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Background Primary sclerosing cholangitis (PSC) is a progressive immune-mediated liver disease, for which no medical therapy has been shown to slow disease progression. However, the horizon for new therapies is encouraging, with several innovative clinical trials in progress. Despite these advancements, there is considerable heterogeneity in the outcomes studied, with lack of consensus as to what outcomes to measure, when to measure and how to measure. Furthermore, there has been a paradigm shift in PSC treatment targets over recent years, moving from biochemistry-based endpoints to histological assessment of liver fibrosis, imaging-based biomarkers and patient-reported outcome measures. The abundance of new interventional trials and evolving endpoints pose opportunities for all stakeholders involved in evaluating novel therapies. To this effect, there is a need to harmonise measures used in clinical trials through the development of a core outcome set (COS).Methods and analysis Synthesis of a PSC-specific COS will be conducted in four stages. Initially, a systematic literature review will be performed to identify outcomes previously used in PSC trials, followed by semistructured qualitative interviews conducted with key stakeholders. The latter may include patients, clinicians, researchers, pharmaceutical industry representatives and healthcare payers and regulatory agencies, to identify additional outcomes of importance. Using the outcomes generated from the literature review and stakeholder interviews, an international two-round Delphi survey will be conducted to prioritise outcomes for inclusion in the COS. Finally, a consensus meeting will be convened to ratify the COS and disseminate findings for application in future PSC trials.Ethics and dissemination Ethical approval has been granted by the East Midlands—Leicester Central Research Ethics Committee (Ref: 24/EM/0126) for this study. The COS from this study will be widely disseminated including publication in peer-reviewed journals, international conferences, promotion through patient-support groups and made available on the Core Outcomes Measurement in Effectiveness Trials (COMET) database.Trial registration number 1239.

Background: Alagille syndrome (ALGS) is a multisystem disorder involving at least three systems among the liver, heart, skeleton, face, and eyes. Common cardiac associations include pulmonary artery stenosis/atresia, atrial septal defect (ASD), ventricular septal defect (VSD) and tetralogy of fallot (ToF). Coarctation of aorta (CoA), renal and intracranial arteries are commonly involved vessels in Alagille syndrome. We present two cases with rare cardiovascular manifestations of Alagille syndrome. Case description: Case 1: A 25-year-old female with a history of Alagille syndrome presented to the cardiologist office for progressive exertional dyspnoea, orthopnoea, and palpitations. She was tachycardiac on examination and had an apical diastolic rumble. A transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction (LVEF) of 60% and parachute mitral valve (PMV) with severe mitral stenosis. A transoesophageal echocardiogram (TOE) showed insertion of chordae into the anterolateral papillary muscle, severe mitral stenosis with a valve area of 0.7 cm. She was referred to a congenital heart disease specialist and underwent robotic mitral valve replacement with improvement in her symptoms. Case 2: A 27-year-old female with known Alagille syndrome and resistant hypertension presented to the cardiologist office due to progressive exertional dyspnoea for a year. She was hypertensive and had a new 2/6 systolic ejection murmur along the left upper sternal border. TTE revealed an LVEF of 60% and pulmonary artery pressure of 19 mmHg. A CoA was suspected distal to the left subclavian artery due to a peak gradient of 38 mmHg. Cardiac magnetic resonance (CMR) imaging ruled out CoA, and diffuse narrowing of the descending thoracic aorta measuring 13–14 mm in diameter was noted. The patient was referred to a congenital heart disease specialist for further management. Conclusion: PMV presenting as mitral stenosis and mid-aortic syndrome are not commonly described anomalies in association with Alagille syndrome. TTE, TOE and CMR played a key role in diagnosis and management of these patients.

