systems to encompass a broader range of linguistic capabilities, cultural understanding, and diverse clinical scenarios to improve diagnostic utility in real-world settings.

Longitudinal Changes in Diagnostic Accuracy of a Differential Diagnosis List Developed by an AI-Based Symptom Checker: Retrospective Observational Study.

Artificial intelligence (AI) symptom checker models should be trained using real-world patient data to improve their diagnostic accuracy. Given that AI-based symptom checkers are currently used in clinical practice, their performance should improve over time. However, longitudinal evaluations of the diagnostic accuracy of these symptom checkers are limited. This study aimed to assess the longitudinal changes in the accuracy of differential diagnosis lists created by an AI-based symptom checker used in the real world. This was a single-center, retrospective, observational study. Patients who visited an outpatient clinic without an appointment between May 1, 2019, and April 30, 2022, and who were admitted to a community hospital in Japan within 30 days of their index visit were considered eligible. We only included patients who underwent an AI-based symptom checkup at the index visit, and the diagnosis was finally confirmed during follow-up. Final diagnoses were categorized as common or uncommon, and all cases were categorized as typical or atypical. The primary outcome measure was the accuracy of the differential diagnosis list created by the AI-based symptom checker, defined as the final diagnosis in a list of 10 differential diagnoses created by the symptom checker. To assess the change in the symptom checker's diagnostic accuracy over 3 years, we used a chi-square test to compare the primary outcome over 3 periods: from May 1, 2019, to April 30, 2020 (first year); from May 1, 2020, to April 30, 2021 (second year); and from May 1, 2021, to April 30, 2022 (third year). A total of 381 patients were included. Common diseases comprised 257 (67.5%) cases, and typical presentations were observed in 298 (78.2%) cases. Overall, the accuracy of the differential diagnosis list created by the AI-based symptom checker was 172 (45.1%), which did not differ across the 3 years (first year: 97/219, 44.3%; second year: 32/72, 44.4%; and third year: 43/90, 47.7%; P=.85). The accuracy of the differential diagnosis list created by the symptom checker was low in those with uncommon diseases (30/124, 24.2%) and atypical presentations (12/83, 14.5%). In the multivariate logistic regression model, common disease (P<.001; odds ratio 4.13, 95% CI 2.50-6.98) and typical presentation (P<.001; odds ratio 6.92, 95% CI 3.62-14.2) were significantly associated with the accuracy of the differential diagnosis list created by the symptom checker. A 3-year longitudinal survey of the diagnostic accuracy of differential diagnosis lists developed by an AI-based symptom checker, which has been implemented in real-world clinical practice settings, showed no improvement over time. Uncommon diseases and atypical presentations were independently associated with a lower diagnostic accuracy. In the future, symptom checkers should be trained to recognize uncommon conditions.

Young Minds, Rare Finds, and the Path to Publish Case Reports

A case report (CR) is a type of medical literature that demonstrates the scientific documentation of a rare disease/phenomenon, an unusual presentation of common diseases, or an innovative treatment for the disease. CRs can serve as an impetus for further research, prompting investigators to explore the potential associations, mechanisms, or therapeutic interventions suggested by individual case observations. However, emerging researchers often encounter various challenges while documenting CRs for publication, including limited experience, difficulty navigating relevant literature, ethical considerations, and publication barriers. This article focuses on empowering emerging researchers for the medical writing of CRs by providing a roadmap from observation to publication in a minimum duration, along with the implication of artificial intelligence (AI) in CR writing, highlighting AI’s potential to streamline drafting processes while addressing technical limitations, biases, and ethical concerns associated with its use. Thus, equipping emerging researchers with the necessary tools and resources, fostering confidence and competence by demystifying the CR writing process, and empowering aspiring authors to contribute meaningfully to the scientific literature.

