Autoimmune Pancreatitis Type 2: Case Report

© 2017, © 2017 American Federation for Medical Research. A middle-aged man presents with acute pancreatitis of unknown etiology and is found to have a presentation consistent with the diagnosis of type 2 autoimmune pancreatitis (AIP). AIP is a group of rare heterogeneous diseases that are challenging to diagnose. There are 2 types of AIP. Type 1 disease is the more common worldwide than type 2 AIP. While type 1 AIP is associated with IgG4-positive antibodies, type 2 AIP is IgG4 antibody negative. Both types of AIP are responsive to corticosteroid treatment. Although type 1 AIP has more extrapancreatic manifestations and more commonly relapses, this is a case of a patient with type 2 AIP with inflammatory bowel disease and relapsing course

Prevalence and Risk Factors for Dyslipidemia Among Adults in Rural and Urban China: Findings From the China National Stroke Screening and Prevention Project (CNSSPP)

Background: Dyslipidemia is a modifiable risk factor for cardiovascular disease (CVD). We investigated the prevalence and associated risk factors of dyslipidemia- raised total cholesterol (TC), raised triglycerides (TG), raised low-density lipoprotein (LDL-C), low high-density lipoprotein (HDL-C), and raised non-high-density lipoprotein (non-HDL-C) in rural and urban China. Methods: We analyzed data from 136,945 participants aged 40-100 years of the CNSSPP project for 2014. Dyslipidemia was defined by the NCEP-ATP III and the 2016 Chinese guidelines for the management of dyslipidemia in adults. Complete data on demographic, metabolic and lifestyle characteristics were used. Chi-square tests and multivariable logistic regression were used to obtain age- and sex-adjusted prevalence and risk factors for dyslipidemia among participants. Results: A total of 53.1% participants lived in rural areas. The prevalence of dyslipidemia was similar among rural and urban participants (43.2% vs. 43.3%). Regarding the components of dyslipidemia: urban compared with rural participants had a higher prevalence of low HDL-C (20.8% vs. 19.2%), whereas the prevalence of raised LDL-C (7.8% vs. 8.3%), raised TC (10.9% vs.11.8%) and raised non-HDL-C (10.0% vs. 10.9%) were lower in urban residents, (all p \u3c 0.001). Women were more likely to have raised TC than men (adjusted OR [AOR] =1.83, 95% confidence interval [CI]:1.75-1.91), raised LDL-C (AOR = 1.55, 95% CI: 1.47-1.63) and high non-HDL-C (AOR = 1.52 95% CI: 1.45-1.59) (all p \u3c 0.001). Compared with rural, urban participants had higher odds of dyslipidemia: low HDL-C (AOR = 1.04, 95% CI: 1.01-1.07), and raised TG (AOR = 1.06, 95% CI: 1.04-1.09). Hypertension and current drinker were less likely to get low HDL-C with AOR 0.93 (95% CI: 0.90-0.96) and AOR 0.73 (95% CI: 0.70-75), respectively. Overweight, obesity, central obesity and diabetes had higher odds of all dyslipidemias (p \u3c 0.001). Conclusions: Low HDL-C was higher in urban areas, whereas the remaining dyslipidemia types were more common in rural areas. Dyslipidemia was more common in women in both areas of residence. Overweight, obesity, central obesity and diabetes were associated with dyslipidemias. The need to intensify intervention programs to manage dyslipidemia and risk factors should be prioritized

Development and Validation of an RP-HPLC Method for the Quantitative Analysis of Triclosan in Human Urine