Background: Wellens’ syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2–3 (may extend to involve all precordial and lateral limb leads – the type B Wellens’ pattern). A Wellens’ EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD). However, there are no reported cases of an association of a Wellens’ EKG pattern with myopericarditis. Here, we present such a rare case. Case description: A thirty-one-year-old female with known essential hypertension and psoriatic arthritis presented with a constant, central chest pain radiating to the shoulders and back. The patient’s physical examination was unremarkable at presentation other than elevated blood pressure at 170/68 mmHg. An EKG at presentation demonstrated deep symmetric T-wave inversions in anterolateral leads with elevated high-sensitivity troponin, and an elevated erythrocyte sedimentation rate. The patient was referred to the cardiac catheterisation laboratory for concerns of a Wellens’ EKG pattern; however, invasive angiography demonstrated only obtuse marginal branch disease – no LAD disease was noted. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of myopericarditis and absence of myocardial infarction. The patient was medically managed and discharged home in a stable condition. Conclusion: In literature and established clinical practice, the Wellens’ EKG pattern is considered highly concerning for critical ostial/proximal LAD stenosis. However, we now propose that myopericarditis may be considered in a differential diagnosis for this EKG pattern.

Background: Atypical myxoma has been reported in various locations in the heart, however, myxoma involving the pulmonary valve is rare. Here we present a case of pulmonic valve myxoma which was resected via a percutaneous approach. Case Report: A 66-year-old female with known metastatic adenocarcinoma of the lung, and chronic obstructive pulmonary disease presented with acute onset shortness of breath for two days. The patient experienced respiratory arrest en-route to the hospital and required intubation. Computed tomography angiography (CTA) of the chest revealed a new 1.4 x 1.6 cm intracardiac mass along the pulmonary valve. Further evaluation with cardiac magnetic resonance imaging revealed it to be a large vascular tumor on the ventricular side of the pulmonary valve, attached with a narrow stalk. Due to high surgical risk, the patient underwent transesophageal echocardiographic guided percutaneous removal of the mass. Pathology confirmed the mass to be a myxoma. Conclusion: Atypical myxoma should be considered in the differential diagnosis of valvular masses. Percutaneous resection of valvular masses may be feasible in high-risk surgical patients.

“Cases of SCMR” is a case series on the SCMR website (https://www.scmr.org) for the purpose of education. The cases reflect the clinical presentation, and the use of cardiovascular magnetic resonance (CMR) in the diagnosis and management of cardiovascular disease. The 2022 digital collection of cases are presented in this manuscript.

Aims: Mitral Annular Disjunction (MAD) refers to embryologic fibrous separation between mitral annular ring and basal left ventricular myocardium. Since its original description, the role of MAD in arrhythmic mitral valve prolapse (MVP) has been the subject of active research. In this study we sought to assess prognostic and imaging characteristics of MVP patients with and without underlying MAD. Methods and results: Patients with posterior or bi-leaflet MVP were retrospectively identified via a review of all patients referred to our cardiac magnetic resonance (CMR) imaging laboratory from January 2015 to May 2022. MVP patients were further stratified by underlying MAD status. A total of 100 MVP patients undergoing CMR imaging (52 MVP patients with posterior MAD) were retrospectively identified with female comprising 55 % of the cohort. MVP patients with MAD were more likely to have an abnormal basal inferolateral/ papillary muscles LGE (51 % vs 21 %, p

Abstract Introduction Pain is a global phenomenon encompassing many subtypes that include neuropathic, musculoskeletal, acute postoperative, cancer, and geriatric pain. Traditionally, opioids have been a mainstay pharmacological agent for managing many types of pain. However, opioids have been a subject of controversy with increased addiction, fatality rates, and cost burden on the US healthcare system. Cannabinoids have emerged as a potentially favorable alternative or adjunctive treatment for various types of acute and chronic pain. This narrative review seeks to describe the efficacy, risks, and benefits of cannabinoids as an adjunct or even potential replacement for opioids in the treatment of various subtypes of pain. Methods In June of 2022, we performed a comprehensive search across multiple databases for English-language studies related to the use of cannabinoids in the treatment of various types pain: neuropathic pain, musculoskeletal pain, acute postoperative pain, cancer pain, and geriatric pain. Data from meta-analyses, systematic reviews, and randomized control trials (RCTs) were prioritized for reporting. We sought to focus our reported analysis on more recent literature as well as include older relevant studies with particularly notable findings. Results There is conflicting evidence for the use of cannabinoids in the management of pain. While cannabinoids have shown efficacy in treating specific chronic pain subtypes such as neuropathic pain, fibromyalgia pain, and geriatric pain, they do not show as clear benefit in acute postoperative and the majority of musculoskeletal pain syndromes. Data trends towards cannabinoids having a positive effect in treating cancer pain, but results are not as conclusive. To date, there is a paucity of data comparing cannabinoids directly to opioids for pain relief. Overall, the side effects of cannabinoids appear to be relatively mild. However, there is still potential for addiction, altered brain development, psychiatric comorbidities, and drug–drug interactions. Conclusion Cannabinoids may be effective in specific subtypes of pain, but current evidence and guidelines do not yet support its use as the first-line treatment for any type of acute or chronic pain. Rather, it may be considered a good adjunct or alternative for patients who have failed more typical or conservative measures. Additional studies are needed with standardized forms of cannabinoids, route of delivery, and dosing for greater-powered analysis. Providers must weigh the individualized patient risks, benefits, and concurrent medication list in order to determine whether cannabinoids are appropriate for a patient’s pain treatment plan.