Primary Disseminated Peritoneal Hydatidosis: A Rare Presentation of Common Infectious Disease

Introduction: Human hydatidosis, being caused by the larvae of Echinococcus granulosus, rarely presents as disseminated peritoneal disease which can be either primary or secondary. Iatrogenic secondary peritoneal echinococcosis is more common while primary form of infection is found occasionally. Radiological imaging including ultrasonography or computed tomography (CT) scan is considered the most essential diagnostic modality. The mainstay of treatment for localized hydatid cysts or infected cysts and multiple septations is the surgical management in the form of excision. Disseminated hydatid disease presents with varied manifestations involving multiple organs. However, primary peritoneal hydatidosis is being rare entity, accounting for only 2% of cases of abdominal hydatidosis. The dissemination to multiple organs usually occurs through either lymphatic or systemic circulation. Case Report: In this case report, we present an uncommon presentation of primary disseminated peritoneal hydatidosis. On further evaluation, the patient was diagnosed to have peritoneal hydatidosis with hepatic and lung hydatid cyst involvement on contrast-enhanced CT abdomen. The patient was managed conservatively with oral tablet albendazole 400 mg twice a day during his 1st admission and later presented again with acute abdomen, and then, radical surgery in the form of pericystectomy was carried out but patient developed large gastric perforation, for which again surgery was attempted, but patient succumbed to his illness. In this case, the rare presentation of primary disseminated peritoneal hydatidosis as acute abdomen was observed. Conclusion: Primary disseminated peritoneal hydatidosis as the presentation of acute pain abdomen is rare entity. This case emphasizes an atypical presentation of hydatidosis.

Challenges of Cutaneous Care in Hyperthyroidism: A Case Report

Cutaneous manifestations of thyroid disease are one of the first notable signs of thyroid hormone dysregulation. Skin changes in hyperthyroidism vary from individual to individual. In dark skinned Africans it may be challenging to detect these dermatoses and care for the patients with these dermatoses if they arise. Making the actual cutaneous diagnosis in hyperthyroidism may be impaired by co-morbidities, drug-drug interactions, hypersensitive reactions, unusual presentation of common diseases, immunosuppression that may result to opportunistic infections and similar presentations of dermatoses. There may be dermatoses that may co-exist with other dermatoses within the same site. The peculiarity of our case report is that we present three females with hyperthyroidism that cut across different age groups with different cutaneous lesions. This case report aims to present the challenges of making accurate skin diagnosis and challenges that arise in actually caring for them. Counselling the patient on the appropriate care and prognosis of these skin lesions would help in improvement of quality of life and unwanted expectations

Clinical signs and symptoms of Wilson disease in a real-world cohort of patients in the United States: a medical chart review study

IntroductionThere are limited data from the United States regarding the real-world signs and symptoms of Wilson disease (WD). This retrospective, observational medical chart review was conducted to identify real-world characteristics of patients with WD in the United States, as well as WD signs and symptoms at diagnosis and over time.MethodsDe-identified clinical data were abstracted from medical charts of US patients diagnosed with WD between January 1, 2012, and June 30, 2017. Hepatic, neurologic, and psychiatric biochemical findings, signs, and symptoms were characterized at diagnosis and follow-up/during treatment.ResultsIn total, 225 WD patients were included in the study. The mean (SD) age at diagnosis was 24.7 (9.8) years, and 65.3% were male. Median (Q1–Q3) follow-up after diagnosis was 39.5 (33.8–60.4) months. The most common disease presentation at WD diagnosis was combined neurologic/psychiatric and hepatic (52.9%), followed by neurologic/psychiatric (20.0%), hepatic (16.9%), and asymptomatic (10.2%). Common clinical characteristics at diagnosis were Kayser-Fleischer rings (77.2%), low ceruloplasmin levels (95.2%), high hepatic copper (97.8%), elevated 24-hour urinary copper excretion (90.2%), and abnormal liver function tests (38.7%–85.1%). At diagnosis, the most common biochemical findings or hepatic sign/symptoms were abnormal liver enzymes (50.7%), abdominal pain (16.6%), and fatigue (15.7%). The most common neurologic signs/symptoms were headache (18.3%), dysarthria (17.4%), and ataxia (17.0%). Common psychiatric signs/symptoms included anxiety/depression/other mood changes (36.2%), emotional lability (12.8%), and increased irritability/anger outbursts (9.2%). Prevalence of biochemical abnormalities or signs/symptoms among patients at diagnosis and after ~1-year follow-up were neurologic (60.1% and 44.0%), hepatic (69.6% and 37.8%), and psychiatric (53.7% and 37.6%), respectively. Common new onset symptoms at ~1-year post-WD diagnosis were abnormal liver enzymes (5.6%), headache (6.2%), and anxiety/depression/other mood changes (7.2%).ConclusionsThese real-world, descriptive data highlight the clinical complexity and heterogeneity of WD and the need for better education about diagnostic testing and multidisciplinary support. Although rare, the neurologic, psychiatric, and hepatic signs/symptoms of WD have a substantial clinical impact.