Triclosan (TCS), a synthesized chlorinated phenolic compound, is commonly utilized in consumable products as an antimicrobial agent. TCS has sparked widespread awareness because of its toxicity and possible negative effect on public health in recent years. In this study, a highly sensitive, fast, and cost-effective isocratic reversed-phase high-performance liquid chromatography (RP-HPLC) method coupled with solid-phase extraction for analysis of triclosan in human urine samples was developed. The method utilized methanol and water in a ratio of 90 : 10 as the mobile phase on a Phenomenex Luna 3 µm C18(2) 100 Å, 150 × 4.60 mm stationary phase, with a runtime of 5 minutes. The method showed good resolution of triclosan in the presence of the sample matrix. Validation of the method was performed according to the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use (ICH). Linearity was tested over a range of 0.00625 µg/mL to 6.4 µg/mL, as accuracy recorded a recovery of 89.25%, 91.0%, and 92.75%. Limits of detection (LOD) and quantification (LOQ) were obtained to be 0.0173 µg/mL and 0.0525 µg/mL, respectively. The method proved to be robust over a temperature range of 26°C, 30°C, and 35°C and a flow rate of 0.5 ml, 1.0 ml, and 1.5 ml. The developed method was employed to detect and quantify triclosan in 153 urine samples, comprising 60 samples from Ibadan, Nigeria, and 93 samples from Kumasi, Ghana. Triclosan was detected in a total of 52 samples with an average content of 0.054588 µg/ml. This method can therefore be used for the routine analysis of triclosan in urine samples

Study protocol: analysis of regional lung health policies and stakeholders in Africa

Background Lung health is a critical area for research in sub-Saharan Africa. The International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA) is a collaborative programme that seeks to fill evidence gaps to address high-burden lung health issues in Africa. In order to generate demand for and facilitate use of IMPALA research by policy-makers and other decision-makers at the regional level, an analysis of regional lung health policies and stakeholders will be undertaken to inform a programmatic strategy for policy engagement. Methods and analysis This analysis will be conducted in three phases. The first phase will be a rapid desk review of regional lung health policies and stakeholders that seeks to understand the regional lung health policy landscape, which issues are prioritised in existing regional policy, key regional actors, and opportunities for engagement with key stakeholders. The second phase will be a rapid desk review of the scientific literature, expanding on the work in the first phase by looking at the external factors that influence regional lung health policy, the ways in which regional bodies influence policy at the national level, investments in lung health, structures for discussion and advocacy, and the role of evidence at the regional level. The third phase will involve a survey of IMPALA partners and researchers as well as interviews with key regional stakeholders to further shed light on regional policies, including policy priorities and gaps, policy implementation status and challenges, stakeholders, and platforms for engagement and promoting uptake of evidence. Discussion Health policy analysis provides insights into power dynamics and the political nature of the prioritisation of health issues, which are often overlooked. In order to ensure the uptake of new knowledge and evidence generated by IMPALA, it is important to consider these complex factors

Derivation and validation of a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality in 20 countries

INTRODUCTION: Existing risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality across various settings. METHODS: We used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool. RESULTS: A total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84). CONCLUSIONS: The PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality

In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset

Objectives We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. Methods We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. Results Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). Conclusion Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years

Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: Methodology and applications

Background The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines. Methods Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set. Results Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males. Conclusions This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly

Angioimmunoblastic T-cell lymphoma, a rare disease causing recurrent chylothorax.

Angioimmunoblastic T-cell lymphoma (AITL) is a rare type of lymphoid malignancy with most affected patients presenting in their late 60’s with nonspecific symptoms, laboratory signs and advanced stage disease. 78 year old female with history of hypertension presented to the hospital with complaints of dyspnea, dry cough and fatigue of one week duration. She denied having fever, chills, night sweats or recent weight loss. Labs on admission were significant for leukopenia with lymphocytopenia, thrombocytopenia, hyponatremia and hyperglobulinemia. Computer tomography chest and abdomen showed bilateral multifocal lung infiltrates, large left side pleural effusion, diffuse lymphadenopathy and splenomegaly. She was started on empiric antibiotics for community acquired pneumonia. Sputum culture did not identify any offending organism and although thoracentesis was consistent with exudative fluid, microbiology and pathologic studies also did not offer a diagnosis. Fine needle aspiration of a suspicious lymph node was also negative. She was discharged home to complete treatment for pneumonia but over the next two months, she presented on three different occasions with the same respiratory symptoms. Serial thoracentesis thereafter showed chylous fluid that was fast re-accumulating. A repeat flow cytometry of the pleural fluid was concerning for a lymphoproliferative process and subsequent excisional biopsy with molecular studies performed on rearrangement of T-cell receptors resulted in eventual diagnosis of Angioimmunoblastic T-cell lymphoma stage IV due to associated lung involvement. She declined aggressive management and opted for palliative care. Lymphoma presenting with chylothorax is not common due to early diagnosis of most lymphoma but it can be the initial presentation of AITL because most patients present with nonspecific symptoms and lab findings that make diagnosis difficult and delayed. In our patient, eventual diagnosis was three months from initial presentation. This is not ideal because most patients who succumb to the disease tend to do so from progressive worsening nutritional status and immunosuppression that ensues as the disease advances. The recurrent chylothorax seen in our patient is likely a result of tumor burden that obstructed chyle drainage through the thoracic duct and may have resolved with adequate treatment of the disease. Multiple laboratory abnormalities and B-type symptoms in a patient with unclear primary process should prompt workup for a possible neoplastic disease, particularly lymphoma. Clinicians who suspect a lymphoproliferative process in patients with diffuse lymphadenopathy and pulmonary symptoms of unclear etiology should consider getting an excisional tissue biopsy for further diagnostic studies. PCR based studies that assess for cell locality is also helpful in particularly difficult cases