Coronavirus disease 2019 (COVID-19) is an infection that can result in lung issues such as pneumonia and, in extreme situations, the most severe acute respiratory syndrome. COVID-19 is widely investigated by researchers through mathematical models from different aspects. Inspired from the literature, in the present paper, the generalized deterministic COVID-19 model is considered and examined. The basic reproduction number is obtained which is a key factor in defining the nonlinear dynamics of biological and physical obstacles in the study of mathematical models of COVID-19 disease. To better comprehend the dynamical behavior of the continuous model, two unconditionally stable schemes, i.e., mixed Euler and nonstandard finite difference (NSFD) schemes are developed for the continuous model. For the discrete NSFD scheme, the boundedness and positivity of solutions are discussed in detail. The local stability of disease-free and endemic equilibria is demonstrated by constructing Jacobian matrices for NSFD scheme; nevertheless, the global stability of aforementioned equilibria is verified by using Lyapunov functions. Numerical simulations are also presented that demonstrate how both the schemes are effective and suitable for solving the continuous model. Consequently, the outcomes obtained through these schemes are completely according to the solutions of the continuous model.

Abstract Epilepsy is a serious chronic neurological disorder, can be detected by analyzing the brain signals produced by brain neurons. Neurons are connected to each other in a complex way to communicate with human organs and generate signals. The monitoring of these brain signals is commonly done using Electroencephalogram (EEG) and Electrocorticography (ECoG) media. These signals are complex, noisy, non-linear, non-stationary and produce a high volume of data. Hence, the detection of seizures and discovery of the brain-related knowledge is a challenging task. Machine learning classifiers are able to classify EEG data and detect seizures along with revealing relevant sensible patterns without compromising performance. As such, various researchers have developed number of approaches to seizure detection using machine learning classifiers and statistical features. The main challenges are selecting appropriate classifiers and features. The aim of this paper is to present an overview of the wide varieties of these techniques over the last few years based on the taxonomy of statistical features and machine learning classifiers—‘black-box’ and ‘non-black-box’. The presented state-of-the-art methods and ideas will give a detailed understanding about seizure detection and classification, and research directions in the future.

Peripheral nerve stimulation (PNS) has been utilized for over 50 years with accumulating evidence of efficacy in a variety of chronic pain conditions. The level and strength of evidence supporting the use of PNS for peripheral neuropathic pain remains unclear. The purpose of this review is to synthesize data from prospective studies on the efficacy of PNS for neuropathic pain as it pertains to pain intensity, neurological deficits/neuropathy (e.g., weakness, sensory deficits, gait/balance), and other secondary outcomes (quality of life, satisfaction, emotional functioning, and adverse events). In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, this review identified articles from MEDLINE(R), EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Overall, per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, pooled results demonstrate very low quality or low quality of evidence supporting modest to substantial improvement in pain and neurological function after PNS implantation for treatment of peripheral neuropathic pain. PNS for phantom limb pain was the only indication that had moderate level evidence. Future prospective and well-powered studies are warranted to assess the efficacy of PNS for peripheral neuropathic pain.

