Recurrent Spontaneous Pneumothorax Secondary to Marijuana and Tobacco Abuse

Primary spontaneous pneumothorax occurs in patients without apparent clinical lung disease, with a higher incidence in tall, thin males between the ages of 10 and 30. Tension pneumothorax is a life-threatening condition that can develop within minutes due to progressive air accumulation in the pleural space; mechanical pressure can lead to significant cardiorespiratory compromise. Tobacco association with a higher incidence of spontaneous pneumothorax has been well documented, but marijuana and spontaneous pneumothorax connection has not been well studied. However, it has been observed that patients who use marijuana and tobacco simultaneously have a higher incidence of spontaneous tension and larger pneumothoraces, as well as longer postoperative stay and higher recurrence than cigarette-only users. We present a case of a 26-year-old young male with a history only significant for excessive tobacco and marijuana smoking who developed multiple recurrent spontaneous pneumothorax and had to undergo right-sided video-assisted thoracoscopic surgery (VATS) with minimally invasive thoracotomy and had a prolonged hospital stay. With our case report, we hope to add to the evidence the effects of combined marijuana and tobacco smoking on bullous lung disease and pneumothorax while emphasizing the importance of conducting a detailed substance use history in patients with spontaneous pneumothorax.

Preventive Saline Irrigation of the Bile Duct to Reduce the Rate of Residual Common Bile Duct Stones Without Intraductal Ultrasonography: A Systematic Review and Meta-Analysis

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) has been proven efficacious in the removal of CBD stones. Even after endoscopic stone removal, recurring cholangitis due to a residual common bile duct (CBD) stone is prevalent in clinical practice with a residual recurrence rate of 4-24% after successful stone retrieval. This comprehensive study and meta-analysis aimed to determine if preventive saline irrigation of the bile duct (PSIB) reduces the amount of residual CBD stones. Through a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science until November 20, 2022, we identified 164 articles comparing the efficacy of PSIB and non-PSIB post-endoscopic CBD stone removal. After stringent selection, three studies were included for meta-analysis using ReviewManager (ReVman version 5.4.1; Cochrane, London, UK). Using a random effect (RE) model, we derived a pooled odds ratio (OR) with confidence interval (CI) (95%CI). A total of three studies have been included in the analysis. Out of which, two are randomized controlled trials (RCTs) and one is a non-randomized study. Out of 323 patients, 157 underwent PSIB after an endoscopic stone removal of CBD stones to reduce the residual of CBD stones, whereas 166 did not undergo saline irrigation (non-PSIB). In our analysis, PSIB significantly reduced the risk of residual stones (OR: 0.22, 95%CI: 0.11-0.45). However, there was no notable link between PSIB and post-irrigation cholangitis (OR: 1.08, 95%CI: 0.21-2.21). Although not statistically significant, PSIB showed a trend toward lowered risks of post-procedural pancreatitis (OR: 0.65), bleeding (OR: 0.68), and other complications (OR: 0.64). PSIB effectively reduces residual CBD stones after endoscopy, offering a cost-effective alternative to invasive procedures such as intraductal ultrasound (IDUS). However, larger RCTs are needed to validate its definitive role.

Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia?

Pneumatosis intestinalis (PI) is a relatively rare gastrointestinal finding that has a wide variety of causes - ranging from benign to life-threatening. It is described as the pathological presence of gas within the bowel wall with multiple hypotheses emerging as to the likely mechanism. An important indicator of a life-threatening source of PI is the presence of gas within the hepatic portal vein, referred to as hepatic portal venous gas (HPVG). While non-specific for isolated PI, HPVG has been reported in PI patients to be associated with bowel ischemia and is thereby considered an indication for emergent management. Herein we report a case involving an atypical presentation of altered mental status in which the patient was found to have PI with contemporaneous HPVG. These findings have been reported to have a high mortality rate. Our patient rapidly deteriorated during their hospital course, expiring shortly after being deemed a poor surgical candidate due to their severe co-morbidity burden. Through this case, we review evidence supporting the management of patients with PI and concurrent HPVG from an extensive review of available literature. While PI is a non-specific finding and commonly a source of diagnostic confusion, a better understanding of its natural course and potentially unorthodox sequela may afford more directed and crucial care for critically ill patients, in which time is often a precious commodity.

Correction: Recurrent Brain Metastasis Versus Radiation-Induced Necrosis: A Case Report and Literature Review

[This corrects the article DOI: 10.7759/cureus.34400.].

