Unusual clinical course Background:Human papilloma virus is a ubiquitous and preventable disease with the potential to cause recurrent respiratory papillomatosis. These papillomas affect the mucosal surface of the airways and may lead to airway obstruction. The papillomas require excision when breathing is compromised, and may be fatal if untreated. Rarely, these papillomas progress to cancer. Case Report:We report the case of a 21-year-old woman with a history of HPV 11-and 16-positive recurrent laryngeal and respiratory papillomatosis (RRP) since the age of 7 months, requiring multiple local resections in her respiratory tract. Chest CT demonstrated multiple cavitary lesions throughout both lungs with a rapidly growing mass that occupied most of her right lung. Imaging supported a diagnosis of malignant transformation to squamous cell carcinoma of the lung. Bilateral involvement of the lungs indicated stage IVa squamous cell lung cancer, which is not curable. Conclusions:Clinicians should suspect malignant transformation in patients with HPV type 11, especially if they have required multiple excisions. Earlier age at onset and number of excisions may be predictors for severity of the disease course. These patients need continued surveillance imaging to allow early interventions if malignant transformation occurs. We present the case of a 21-year-old being diagnosed with an incurable disease that may have been avoided with adequate preventive care.
BACKGROUND: While flexible epidural catheters reduce the risk of paresthesia and intravascular cannulation, they may be more challenging to advance beyond the tip of a Tuohy needle. This may increase placement time, number of attempts, and possibly complications when establishing labor analgesia. This study investigated the ability to advance flexible epidural catheters through different epidural needles from 2 commonly used, commercially available, epidural kits. METHODS: We hypothesized that the multiorifice wire-reinforced polyamide nylon blend epidural catheters will have a higher rate of successful first attempt insertion than the single-end hole wire-reinforced polyurethane catheters for the establishment of labor analgesia. The primary outcome was a difference in proportions of failure to advance the epidural catheter between the 2 epidural kits and was tested by a χ2 test. Two-hundred forty epidural kits were collected (n = 120/group) for 240 laboring patients requesting epidural analgesia in this open-label clinical trial from November 2018 to September 2019. Two-week time intervals were randomized for the exclusive use of 1 of the 2 kits in this study, where all patients received labor analgesia through either the flexible epidural catheter “A” or the flexible epidural catheter “B.” Engineering properties of the equipment used were then determined. RESULTS: Flexible epidural catheter “A,” the single-end hole wire-reinforced polyurethane catheter, did not advance at the first attempt in 15% (n = 18 of 120) of the parturients compared to 0.8% (n = 1 of 120) of the catheter “B,” the multiorifice wire-reinforced polyamide nylon blend epidural catheter (P < .0001). Twenty-five additional epidural needle manipulations were recorded in the laboring patients who received catheter “A,” while 1 epidural needle manipulation was recorded in the parturients who received catheter “B” (P < .0001). Bending stiffness of the epidural catheters used from kit “B” was twice the bending stiffness of the catheters used from kit “A” (bending stiffness catheters “A” 0.64 ± 0.04 N·mm2 versus bending stiffness catheters “B” 1.28 ± 0.20 N·mm2, P = .0038), and the angle formed by the needle and the epidural catheter from kit “A” was less acute than the angle formed from kit “B” (kit “A” 14.17 ± 1.72° versus kit “B” 21.83 ± 1.33°, P = .0036), with a mean difference of 7.66° between the 2 kits’ angles. CONCLUSIONS: The incidence of an inability to advance single-end hole wire-reinforced polyurethane catheter was higher compared to the use of multiorifice wire-reinforced polyamide nylon blend epidural catheter. Variation of morphological features of epidural needles and catheters may play a critical role in determining the successful establishment of labor epidural analgesia.