The microwave (μWave) spectrum or low-frequency spectrum has become overcrowded due to the ever-increasing demand in bandwidth-intensive applications, such as video streaming and gaming. Owing to the fact that the spectral efficiency of μWave links is approaching its fundamental limits, there is a growing consensus in both industry and academia that millimeter wave (mmWave) will play an important role in increasing data rate and scarcity of spectrum. To redress the predicament and to ensure adequate availability of bandwidth, increasing attentions have been paid to the use of mmWave spectrum for future broadband wireless networks. The mmWave spectrum offers wider bandwidth compared to the μWave spectrum and a promising solution to overcome the scarcity of spectrum while providing gigabits per second (Gb/s) of data rates. To fully exploit the high potential rates of mmWave in mobile networks, a number of technical problems must be addressed. The mmWave signal transmission suffers from the issues of blockage and deafness. The former challenge is characterized by the loss of Quality of Service (QoS) in non-line-of-sight (NLOS) conditions, while the latter is characterized by the misalignment between the main lobe of transmitter and the receiver beam. Two strategies can be adopted to deal with the issues:1) relaying, use of another path with the help of relay(s) providing line-of-sight (LOS) link(s) and b) fall back, in the case of service interruption, switch back to the μWave spectrum-based transmission switching between mmWave and μWave frequency bands can support higher rates and QoS requirements. However, a tradeoff exists in employing any of the aforementioned strategies. In this paper, we study the joint spectrum allocation and relay selection problem to maximize the weighted sum rate relay selection (using resource block and time slot) along with a fallback approach for spectrum allocation in an HMMC network. A fallback approach is introduced to enable the hybrid transmission of μWave and mmWave, and an iterative bipartite relay-spectrum selection algorithm is proposed to solve the problem. The performance evaluation results show that the proposed fallback approach outperforms the conventional μWave or mmWave transmission schemes in terms of data rate, transmit power, and the number of users.

OBJECTIVE: To determine the frequency of Anxiety and Depression among Diabetic patients and association with duration of Diabetes Mellitus. METHODOLOGY: Descriptive cross-sectional study conducted at the Out-patient Department (OPD) of Department of Medicine and Allied, Al-Tibri Medical College hospital, Karachi from August 2017 to December 2017. Total 194 patients of both gender with age range from 18 and 70 years suffering from Diabetes Mellitus type 2 were enrolled. The duration of diabetes was taken as less than 5 years, 5-7 years and above 7 years. The frequency of Anxiety and Depression were assessed by Beck Anxiety Inventory and Beck Depression Inventory. The data was analyzed by using SPSS version 20. RESULTS: The average age of the patients was 50.35±8.85. Out of 194 cases 102 (52.6%) were females and 92(47.40%) were males. Amongst total (92.80%) were married. Anxiety was found to be 47(24.2%) mild to moderate anxiety, 33(17.0%) suffering from moderate to severe anxiety and 58 (29.9%) were having severe anxiety. Depression was 28 (14.4%) mild depression, 74 (38.1%) moderate depression and 40 (20.6%) severe depression. Statistically depression was significantly associated with duration of diabetes with P-value of 0.000. CONCLUSION: It is to be concluded that the frequency of anxiety and depression in patients of Diabetes is very high and depression is ignificantly associated with duration of Diabetes Mellitus.