Recurrent Brain Metastasis Versus Radiation-Induced Necrosis: A Case Report and Literature Review

Radiotherapy is the cornerstone of brain metastasis management. With the advancement of therapies, patients are living longer, exposing them to the long-term effects of radiotherapy. Using concurrent or sequential chemotherapy, targeted agents, and immune checkpoint inhibitors may increase the incidence and severity of radiation-induced toxicity. Recurrent metastasis and radiation necrosis (RN) appear indistinguishable on neuroimaging, making it a diagnostic dilemma for clinicians. Here, we present a case of RN in a 65-year-old male patient who previously had brain metastasis (BM) from primary lung cancer, misdiagnosed initially as recurrent BM.

Hereditary hemochromatosis: Temporal trends, sociodemographic characteristics, and independent risk factor of hepatocellular cancer – nationwide population-based study

BACKGROUND

Hereditary hemochromatosis (HH) has an increased risk of hepatocellular cancer (HCC) both due to genetic risks and iron overload as iron overload can be carcinogenic; HH impacts the increasing risk of HCC, not only through the development of cirrhosis but concerning hepatic iron deposition, which has been studied further recently.

AIM

To evaluate HH yearly trends, patient demographics, symptoms, comorbidities, and hospital outcomes. The secondary aim sheds light on the risk of iron overload for developing HCC in HH patients, independent of liver cirrhosis complications. The study investigated HH (without cirrhosis) as an independent risk factor for HCC.

METHODS

We analyzed data from National Inpatient Sample (NIS) Database, the largest national inpatient data collection in the United States, and selected HH and HCC cohorts. HH was first defined in 2011 International Classification of Disease - 9^th edition (ICD-9) as a separate diagnosis; the HH cohort is extracted from January 2011 to December 2019 using 275.01 (ICD-9) and E83.110 (ICD-10) diagnosis codes of HH. Patients were excluded from the HH cohort if they had a primary or secondary diagnostic code of cirrhosis (alcoholic, non-alcoholic, and biliary), viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), and non-alcoholic steatohepatitis (NASH). We removed these patients from the HH cohort to rule out bias or ICD-10 diagnostic errors. The HCC cohort is selected from January 2011 to December 2019 using the ICD-9 and ICD-10 codes of HCC. We selected a non-HCC cohort with the 1:1 fixed ratio nearest neighbor (greedy) propensity score method using the patients' age, gender, and race. We performed multivariate analysis for the risk factors of HCC in the HCC and non-HCC matched cohort. We further analyzed HH without cirrhosis (removing HH patients with a diagnosis of cirrhosis) as an independent risk factor of HCC after adjusting all known risk factors of HCC in the multivariate model.

RESULTS

During the 2011-2019 period, a total of 18031 hospitalizations with a primary or secondary diagnosis of HH (excluding liver diseases) were recorded in the NIS database. We analyzed different patients’ characteristics, and we found increments in inpatient population trend with a Ptrend < 0.001 and total hospital cost of care trend from $42957 in 2011 to $66152 in 2019 with a Ptrend < 0.001 despite no change in Length of Stay over the last decade. The multivariate analyses showed that HH without cirrhosis (aOR, 28.8; 95%CI, 10.4–80.1; P < 0.0001), biliary cirrhosis (aOR, 19.3; 95%CI, 13.4–27.6; P < 0.0001), non-alcoholic cirrhosis (aOR, 17.4; 95%CI, 16.5–18.4; P < 0.0001), alcoholic cirrhosis (aOR, 16.9; 95%CI, 15.9–17.9; P < 0.0001), hepatitis B (aOR, 12.1; 95%CI, 10.85–13.60; P < 0.0001), hepatitis C (aOR, 8.58; 95%CI, 8.20–8.98; P < 0.0001), Wilson disease (aOR, 4.27; 95%CI, 1.18–15.41; P < 0.0001), NAFLD or NASH (aOR, 2.96; 95%CI, 2.73–3.20; P < 0.0001), alpha1-antitrypsin deficiency (aOR, 2.10; 95%CI, 1.21–3.64; P < 0.0001), diabetes mellitus without chronic complications (aOR, 1.17; 95%CI, 1.13–1.21; P < 0.0001), and blood transfusion (aOR, 1.80; 95%CI, 1.69–1.92; P < 0.0001) are independent risk factor for liver cancer.

CONCLUSION

Our study showed an increasing trend of in-hospital admissions of HH patients in the last decade. These trends were likely related to advances in diagnostic approach, which can lead to increased hospital utilization and cost increments. Still, the length of stay remained the same, likely due to a big part of management being done in outpatient settings. Another vital part of our study is the significant result that HH without cirrhosis is an independent risk factor for HCC with adjusting all known risk factors. More prospective and retrospective large studies are needed to re-evaluate the HH independent risk in developing HCC.