Ten Tips on How to Write and Publish a Case Report

Case report is a form of medical writing that describes an unusual presentation of common diseases, a rare disease / phenomenon, or a novel treatment of disease in a scientific manner. Case report is often seen as an easy and quick form of medical writing. However, it can be daunting at times, if the writer does not know where to begin and how to write different sections of a case report. We share ten easy and practical tips that can help novice and expert medical writer alike, to draft a ‘publication’ worthy case report in the minimum amount of time. These tips will help the writer to avoid common mistakes associated with case reports.

A retrospective study of Aeromonas hydrophila infections at a university tertiary hospital in Saudi Arabia

BackgroundAeromonas hydrophila can cause a wide range of diseases and is mainly found in patients with underlying diseases. Globally the data on Aeromonas infections is limited, and no studies have been published about the situation in Saudi Arabia. The aim of this study was to investigate the risk factors, clinical presentation, treatment, and outcomes of Aeromonas infections in Saudi Arabia.MethodsA retrospective study was performed at a tertiary university hospital with 1000 beds in Jeddah, Saudi Arabia. All patients 14 years and older with Aeromonas-positive cultures between January 1, 2015, and December 31, 2022 were included. Patient information was extracted from the electronic health records, including patient demographics, comorbidities, presenting symptoms, source of infection, human immunodeficiency virus status, culture results and antimicrobial susceptibility, use of immunosuppressive medication, and 30-day mortality.ResultsIn total 24 patients were identified with Aeromonas hydrophila-positive cultures, 22 of which were males (91.7%), and most (75%) had hospital-acquired infections. The 30-day mortality was 20.8%. All Aeromonas cultures were susceptible to gentamicin, cefepime, and ciprofloxacin, while the majority were resistant to ceftazidime (83.3%) and meropenem (62.5%). The most common disease presentation was skin and soft tissue infection (33.3%), the most common clinical sign was fever (58.3%), and the most common symptom was abdominal pain (37.5%). Comorbidities were very common (median 3, range 1–7). Pitt bacteremia score (p < 0.001), Charlson weighted comorbidity index (p < 0.02), international normalized ratio (p < 0.005), and the number of comorbidity factors (p < 0.05) were all associated with 30-day mortality due to Aeromonas infection. The number of comorbidities had the best predictive value (83.3%) of 30-day mortality (p < 0.05, Odds ratio 3.253, 95% confidence interval: 1.088–9.729).ConclusionsAeromonas hydrophila is an important pathogen to consider in nosocomial infections. The number of comorbidities had the best predictive value of 30-day mortality. The susceptibility pattern of this organism indicates that, in Saudi Arabia, when an Aeromonas infection is suspected, treatment with quinolone along with other broad-spectrum antibiotics should be started until the culture and susceptibility results are known.

Impact of Changing ACGME Case Requirements on Radiation Oncology Resident Rotation Structure

The ACGME has updated case requirements for radiation oncology residents beginning with the graduating class of 2026, specifically introducing minimum cases across a wider range of disease sites. We aimed to assess the impact the ACGME update will have on residency rotation scheduling in our training program by retrospectively applying the case minimums to recent graduating classes and determining how rotations should be modified to meet the new standards. Our program utilizes the apprentice model where residents are assigned 1:1 or 1:2 to faculty supervisors. We abstracted case log information from residents graduating between 2020 and 2022, and cases were categorized based on the new ACGME requirements. We also abstracted total department treatment courses from our treatment tracking software which records disease site and resident participation. Hypothetical schedules were created to determine how resident rotations can be structured to ensure adequate exposure to meet all case minimums. The mean number of cases for graduating residents was 666 (range: 563-755). Six (67%) graduating residents would have not met at least one new ACGME site-specific requirement. The most common delinquencies were esophagus, anorectal, non-prostate genitourinary (GU), and lymphoma for which at least 3 residents each did not meet. Review of the treatment tracking software confirmed adequate case volume for these disease sites but that they were often not performed by a resident. We observed that these disease sites were less likely to be performed by a resident than other disease sites at our institution. Specifically, in 2022, 25% of all simulations went uncovered by residents but at-risk disease sites such as GI and GU each averaged 35% of simulations uncovered. We observed that when we retrospectively applied new ACGME minimums to recent graduating classes most residents would have been considered non-compliant despite adequate case volume at our institution. Case exposure, particularly for less common disease presentations, was highly dependent on rotation assignment. In the setting of increasing faculty-to-resident ratio requirements, conventional 1:1 assignments may not be adequate to meet new ACGME site minimums. We are currently comparing different resident coverage models that can be coupled with our traditional apprentice model to increase breadth of case exposure without compromising educational yield. Two models have arisen: a hybrid model where residents traditionally cover one attending and then cover the consults/simulations only of a second attending and a consult service model where residents are paired with 2 or more attendings but only see consults/simulations with these attendings. Coupling these models alongside the traditional apprentice model projects not only increased coverage of all simulations but improves coverage of traditionally "missed" simulations to at least 83% and upwards of 90% on most simulated schedules.

Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors.

To assess the usefulness of case reports as sources for research on diagnostic errors in uncommon diseases and atypical presentations. We reviewed 563 case reports of diagnostic error. The commonality of the final diagnoses was classified based on the description in the articles, Orphanet, or epidemiological data on available references; the typicality of presentation was classified based on the description in the articles and the judgment of the physician researchers. Diagnosis Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC), and Generic Diagnostic Pitfalls (GDP) taxonomies were used to assess the factors contributing to diagnostic errors. Excluding three cases in that commonality could not be classified, 560 cases were classified into four categories: typical presentations of common diseases (60, 10.7 %), atypical presentations of common diseases (35, 6.2 %), typical presentations of uncommon diseases (276, 49.3 %), and atypical presentations of uncommon diseases (189, 33.8 %). The most important DEER taxonomy was "Failure/delay in considering the diagnosis" among the four categories, whereas the most important RDC and GDP taxonomies varied with the categories. Case reports can be a useful data source for research on the diagnostic errors of uncommon diseases with or without atypical presentations.

The Demographic and Clinicopathological Characteristics of Hepatopancreatobiliary Cancers From a Specialized Center in India.

Introduction Hepatopancreatobiliary (HPB) cancers are a distinct group requiring specialized multidisciplinary care. The present study was an analysis of HPB cancers. Methods The institutional data for two years from 2017 to 2018 was retrieved from the hospital-based cancer registry (HBCR) database in Excel format (Microsoft® Corp., Redmond, WA). The demographic details, method of diagnosis, tumor characteristics, and disease extent of the patients with HPB primary sites were retrospectively analyzed. Results Out of the 1417 patients with HPB malignancies, 1193 were analyzed. Most of the patients at our center hailed from North India. The distribution of HPB cancers was as follows: hepatocellular carcinoma (HCC) (n=717, 60.1%), gallbladder (GB) (n=230, 19.3%), periampullarycarcinoma (n=76, 6.37%), head of the pancreas (HOP) (n=55, 4.61%), extrahepatic bile duct (EBD) (n=53, 4.44%), intrahepatic bile duct (IBD) (n=32, 2.68%), and body of the pancreas (BOP) (n=30, 2.52%). The most common disease presentation of HPB cancers was in the seventh and sixth decades of life. Male predominance was seen in all HPB cancers except in GB with a higher incidence in females. The predominant cause of chronic liver disease (CLD) with HCC was viral-related (53.7%) with hepatitis B virus (HBV) (34.3%) higher than hepatitis C virus (HCV) (19.2%)followed by non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) (24.8%) and then alcohol. Adenocarcinoma was the most common morphology in pancreatobiliary malignancies. The disease presentation was locoregional in 63.4% of HCC, 69.7% of periampullary carcinoma, and 50.9% of HOP cases. The patients with EBD and IBD cancers presented commonly with locoregional disease extent in 60.4% and 62.5%, respectively. Perihilar subsite was more commonly detected (71.7%) as compared to the distal one in the patients with EBD cancers. The patients with GB cancers (GBC) presented with distant metastases in 53.5% and locoregional disease in 33%. Distant metastases were present in 76.7% of the patients with BOP cancers. The liver was a common site of distant metastases in GB, periampullary, and pancreatic cancers. Conclusions The present study highlights the characteristics and the variations in disease presentation in different primary tumor sites of HPB cancers. In view of the common locoregionally advanced disease presentation of HCC, the patients with CLD need surveillance for the early detection of lesions. As the patients with HPB cancers show advanced disease presentation, effective locoregional and systemic therapies are needed.