Al-Madih Al-Nabavi is a popular Islamic poetry composition among the Muslim poets because the prophet Muhammad (PBUH) is beloved personality of all Muslims and the respectable to be followed in every movement of life. The poets in every era of Islamic History said their poetry verses in the praise of Prophet Muhammad (PBUH) in the subjective means including the various topics of Al-Madih Al-Nabavi. The poets of other nations like Persian and Urdu nations started expressing their emotions and sentiments of love to the Prophet Muhammad (PBUH). Ameer Meenai was a great poet of Urdu literature in sub-continent. He was born in Lucknow, India in 1826. He started poetry in his early age. His chapter on Eulogistic Poetry has great fame and published in 1916 with the title of “Mahamid Khatam-ul-Nabiyyeen (PBUH)”. He was impressed by teachings of the Holy Quran. In this article, we will discuss the impact of the Holy Quran in his poetry. This is very important topic of research in literature, especially in Muslim Literature in the world. With the hope that this work will be beneficial for the further researches and for the new scholars as well. This article, basically, focuses upon poetical works of Ameer Meenai, especially on “Mahamid Khatam-ul-Nabiyyeen (PBUH)” and highlights the topics of Holy Quran, its causes and effects of teachings of Holy Quran on his poetry. To find out the results in this field, this research comparatively analyzed the poetical works of Ameer Meenai. After conducting the study of his poetical works, the researcher came to know that there is a remarkable impact of Holy Quran on the poetry of Ameer Meenai. For example, he was interested in miracles and Seerat-ul-Nabi (PBUH) among the other topics of Holy Quran. Similarly, in his Eulogistic poetry there is explanation and justifications of Quranic topics. However, finest of his works are those in which he used, word by word, Quranic verses in his poetry composition that shows distinctions of both languages and highlights the limitations of poetry and prose.

Background: Thyroid disorders are a commonly encountered problem in hilly areas of Pakistan. The objectives of the study were to determine the frequency and distribution of thyroid disorders among patients presenting with suggestive signs & symptoms of thyroid disorders in Hazara Division, Pakistan. Material and Methods: This cross-sectional study was conducted in Departments of Medicine and Pediatrics & Neonatology, Ayub Medical College, Abbottabad, KP, Pakistan from January, 2017 to January, 2018. Exclusion criteria was patients taking medicines such as Lithium and Cordarone. Sample size was 55 selected using consecutive sampling technique. Reference values were taken as follows; serum TSH=0.4-4.0 µIU/L, serum T3=100-200 ng/dL), serum T4=5-13.5 µgm/dL. Demographic variables were sex and age. Research variables were thyroid status (euthyroid/ hyperthyroid/ hypothyroid) and levels of thyroid function tests (TFT). Categorical variables such as sex and thyroid status were calculated by frequency and percentages whereas numeric variables such as age and TFT by Mean and SD. Descriptive statistics were calculated using SPSS Version 20. Results: Out of the total 55 patients, 11 patients were males and 44 patients were females. The minimum age was 20 years, maximum age was 90 years. Mean age was 43.24 years±15.118. Out of the total 55 patients, 14 (25.5%) were euthyroid, 30 patients (54.5%) were hyperthyroid and 11 (20%) patients were hypothyroid. Out of the 14 patients that were euthyroid, seven were males and seven were females. Out of the 30 hyperthyroid patients 26 were females and only 4 were males. All 11 hypothyroid were females. Conclusions: Hyperthyroidism is more common thyroid disorder in Hazara Division specially in adult females.

Headaches are one of the most common medical complaints worldwide, and treatment is often made difficult because of misclassification. Peripheral nerve stimulation has emerged as a novel treatment for the treatment of intractable headaches in recent years. While high-quality evidence does exist regarding its use, efficacy is generally limited to specific nerves and headache types. While much research remains to bring this technology to the mainstream, clinicians are increasingly able to provide safe yet efficacious pain control.

BackgroundHeart rate (HR) recovery has been investigated in specific patient cohorts, but there is less information about the role of HR recovery in general populations. We investigated whether HR recovery has long‐term prognostic significance in primary prevention. Methods and ResultsExercise tests performed between 1993 and 2010 on patients aged 30 to 79 years without cardiovascular disease were included. Mortality was determined from Mayo Clinic records and Minnesota Death Index. Total, cardiovascular, and non‐cardiovascular mortality was reported according to HR recovery

Primary malignant melanoma of the anus and rectum is a rare and aggressive neoplasm that tends to invade locally and metastasize early in the course of the disease. It is often misdiagnosed as hemorrhoids or as one of the other benign anorectal conditions and is thus linked to an overall poor prognosis and a 5-year survival rate of less than 20%. Optimal treatment is still controversial, and current evidence does not show any preferential survival benefit from abdominoperineal resection over wide local excision. Chemotherapy or radiotherapy may be used for advanced disease. We report a 71-year-old female presenting with painful bowel movements and blood in stools. She was eventually found to have a mass arising from the anorectal junction with regional lymph node involvement. The patient underwent an abdominoperineal resection and is currently scheduled for chemotherapy.