Solitary Cystic Mediastinal Lymphangioma: A Rare Incidental Case in an Adult Female

Introduction

Lymphangiomas are rare, congenital malformations arising from lymphatic hyperplasia. More than 90% of cases are found in children under 2 years of age. Cystic lymphangiomas usually occur in the neck and axillary region and only rarely extend to the mediastinum.

Case Description

We present the case of a middle-aged woman who presented with dyspnoea and productive cough. A chest x-ray showed right lower medial lung opacity, and a CT scan of the thorax showed a cystic mediastinal mass, encroaching on the superior vena cava and approaching the trachea and mainstem bronchus. An anterior thoracotomy with tumour resection was performed to relieve compression symptoms. The final pathology report confirmed the diagnosis of mediastinal lymphangioma.

Discussion

Lymphangioma should be considered as one of the differential diagnoses when mediastinal widening is found on chest x-ray, and it should be investigated further with a CT scan and biopsy. Infiltration of surrounding structures can cause compression symptoms and can also make surgical resection more challenging.

LEARNING POINTS

A Rare Case of Recurrent Arterial Thrombosis Secondary to Iron Deficiency Anemia

Iron deficiency anemia is the leading cause of anemia all over the world. Iron deficiency is known to cause reactive thrombocytosis. However, arterial thrombosis secondary to reactive thrombocytosis is a rare entity. In this article, we present a case of a 37-year-old female with recurrent arterial thrombosis due to severe thrombocytosis caused by iron deficiency anemia. The patient developed spleen and kidney infractions, as well as abdominal aortic thrombosis. She was subsequently treated with iron and aspirin with an improvement of the anemia and thrombocytosis, with no further thrombotic complications. Arterial thrombosis is a very serious condition as the thrombus can embolize to carotid arteries leading to stroke or to peripheral blood vessels causing peripheral ischemia and gangrene. Iron deficiency anemia is a reversible cause of thrombocytosis that can be treated very easily to avoid thrombotic complications.

Extracorporeal Membrane Oxygenation (ECMO): A Life Saver in Near-Fatal Asthma

Near-fatal asthma (NFA) is a life-threatening condition that represents the most severe clinical phenotype of asthma and can progress to fatal asthma. Patients with NFA do not respond adequately to conventional medical therapy and urgent intervention is needed to provide adequate oxygenation by invasive mechanical ventilation. While mechanical ventilation is a potentially life-saving intervention, it could cause lung injury, barotrauma, and dynamic hyperinflation due to high ventilator settings resulting in hemodynamic instability. Extracorporeal membrane oxygenation (ECMO) provides full respiratory support with adequate gas exchange in patients with NFA and improves survival rate. We present a case of a young female patient who presented with NFA, and her clinical condition was worsening despite invasive positive pressure mechanical ventilation.

Removal of copper from a copper sulphate solution using an ultrasonic-electrolysis process

The application of ultrasonic-electrolysis process for the removal of copper is studied. In the ultrasonic field cavitation acts as jets and agitates the solution and breaks the barrier layer between the cathode surface and the bulk of the solution. Thus increases metal deposition on the cathode surface. The results show that an ultrasonic field is successful for the removal of low copper concentrations in solution.

Simultaneous recovery of copper and degradation of 2,4-dichlorophenoxyacetic acid in aqueous systems by a combination of electrolytic and photolytic processes

In mixed industrial effluent the presence of metal ions can retard the destruction of organic contaminants and the efficiency of recovery of the metal is reduced by the presence of the organic species. Results are presented for copper-2,4-dichlorophenoxyacetic acid (2,4-D) system in which both effects occur. An electrochemical cell alone can be used to recover copper in the pH range 1.5-4.5 but it is not capable of achieving complete disappearance of 2,4-D by anodic oxidation. A photolytic cell alone can achieve the destruction of 2,4-D at pH 3.5 but leaves copper in solution. A combined photolytic-electrochemical system using an activated carbon concentrator cathode achieves the rapid simultaneous destruction of 2,4-D and recovery of copper. Results are presented for the recovery of more than 90% copper from, and >99.9%, destruction of the organochlorine compound 2,4-D in, a solution containing 100 mg dm(-3) copper and 50 mg dm(-3) 2.4-D. The photolytic degradation of 2,4-D depends on the intensity of the UV-probe. Only 19% degradation is achieved after 8 h with the 150 W UV-probe but the corresponding value with the 400 W UV-probe is 100%. In the case of 150 W UV-probe the degradation of 2,4-D proceeds through the formation of 2,4-dichlorophenol and phenol. The concentration of these intermediates are very low in the case of 400 W UV-probe because the speed of the degradation of 2,4-D is very fast. The addition of TiO2 (1 g dm(-3)), as a semiconductor material, and H202 (1.5 g dm(-3)) as an oxidant, increases the photolytic degradation of 2,4-D.