Introduction: Primary squamous cell biliary carcinoma (SCBC) with liver metastasis is quite rare, and to our knowledge, very few cases have been reported in the literature. The exact pathogenesis of the disease is unestablished; however, it's believed that chronic inflammation predisposes to malignant transformation of squamous metaplasia in biliary glandular epithelium. We report a case of a middle-aged woman who was initially diagnosed with adenocarcinoma of the biliary tree that later transformed into SCBC. Case Description/Methods: A 50-year-old woman with no prior medical history initially presented with postprandial epigastric & right upper quadrant pain. Her symptoms continued to worsen and were associated with early satiety, nausea, and weight loss of 25 pounds over two months, which prompted further evaluation by her primary care physician. CT and MRI (Figure) examination a month later revealed a large heterogeneous area measuring 8.5 x 2.4 x 7.4 cm in the inferior right hepatic lobe with heterogeneous enhancement and involvement of the gallbladder concerning cholangiocarcinoma. Given radiographic findings, she underwent a CT-guided core biopsy of the liver, which showed a necrotic malignant tumor, favoring adenocarcinoma, and was also found to have germline BRCA mutated. PET scan revealed a large partially necrotic FDG avid mass possibly arising from the gallbladder fossa with an invasion of both lobes of the liver and probable involvement of a portion of the ascending colon. There was no gross evidence of distant metastatic disease. The patient underwent staging laparoscopy before initiating chemotherapy, and another biopsy was done, which returned in favor of squamous cell carcinoma, with immunohistochemical stains being positive for CK19, Ber-EP4, & P40; while negative for CK7, CK20, CDX-2, PAX-8, & Mucicarmine. The patient was started on platinum-based chemotherapy due to germline BRCA mutation. However, due to her poor performance status and recurrent cholangitis related to her cancer and chemotherapy, she could not stay on treatment for an adequate period of time to assess for a response. Discussion: Primary SCBC remains an unexplored aggressive malignancy with a poor prognosis. Diagnosis can be challenging and requires high clinical suspicion due to the scarcity of specific laboratory workup. Pathological diagnosis remains the gold standard; however, it also carries its own challenges. Treatment is usually case-oriented, and definitive protocols have yet to be established.[1817] Figure 1. a: MRCP showing 12.9 cm heterogeneous mass with a large necrotic center involving the right and left hepatic lobes, common hepatic duct, and proximal common bile duct as well as the ascending colon, especially near the hepatic flexure. b: MRCP showing Intrahepatic (left greater than right) and extrahepatic biliary ductal dilatation due to invasion and/or extrinsic compression in the region of the porta hepatis and proximal extrahepatic biliary tree.
(1) Background: Data on COVID-19 outcomes and disease course as a function of different medications used to treat cardiovascular disease and chronic kidney disease (CKD), as well as the presence of different comorbidities in primarily Black cohorts, are lacking. (2) Methods: We conducted a retrospective medical chart review on 327 patients (62.6% Black race) who were admitted to the Detroit Medical Center, Detroit, MI. Group differences (CKD vs. non-CKD) were compared using the Pearson χ2 test. We conducted univariate and multivariate regression analyses for factors contributing to death during hospitalization due to COVID-19 (primary outcome) and ICU admission (secondary outcome), adjusting for age, sex, different medications, and comorbidities. A sub-analysis was also completed for CKD patients. (3) Results: In the fully adjusted model, a protective effect of ACEi alone, but not in combination with ARB or CCB, for ICU admission was found (OR = 0.400, 95% CI [0.183–0.874]). Heart failure was significantly associated with the primary outcome (OR = 4.088, 95% CI [1.1661–14.387]), as was COPD (OR = 3.747, 95% CI [1.591–8.828]). (4) Conclusions: Therapeutic strategies for cardiovascular disease and CKD in the milieu of different comorbidities may need to be tailored more prudently for individuals with COVID-19, especially Black individuals.
Early on in the COVID-19 pandemic it was reported that angiotensin converting enzyme 2 inhibitors (ACE2i) could be associated with worse disease course due to potential increase in ACE2 receptors which SARS-CoV2 virus uses for cellular entry. Subsequent studies refuted such concerns, reporting that the continued use of ACEis and angiotensin receptor blockers (ARBs) in hypertensive individuals is in fact protective. Moreover, certain comorbidities, such as hypertension and heart disease, have been linked to an increased risk of disease severity. However, there is still paucity of data evaluating the effects of the use of different antihypertensive medications, steroids and beta blockers in chronic kidney disease (CKD) populations and in individuals with normal kidney function. This study was designed to evaluate the potential risk associated with renin angiotensin system inhibitors, calcium channel blocker, mineralocorticoid receptor blocker, steroids and beta blockers in a cohort of mostly African Americans and Caucasians. We conducted a retrospective study on patients who were admitted to the Detroit Medical Center, Detroit, MI during March and April of 2020. The data were collected through the medical chart reviews. We assessed 330 patients using inclusion criteria of age > 18 years and a positive SARS-CoV2 PCR test. We used the mean, standard deviation/standard error of mean, and percentages when appropriate for the description of patient characteristics. Group differences (CKD vs. non-CKD) were compared using the Pearson χ2 test. P-values of <0.05 were regarded as significant. We conducted binary logistic regression analysis to determine the effect of biological sex and CKD status on death due to COVID-19 during hospitalization. We conducted multivariate regression analysis for factors contributing to death during hospitalization due to COVID-19 and ICU admission, evaluating the contribution of different medications, comorbidities, and clinical course of the disease. On regression analyses, the odds of death in the hospital due to COVID-19 infection was not significantly associated with either biological sex or CKD status in our sample population. The odds of dying in the hospital were higher in patients who were on calcium channel blockers (OR 2.99, 95% CI 1.29-6.93, P = 0.01) and steroids (OR 4.23, 95% CI 1.17-15.31, P = 0.03). The only significance for ICU admission was obtained for steroid use (OR 1.872, 95% CI 1.059-3.311, P = 0.03). Likewise, COPD was the only comorbidity found to be associated with ICU admission (OR 2.38, 95% CI 1.282 - 4.426, P = 0.006), Significant associations were not observed for patients taking ACEis, ARBs, mineralocorticoid receptor inhibitors, diuretics, beta blockers and sympatholytics. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.
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