Therapeutic misadventure with a beta blocker during a thyroid storm in an undiagnosed hyperthyroid Patient.

Thyroid storm (TS) is a rare life threatening endocrine emergency. Estimates for mortality rate for untreated TS ranges from 50%-90%[1,2].; however if managed appropriately, mortality drops to less than 20%[2]. Management can include glucocorticoids, propranolol, propylthiouracil(PTU) or methimazole and iodine solution. Each have established roles in controlling the hyperdynamic state in the storm. What is not well established is subclinical cardiomyopathy that may exist with chronic uncontrolled hyperthyroidism. We present a case in which propranolol, used appropriately, led to cardiovascular collapse during the management of a thyroid storm. 48 year old female with a medical history significant for hypertension presented with a 1 day history of severe dyspnea. On arrival vitals were: BP 177/103, pulse 127, RR 28 and pulse ox 92% on room air. She had anasarca and a GCS of 6. She was intubated for airway protection. Head CT was normal. Labs were sodium 128, bicarbonate 18, glucose 38, anion gap 14, lactic acid 5, leukocytes of 12000, Hb 7.3. ABG was pH 7.04, PCO2 45, PaO2 138 on 100% O2 at PEEP of 10, immediately after intubation. TSH was undetectable, FT4 was \u3e 8ng/dL with FT3 of 11pg/mL. Echocardiogram showed EF of 45%, RV dilation and biatrial enlargement. She received glucocorticoids, PTU and oral propranolol. Shortly afterwards she became bradycardic, hypotensive then developed pulseless electrical activity (PEA) despite glucagon and aggressive IV fluids. ROSC was achieved after 8 minutes of ACLS protocol. Within minutes she became bradycardic and hypotensive again then became pulseless again despite glucagon and attempts at transcutaneous pacing. After ROSC with ACLS protocol, she was eventually stabilized with aggressive IV fluid, 5 vasopressors and a bicarbonate drip. That night, she had a third cardiac arrest. After ROSC, an emergency bedside laparotomy was performed for decompression of compartment syndrome. Her hospital course was complicated by hematologic abnormalities requiring multiple blood products, gastrointestinal blood loss, NSTEMI and dialysis dependent renal failure. The concept of thyrocardiac disease must be kept in mind when managing a thyroid storm. In long standing hyperthyroidism, the resulting cardiomyopathy is compensated by tachycardia and increased sensitivity to catecholamines [3]. This compensatory mechanism depends on tachycardia to maintains adequate cardiac output. Failure to consider this led to our therapeutic misadventure. Current management of TS includes the use of propranolol to lessen the adrenergic effect on the heart and to inhibit peripheral conversion of T4 to T3. This patient’s experience suggested that abrupt disruption of this compensatory state with beta blockade puts the body at risk for cardiovascular collapse. Until management guidelines are updated, it is imperative to for clinicians to avoid beta blockers or use short acting beta blockers with extreme caution when managing TS