Interstitial brachytherapy in carcinoma of the penis

AIM

Keeping in line with the increasing emphasis on organ preservation, we at the Tata Memorial Hospital have evaluated the role of Ir-192 interstitial implant as regards local control, functional and cosmetic outcome in early as well as locally recurrent carcinoma of the distal penis.

PATIENTS AND METHODS

From October 1988 to December 1996, 23 patients with histopathologically proven cancer of the penis were treated with radical radiation therapy using Ir-192 temporary interstitial implant. Our patients were in the age group of 20 to 60 years. The primary lesions were T1 in 7, T2 in 7 and recurrent in 9 patients. Only 7 patients had palpable groin nodes at presentation, all of which were pathologically negative. The median dose of implant was 50 Gy (range 40 to 60 Gy), using the LDR afterloading system and the Paris system of implant rules for dosimetry. Follow-up ranged from 4 to 117 months (median 24 months).

RESULTS

At last follow-up 18 of the 23 patients remained locally controlled with implant alone. Three patients failed only locally, 2 locoregionally and 1 only at the groin. Of the 5 patients who failed locally, 4 were successfully salvaged with partial penectomy and remained controlled when last seen. Local control with implant alone at 8 years was 70% by life table analysis. The patients had excellent functional and cosmetic outcome. We did not record any case of skin or soft-tissue necrosis. Only 2 patients developed meatal stenosis, both of which were treated endoscopically.

CONCLUSION

Our results lead us to interpret that interstitial brachytherapy with Ir-192 offers excellent local control rates with preservation of organ and function. Penectomy can be reserved as a means for effective salvage.

Interstitial brachytherapy in soft tissue sarcomas. The Tata Memorial Hospital experience

BACKGROUND

Soft tissue sarcomas are relatively rare tumors with an aggressive natural history associated with a high propensity for local recurrence following conservative surgery. It accounts for 1.8% of all cancers seen at the Tata Memorial Hospital, Mumbai. Organ preserving surgery and tumor bed brachytherapy have revolutionized the management of soft tissue sarcomas.

PATIENTS AND METHODS

One hundred and seventy-seven patients with histologically proven non-metastatic cases of soft tissue sarcomas in the age group of 16 to 79 years (median 41 years) were treated at the Tata Memorial Hospital between January 1983 and December 1992. One hundred and fifty-one patients who had completed a minimum of 24 months of treatment were studied. There were 100 males (66%) and 51 females (33%). The majority had recurrent lesions (70.3%). Extremities were involved in 75% of patients. Spindle cell sarcoma was the major histologic variant (30%). The patients underwent function preserving surgery and temporary afterloading Ir-192 tumor bed brachytherapy with or without external radiotherapy.

RESULTS

In patients receiving brachytherapy only, 25 out of 33 (75%) were locally controlled after a median follow-up of 30 months. After successful salvage of local failures the overall local control improved to 82%. Similarly in the patients who received both interstitial brachytherapy and external irradiation, the local control rate after a median follow-up of 40 months was 71% which improved to 86% after successful salvage. The overall treatment related complication rate was less than 1%. The only marginally significant prognostic factor for local control was tumor grade (p = 0.06).

CONCLUSIONS

The sequential combination of limited surgery and tumor bed brachytherapy with or without external radiotherapy has been established as an effective alternative to more ablative procedures like amputation. Histologic grade has proven to be a significant factor determining local control.

Radiotherapy of carcinoma of the buccal mucosa

A retrospective study of 399 cases of buccal cancer, presenting to the Tata Memorial Hospital, Bombay, during January to December 1984 was undertaken to define the efficacy of various treatment modalities in different clinical stages. Analysis of treatment technique and response was carried out in 185 cases that completed adequate therapy. Sixty percent of patients with stage I and II disease (21/35) received radiation therapy alone as the primary modality of treatment. Patients (150) with stage III or IV disease received palliative irradiation (57 cases), radical surgery (54 cases), or a combination of both (39 cases). The 2-year disease-free survival (DFS) rates were 48% for radiotherapy and 46% for surgery in the early stages and 5% and 33%, respectively, for advanced stages. Radiotherapy with a modified technique is recommended for the early-stage cancers and preoperative irradiation with adjuvant chemotherapy or hyperthermia for the advanced stages.