Radiation therapy has a solid role in the management of breast adenocarcinoma. It significantly reduces the rates of disease recurrence. Nevertheless, radiation therapy is not without side effects and patients who have undergone breast irradiation are at increased risk for lung disease, sarcomas, acute leukemia and esophageal cancer. We present a case of radiation-induced breast osteosarcoma 29 years after radiation therapy and lumpectomy for breast adenocarcinoma. The patient had several disease recurrences after surgical resection and was found to have pulmonary metastases.

Leukocytoclastic vasculitis (LCV) is a small-vessel vasculitis with a reported incidence rate of 30 cases per million persons per year. It usually presents as a palpable purpuric skin rash on legs, though any part of the body can be affected. LCV rash may have an associated burning sensation or pain and in some cases may involve internal organs. In some cases, LCV rash may present as nodules, recurrent ulcerations or asymptomatic lesions. The diagnosis of LCV is usually made on skin biopsy. Etiological triggers may not be identified in as many as half of the cases. Treatment is usually conservative and includes identification and removal or treatment of the etiological trigger except in cases with internal organ involvement where systemic steroids and immunosuppressant may be necessary. In this article we present a case of indomethacin-associated LCV that improved with discontinuation of the offending agent.

Ovarian cancer is the second most common gynecological cancer in the Western world. Despite a good response to treatment, most patients with ovarian cancer will relapse. The abdominal, pelvic, and retroperitoneal cavities represent the most common sites of ovarian cancer recurrence, with inguinal lymph node involvement rarely reported. Herein we report the case of a 48-year-old Caucasian female who underwent successful surgical and chemotherapy treatment for ovarian epithelial cancer. Two years later, the patient was found to have painless left inguinal adenopathy, which was subsequently found to be metastatic ovarian cancer. CA-125 levels were elevated despite the lack of any foci of metabolically active tissue on imaging. Inguinal lymph node involvement is a rare sign of ovarian cancer. Despite that, it is essential to consider ovarian cancer in the differential diagnosis for inguinal lymphadenopathy in a female patient.

E-learning is basically the integration of various technologies. E-Learning technology is now maturing and we can find a multiplicity of standards. New technologies such as agents and web services are promising better results. In this paper we have proposed an e-learning architecture that is dependent on intelligent agent systems and web services. These communication technologies will make the architecture more robust, scalable and efficient.

Introduction: As evidence-based medicine is increasingly being adopted in medical and surgical practice, effective processing and interpretation of medical literature is imperative. Databases presenting the contents of medical literature have been developed; however, their efficacy merits investigation. The objective of this study was to quantify surgical and orthopaedic content within five evidence-based medicine resources: DynaMed, Clinical Evidence, UpToDate, PIER, and First Consult. Methods: We abstracted surgical and orthopaedic content from UpToDate, DynaMed, PIER, First Consult, and Clinical Evidence. We defined surgical content as that which involved surgical interventions. We classified surgical content by specialty and, for orthopaedics, by subspecialty. The amount of surgical content, as measured by the number of relevant reviews, was compared with the total number of reviews in each database. Likewise, the amount of orthopaedic content, as measured by the number of relevant reviews, was compared with the total number of reviews and the total number of surgical reviews in each database. Results: Across all databases containing a total of 13268 reviews, we identified an average of 18% surgical content. Specifically, First Consult and PIER contained 28% surgical content as a percentage of the total database content. DynaMed contained 14% and Clinical Evidence 11%, whereas UpToDate contained only 9.5% surgical content. Overall, general surgery, pediatrics, and oncology were the most common specialty areas in all databases. Discussion: Our findings suggest that the limited surgical content within these large scope resources poses difficulties for physicians and surgeons seeking answers to complex clinical questions, specifically within the field of orthopaedics. This study therefore demonstrates the potential need for, and benefit of, surgery-specific or even specialty-specific tools.

