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Prabhu M, Wilkie G, MacEachern M, LaBuda D, Purtell J, Rao K, Riley LE, Fuller M, Rosser M, Habib AS, Bauer ME. Procalcitonin levels in pregnancy: A systematic review and meta-analysis of observational studies. Int J Gynaecol Obstet 2023; 163:484-494. [PMID: 37118923 DOI: 10.1002/ijgo.14813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND The utility of procalcitonin to identify obstetric sepsis is unknown. OBJECTIVE To calculate the mean (range) procalcitonin in pregnancy among healthy women not in labor (group 1), healthy women in labor (group 2), and women with preterm prelabor rupture of membranes (PPROM) without clinical chorioamnionitis (group 3). SEARCH STRATEGY NLM PubMed, Elsevier Embase, and Wiley Cochrane Central Register of Controlled Trials from inception to February 21, 2022. SELECTION CRITERIA Ten or more pregnant women with procalcitonin reported at more than 20 weeks of pregnancy, with information on labor, PPROM, and infection. Exclusions were major medical comorbidities. DATA COLLECTION AND ANALYSIS Each abstract and full-text review was independently reviewed by the same two authors. Quality was reviewed using the Newcastle-Ottawa Scale. A meta-analysis was performed using a random effects model. MAIN RESULTS The systematic review included 25 studies: 10 (40%) of good quality and 15 (60%) of poor quality. The meta-analysis included 21 studies. Mean procalcitonin in group 1 was 0.092 ng/mL (range 0.036-0.049 ng/mL), in group 2 it was 0.130 ng/mL (range 0.049-0.259 ng/mL), and in group 3 it was 0.345 ng/mL (range 0.005-1.292 ng/mL). CONCLUSIONS Among healthy pregnant women not in labor, procalcitonin levels are comparable to those in non-pregnant adults and may be useful in identifying infection. Procalcitonin levels in other groups overlap abnormal values of procalcitonin in non-pregnant adults, and may not discriminate infection among women in labor or with obstetric comorbidities. PROSPERO CRD42020157376, registered 4/28/2020.
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Affiliation(s)
- Malavika Prabhu
- Department of Obstetrics & Gynecology, Weill Cornell Medicine, New York, New York, USA
| | - Gianna Wilkie
- Department of Obstetrics & Gynecology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | | | - Dana LaBuda
- University of Michigan, Ann Arbor, Michigan, USA
| | | | - Krishna Rao
- Division of Infectious Diseases, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura E Riley
- Department of Obstetrics & Gynecology, Weill Cornell Medicine, New York, New York, USA
| | - Matthew Fuller
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Morgan Rosser
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Melissa E Bauer
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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Almujarkesh MK, Damughatla AR, Bathla J, Sugg K, LaBuda D, Alkassis S, Al Hallak MN. Primary Squamous Cell Biliary Carcinoma With Liver Metastasis Is Rare but Malicious. Gastroenterology Res 2023; 16:276-279. [PMID: 37937226 PMCID: PMC10627356 DOI: 10.14740/gr1637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/12/2023] [Indexed: 11/09/2023] Open
Abstract
Primary squamous cell carcinoma (SCC) of the liver 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 is mostly reported to be associated with hepatic cyst, Caroli's disease, hepatolithiasis, hepatic cirrhosis, and hepatic teratoma. We report a case of a 50-year-old woman with no prior medical history initially, who presented with postprandial epigastric and right upper quadrant pain that continued to worsen and was associated with early satiety, nausea, and weight loss of 25 pounds over 2 months, which prompted further evaluation by her primary care physician. Magnetic resonance imaging (MRI) examination a month later revealed a large heterogeneous area measuring 8.5 × 2.4 × 7.4 cm in the inferior right hepatic lobe with heterogeneous enhancement and involvement of the gallbladder, concerning for cholangiocarcinoma. Given radiographic findings, she underwent a computed tomography (CT)-guided core biopsy of the liver, which showed a necrotic malignant tumor favoring adenocarcinoma and was also found to have germline BRCA mutation. A positron emission tomography (PET) scan revealed a large partially necrotic fluorodeoxyglucose (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 prior to initiating chemotherapy, and another biopsy was done, which returned in favor of SCC, with immunohistochemical stains being positive for cytokeratin (CK)19, Ber-EP4 (epithelial antigen recognized by Ber-EP4 antibody), and P40 (DeltaNp63); while negative for CK7, CK20, caudal-type homeobox 2 (CDX-2), paired box 8 (PAX-8), and mucicarmine. The patient started platinum-based chemotherapy due to germline BRCA mutation. However, due to complications associated with therapy and the progression of the disease, the patient eventually chose hospice. Primary SSC remains an unexplored aggressive malignancy that carries an overall poor prognosis. Diagnosis can be challenging and requires high clinical suspicion due to the scarcity in 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.
