A computed tomography scan of a 42-year-old man showed enlarged mesenteric lymphadenopathy with dilated midileal small-bowel loop containing nodular wall thickening and mucosal hyperenhancement (Figure A). He was referred for antegrade double-balloon enteroscopy (DBE). Antegrade DBE showed a large diverticulum with prominent mucosal folds, focal thickening, and an area of ulceration (Figure B) at an insertion depth of 20 feet. Multiple biopsy specimens were taken. Histology discovered poorly differentiated carcinoma with extensive necrosis (Figure C). The tumor cells showed significant nuclear pleomorphism with an irregular nuclear membrane, clumpy chromatin, and brisk mitotic activity. Immunostaining-positive CAM5.2 confirmed the epithelial nature of the tumor. Positive stains for cytokeratin, GAT3, PLAP, and SALL4 with negative Oct34, CD17, AFP, and CD30 were interpreted as nonspecific, undifferentiated carcinoma. The stains for arginase, hepatocyte, albumin, glypin-3, CDX2, SF1, CK5/ 6, and TTF-1 were negative. The patient was diagnosed with undifferentiated carcinoma arising in ectopic gastric tissue in the small bowel. Based on our literature review, this is a case of DBEassisted diagnosis of malignancy arising from Meckel's diverticulum. Conflicts of interest The authors disclose no conflicts.
Cushing’s syndrome (CS) is an uncommon endocrine disorder resulting from prolonged exposure to elevated glucocorticoids, with 10-15 million annual cases per the American Association of Neurological Surgeons. Exogenous and endogenous causes can further be divided into adrenocorticotropic hormone (ACTH) dependent (i.e Cushing’s Disease) or ACTH independent. ACTH-independent CS can be caused by primary bilateral macronodular adrenal hyperplasia (PBMAH) representing less than 1% cases of CS. We report a case of a woman presenting with chronic resistant hypertension, episodic blurry vision, weight gain and wasting of extremities. She was diagnosed with Cushing’s syndrome due to PBMAH.
Our patient’s presentation was unusual as she presented at 40 years old, 10 years earlier than expected for PBMAH; and primarily with complaints of episodic blurry vision. Her symptoms also progressed rapidly as signs and symptoms largely presented over the course of 12 months, however responded well to surgical resection.
Background: Sepsis continues to take main stage in healthcare. Therefore, it remains crucial to elucidate contributors to sepsis mortality. The aim of this study is to determine the impact of race, insurance type, and code status on sepsis mortality in a community health system.
Methods:We conducted a retrospective cohort study of inpatient adults of any sex, race, and insurance type with a diagnosis of sepsis, severe sepsis, septic shock, or pneumonia.
Results:We included 913 patients, with an average age of 69 years for expired patients and 62 years for non-expiring patients (P < 0.0001). After controlling for other variables, patients who presented as comfort care arrest were 4.3 (95% confidence interval (CI): 1.8 to 9.9, P = 0.0007) times more likely to have died than full code patients. Those who were comfort care only were 10.6 (95% CI: 0.8 to 140.6, P = 0.0741) times more likely to have died than the full code, although this was not statistically significant.
Conclusions:The results suggest that patients who are comfort care arrest have an increased risk of sepsis mortality. The results show no impact of insurance type or race on sepsis mortality, which is in contrast to some existing literature. The study suggests that institutions may need to investigate internal variables related to sepsis mortality.
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