A cross-sectional questionnaire-based study of medication adherence in children suffering from epilepsy attending pediatric out-patient department at a tertiary care teaching hospital

Background: Epilepsy is a common chronic disease presenting during childhood that requires long-term treatment. Rates of adherence to antiepileptic drugs are variable in children ranging from 25% to 75%. Non-adherent patients are more likely to experience frequent and recurrent seizures which drastically impact the health of the patient. This study was therefore conducted in order to assess the medication adherence of children suffering from epilepsy to the prescribed anti-epileptic drug therapy. Methods: Children diagnosed with epilepsy aged 6-18 years were enrolled in the present cross-sectional questionnaire-based study after prior written informed consent and written informed assent. Children with co-morbidities were excluded from the study (as diagnosed by the Paediatrician). The case record form was filled after interviewing the patients. A questionnaire based on the Morisky medication adherence scale-8 (MMAS) was used to evaluate the quality of life of children. Results: Total 243 patients got enrolled in the study. GTCS was found to be the most common type of epilepsy. Valproate was the most commonly used agent. Out of the 243 patients in total, 201 patients (83%) showed high adherence, 24 patients (10%) showed medium adherence and 18 patients (7%) showed poor adherence to the treatment prescribed. Patients on monotherapy showed higher adherence rates than patients on polytherapy. Medication adherence was highest with Valproate among monotherapy and valproate + carbamazepine among poly-therapy. Conclusions: We conclude that monotherapy with anti-epileptic agents and patient satisfaction is positive predictors of medication adherence leading to a lesser impact of the disease on the child and improved health.

An Uncommon Presentation of Common Disease at Tertiary Care Centre of Northern India

Snake bite is often met emergency in Indian subcontinent especially in rural settings. We sent a case of a 26-year-old male, residing in North India who sented with complaints of swelling over left leg along with breathlessness. His renal functions deteriorated gradually. In view of various physical and laboratory findings, a diagnosis of vasculotoxic snake bite envenomation with acute kidney injury and pulmonary oedema was made. He was managed conservatively with IV fluids, parenteral antibiotics and haemodialysis. Acute kidney injury is an important complication in vasculotoxic snake bites and should be addressed early.

Fibro-Stenosing Crohn's Disease: What Is New and What Is Next?

Fibro-stenosing Crohn's disease (CD) is a common disease presentation that leads to impaired quality of life and often requires endoscopic treatments or surgery. From a pathobiology perspective, the conventional view that intestinal fibro-stenosis is an irreversible condition has been disproved. Currently, there are no existing imaging techniques that can accurately quantify the amount of fibrosis within a stricture, and managing patients is challenging, requiring a multidisciplinary team. Novel therapies targeting different molecular components of the fibrotic pathways are increasing regarding other diseases outside the gut. However, a large gap between clinical need and the lack of anti-fibrotic agents in CD remains. This paper reviews the current state of pathobiology behind fibro-stenosing CD, provides an updated diagnostic and therapeutic approach, and finally, focuses on clinical trial endpoints and possible targets of anti-fibrotic therapies.

Infective endocarditis of quadricuspid aortic valve

BackgroundInfective endocarditis of the aortic valve is a relatively common disease presentation, with surgical intervention a mainstay of treatment in severe cases. Quadricuspid aortic valves are a rare spontaneous developmental anomaly that are more likely to be asymptomatic, and less likely to require a full valve replacement than their hypocuspid counterparts. However, there is very little literature addressing infective endocarditis of this valve variant.Case presentationThis case report presents a case of infective endocarditis of a quadricuspid aortic valve that required replacement with a surgical bioprosthetic valve. The patient is a 30 year old male with a history of polysubstance use, upper extremity aneurysm, and prior tricuspid valve endocarditis. Surgical aortic valve replacement was performed with a 25 mm tissue valve via median sternotomy.ConclusionsThe patient made a full recovery after surgical aortic valve replacement and a course of antibiotics and was discharged home without any complications. This supports that surgical aortic valve replacement is feasible and safe in patients with polycuspid aortic valve endocarditis.