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Affiliation(s)
| | - Anirudh R. Damughatla
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
| | - Jasdeep Bathla
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
| | - Kyle Sugg
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
| | - Dana LaBuda
- School of Medicine, Wayne State University, Detroit, MI, USA
| | - Samer Alkassis
- Department of Oncology, University of California, Los Angeles, CA, USA
| | - Mohammed Najeeb Al Hallak
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
- Department of Oncology, Karmanos Cancer Institute, Detroit, MI, USA
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Almujarkesh MK, Damughatla AR, Shukla A, Alsakarneh S, Koleti P, LaBuda D, Levine DL. Social Determinants in Clinical Decision Making: A Case of Mistaken Hepatic Encephalopathy. Cureus 2023; 15:e40405. [PMID: 37456498 PMCID: PMC10347884 DOI: 10.7759/cureus.40405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Implicit (i.e., unconscious) bias frequently differs from one's explicit or conscious convictions. As humans, we rely on information and experiences that are repeatedly reinforced until they become reflexive, shaping our perceptions of reality. Specialty bias, a form of implicit bias specific to an individual's medical specialty, is a form of this bias. These cognitive processes of making assumptions aid efficient decision-making and likely confers an evolutionary advantage. However, automatic thinking can contribute to stereotyping, prejudice, and discrimination at both explicit and implicit levels. Despite a person's explicit beliefs evolving, the lasting implicit bias significantly impacts their behavioral interactions with individuals from stereotyped groups. We present a case of an 83-year-old non-English speaking gentleman with a reported past medical history of an ischemic stroke who presented with acute encephalopathy and fever without jaundice and Aspartate transaminase/ Alanine transaminase (AST/ALT) of 64 and 34, respectively. He was initially treated for acute meningoencephalitis in the Neurologic Intensive Care Unit. With no clinical improvement in symptoms, his care was transferred to the Internal Medicine service later that week, and it was noted that he had features consistent with liver disease. Further history-taking revealed that the patient was intermittently confused with episodes of constipation. On examination, he had palmar erythema and asterixis, and additional labs showed elevated liver enzymes and ammonia levels. Computerized Tomography of the abdomen was suggestive of cirrhosis. He was treated for hepatic encephalopathy with lactulose and rifampin, with improvement in his mental status. We believe our patient's clinical diagnosis was compromised by incomplete information related to a language barrier, and anchoring biases prevented a thorough history taking from the patient family and later on from the patient. Physician's anchoring bias, a form of implicit bias, can negatively impact outcomes in patients, especially those with limited language proficiency, due to communication barriers leading to misunderstanding of the patient's clinical presentation and overreliance on clinical heuristics.
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Affiliation(s)
| | | | - Asmita Shukla
- Internal Medicine, Wayne State University Detroit Medical Center, Detroit, USA
| | - Saqr Alsakarneh
- Internal Medicine, University of Missouri Kansas City, Kansas City, USA
| | - Pragna Koleti
- Internal Medicine, Suburban Community Hospital, Norristown, USA
| | - Dana LaBuda
- Internal Medicine, Wayne State University, Detroit, USA
| | - Diane L Levine
- Internal Medicine, Wayne State University Detroit Medical Center, Detroit, USA
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Ahmed A, Shukla A, Hubbell N, Almujarkesh MK, LaBuda D, Ouchi T. Early Identification and Intervention in Malignant Transformation of Respiratory Papillomatosis. Am J Case Rep 2023; 24:e937665. [PMID: 36624689 PMCID: PMC9841752 DOI: 10.12659/ajcr.937665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Amar Ahmed
- Department of Internal Medicine, Detroit Medical Center/Wayne State University,Detroit, MI, USA
| | - Asmita Shukla
- Department of Internal Medicine, Detroit Medical Center/Wayne State University,Detroit, MI, USA
| | - Natalie Hubbell
- Department of Internal Medicine, Detroit Medical Center/Wayne State University,Detroit, MI, USA,Corresponding Author: Natalie Hubbell, e-mail:
| | | | - Dana LaBuda
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Takahiro Ouchi
- Department of Internal Medicine, Detroit Medical Center/Wayne State University,Detroit, MI, USA
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Prabhu M, Wilkie G, MacEachern M, LaBuda D, Purtell J, Riley L, Habib A, Bauer M. Procalcitonin Levels in Pregnancy: A Systematic Review and Meta-Analysis of Observational Studies. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pancaro C, Purtell J, LaBuda D, Saager L, Klumpner TT, Dubovoy T, Rajala B, Singh S, Cassidy R, Vahabzadeh C, Maxwell S, Manica V, Eckmann DM, Mhyre JM, Engoren MC. Difficulty in Advancing Flexible Epidural Catheters When Establishing Labor Analgesia: An Observational Open-Label Randomized Trial. Anesth Analg 2021; 133:151-159. [PMID: 33835077 DOI: 10.1213/ane.0000000000005526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Carlo Pancaro
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Jasmine Purtell
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Dana LaBuda
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Leif Saager
- Department of Anesthesiology, University Medical Center, Göttingen, Germany
| | - Thomas T Klumpner
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Timur Dubovoy
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Baskar Rajala
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Shubhangi Singh
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Ruth Cassidy
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Sean Maxwell
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Virgil Manica
- Department of Anesthesiology, Tufts University School of Medicine, Boston, Massachusetts
| | - David M Eckmann
- Department of Anesthesiology and Center for Medical and Engineering Innovation, The Ohio State University, Columbus, Ohio
| | - Jill M Mhyre
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Milo C Engoren
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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