Patients with nephrotic syndrome are at an increased risk for thrombotic events; deep venous thrombosis, renal vein thrombosis, and pulmonary embolism are quite common in patients with nephrotic syndrome. It is important to note that nephrotic syndrome secondary to membranous nephropathy may impose a greater thrombotic risk for unclear reasons. Increased platelet activation, enhanced red blood cell aggregation, and an imbalance between procoagulant and anticoagulant factors are thought to underlie the excessive thrombotic risk in patients with nephrotic syndrome. The current scientific literature suggests that patients with low serum albumin levels and membranous nephropathy may benefit from primary prophylactic anticoagulation. A thorough approach which includes accounting for all additional thrombotic risk factors is, therefore, essential. Patient counseling regarding the pros and cons of anticoagulation is of paramount importance. Future prospective randomized studies should address the question regarding the utility of primary thromboprophylaxis in patients with nephrotic syndrome.

Hairy cell leukemia is a rare lymphoid neoplasm arising from mature B-lymphocytes. Clinically, the disease presents with splenomegaly and abdominal discomfort, frequent infections, fatigue and bleeding because of related cytopenias. Bone marrow biopsy is essential for diagnosis. Below we describe a case of a 70-year-old African-American male who presented to our hematology clinic complaining of fatigue. Clinical exam and computed tomography imaging did not reveal splenic enlargement. Blood work-up revealed pancytopenia and bone marrow was diagnostic for hairy cell leukemia.The patient was started on cladribine, with gradual improvement of his symptoms and blood count abnormalities. Therefore, it is essential to keep hairy cell leukemia in the differential of pancytopenia even in the absence of a splenomegaly.

Primary colorectal lymphoma is a rare malignancy accounting for 3% of all gastrointestinal lymphomas and 0.1-0.5% of all colorectal malignancies. Among primary colorectal lymphomas, the most common histological subtype of colorectal lymphoma is diffuse large B-cell lymphoma. We report a case of an 84-year old Caucasian female who was admitted to the hospital because of a 2 days history of altered mental status. In the emergency department the patient was found to have acute kidney injury and hypercalcemia. On physical examination a large lower quadrant abdominal mass was palpated. Computed tomography scan of abdomen confirmed the presence of a mass along the cecum and proximal ascending colon. Colonoscopy showed a large ulcerated mass and biopsy was consistent with diffuse large B-cell lymphoma. The patient underwent colectomy but refused to receive chemotherapy.

Drug-induced immune hemolytic anemia is a rare condition with an incidence of 1 per million of the population. We report the case of a 36-year-old female who presented to the emergency department complaining of shortness of breath and dark colored urine. Physical examination was significant for pale mucous membranes. The patient reported using ibuprofen for a few days prior to presentation. Complete blood count performed before starting ibuprofen revealed normal platelets and hemoglobin values. On admission, the patient had evidence of hemolytic anemia with hemoglobin of 4.9 g/dL, hematocrit of 14.2%, lactate dehydrogenase 435 IU/L, and reticulocytosis 23.2%. Further testing ruled out autoimmune disease, lymphoma, and leukemia as etiologies for the patient’s new onset hemolytic anemia. Ibuprofen was immediately stopped with a gradual hematologic recovery within 3 days.

Acute postpartum dyspnea in a young, previously healthy adult encompasses numerous conditions. One should be aware of various differential diagnoses including delayed postpartum preeclampsia-induced pulmonary edema where the occurrence is rare but a significant one due its deleterious consequences. We report a case of 26-year-old gravida 1/para 1 female who presented to the hospital with progressive dyspnea after 1 week of normal spontaneous vaginal delivery. On physical examination, her blood pressure was severely elevated. Her clinical signs and symptoms were consistent with pulmonary edema, but diagnostic tests excluded the cardiogenic causes. Further test revealed proteinuria. The patient was diagnosed with delayed postpartum preeclampsia.

Anaplastic thyroid cancer (ATC) comprises 1-2% of all thyroid cancers and is one of the most aggressive cancers with a median survival rate of around four months. The average 5-year survival rate has been reported to be around 3.6%. In this paper, we have discussed management and prognostic variables of a patient with ATC who has survived for more than 5 years. A 59-year-old female was referred to our facility for an elective thyroid and parathyroidectomy for concerns of thyroid papillary cancer and hyperparathyroidism. At the time of surgery, the tumor mass had invaded the muscular layer of esophagus; radicle thyroidectomy parathyroidectomy along with removal of muscle layer of esophagus was performed, and diagnosis of ATC was made. The patient was treated with chemoradiation with a good treatment response and no recurrence of tumor for two and a half years until PET/CT followed by wedge biopsy of lung confirmed ATC recurrence. The patient was treated with another course of radiation treatment with a good treatment response. Since then, the patient has been following in our outpatient oncology clinic and has no evidence of tumor recurrence. Aggressive multimodal approach of combining radicle surgery with chemoradiation treatment in select patients of ATC with no distant metastasis helps improve prognosis.

Hypercalcemia is a common medical problem with an estimated prevalence of 15% among hospitalized patients. Multiple myeloma (MM) and primary hyperparathyroidism (PHPT) are among the most common causes of hypercalcemia but coexistence of both pathologic processes in a patient is an extremely rare phenomenon. In this paper we have discussed a patient presenting with this rare phenomenon. We have also provided a comprehensive review of the scientific literature published on codiagnosis of MM and PHPT.

Chronic back pain is a common presenting complaint that is frequently encountered by clinicians. The challenge for clinicians is identifying the relatively few patients with a significant probability of a more serious problem that requires further evaluation. Such individuals require further evaluation for possible occult malignancy, infection, or fracture. We present a case of a 50-year-old male with a past medical history of chronic back pain and IV drug abuse who presented with acute back pain and in whom a diagnosis of vertebral osteomyelitis was missed during multiple visits to the emergency room.

May-Thurner syndrome (MTS) has been recognized as a clinical entity for almost six decades. The true incidence rate of MTS is unknown and perhaps ranges from 22 to 32% according to the autopsy studies in the early twentieth century. However, MTS related deep venous thrombosis (DVT) accounts for only 2%-3% of all lower limb DVTS. In MTS, the left common iliac vein is compressed against the fifth lumbar vertebrae by the right common iliac artery, as it crosses in front of the vein. Chronic pulsation of the artery is thought to cause elastin, collagen deposition, and intimal fibrosis leading to formation of venous spur and venous thrombosis. MTS can present as acute or chronic DVT leading to pulmonary embolism (PE), chronic leg pain, chronic ulcers, or skin pigmentation changes. In this case report we have described an interesting case of a 28-year-old Caucasian female who presented for evaluation of shortness of breath (SOB) associated with cough for one week. SOB was found to be secondary to massive bilateral pulmonary embolism resulting from extensive MTS related DVT of the left lower extremity. Patient underwent pharmacomechanical treatment with local thrombolysis, thrombectomy, and venoplasty along with stent placement that extended to inferior vena caval junction. Subsequently patient was discharged on coumadin. MTS should be considered in differentials when faced with a case of unilateral DVT particularly in younger age group.

Central venous catheters (CVC) are used commonly in clinical practice. Incidences of CVC-related right atrial thrombosis (CRAT) are variable, but, when right atrial thrombus is present, it carries a mortality risk of 18% in hemodialysis patients and greater than 40% risk in nonhemodialysis patients. Different pathogenic mechanisms have been postulated for the development of CRAT, which includes mechanical irritation of the myocardial wall, propagation of intraluminal clot, hypercoagulability, and hemodynamics of right atria. Presentation of CRAT may be asymptomatic or may be associated with one of the complications of CRAT like pulmonary embolism, systemic embolism, infected thrombi, or hemodynamic compromise. There are no established treatment guidelines for CRAT. We describe an interesting case of a 59-year-old asymptomatic male successfully treated with open heart surgery after failure of medical treatment for a large CRAT discovered during a preoperative evaluation for a kidney transplant. Our case underscores that early detection of CRAT may carry a favorable prognosis as opposed to waiting until catastrophic complications arise. It also underscores the importance of transesophageal echocardiography in the detection of thrombus and perhaps guides clinicians on which treatment modality to be used according to the size of the thrombus.