Osteosarcoma is the most common primary malignant tumor of the long bones. However, primary osteosarcoma of the chest wall, particularly the sternum, is an extremely rare occurrence. We report a 36-year-old male presenting with a hard, immobile, palpable, anterior chest wall mass. A computed tomographic (CT) scan showed a large destructive anterior mediastinal mass involving the manubrium and sternum with multiple bilateral calcified lung masses, pleural effusions and partially calcified aortopulmonary, right hilar and subcarinal lymphadenopathy. Incisional biopsy of the mass revealed grade 2 chondroblastic osteosarcoma. The patient underwent one cycle of chemotherapy with ifosfamide and palliative radiation. Unfortunately, the patient was unable to tolerate ifosfamide and developed severe nausea and vomiting requiring the discontinuation of chemotherapy. Given his metastatic disease and inability to tolerate standard chemotherapy, he was referred to a comprehensive cancer center for advanced clinical trials.

Background Anti-PD-1 agents were approved for advanced melanoma after the landmark trial Checkmate-037. Anti-PD-1 agents can breach immunologic tolerance. Fulminant diabetes is an immune endocrinopathy that results from a violent immune attack leading to complete destruction of pancreatic beta cells in genetically predisposed people. We present a rare case of fulminant diabetes precipitated by anti-PD-1 immunotherapy. Case A 61-year-old male with advanced melanoma presented with a three-day history of nausea, vomiting, and malaise. He was started on nivolumab and ipilimumab. After the third dose, he developed a generalized rash and was prescribed high-dose prednisone. Labs revealed potassium 9.5 mmol/L, sodium 127 mmol/L, bicarbonate <10 mmol/L, blood glucose 1211 mg/dL, anion gap >31 mmol, arterial blood pH 7.14, and beta-hydroxybutyrate 13.7 mmol/L. He was diagnosed with diabetic ketoacidosis. Hemoglobin A1C was 6.9%. C-peptide was undetectable (<0.1 ng/ml). Glutamic acid decarboxylase autoantibodies, zinc transporter 8 autoantibodies, insulin autoantibodies, islet antigen 2 autoantibodies, and islet cell antibodies were all negative. Conclusion Anti-PD-1 immunotherapy is effective in cancers refractory to standard chemotherapy. These agents can precipitate autoimmune disorders. As the use of anti-PD-1 agents is expected to rise, physicians should be educated about the potential side effects. We recommend conducting routine blood glucose checks in patients on these agents.

Background: Cortisol has a positive correlation with obesity, which indicates a relation between obesity and cortisol. Furthermore, there are increased chances of demolished muscle strength up to two times with elevated levels of cortisol. Thus, the aim of the study was to assess the impact of increased cortisol levels on the grip strength and to determine that the grip strength is a possible indicator for accelerated biological ageing. Methodology: This cross-sectional, purposive sampling study was conducted in Karachi, Pakistan. Overall 412 were recruited to participate in the study, the data for age, gender, BMI, grip strength, and cortisol was collected from the participants. The age-wise correlates of hand grip strength were assessed using Multiple linear regression analysis and the mean decline in the grip strength with advancing age is displayed. Results: The mean grip strength of the overall population was 30.75±14.35. It was observed that there was a negative significant correlation between the age and the grip strength (F = 3.57; r=-0.27; p=0.007) i.e. with increasing age a gradual decrease in the grip strength was observed. BMI (Obesity) was also significantly associated with grip strength (p=0.000). Moreover, females were more likely to have weak muscle strength as compared to males (p=0.000). However, no significant association was observed among the grip strength, socioeconomic status & longevity in any of the studied age groups (p>0.05). While a significant correlation was found between grip strength and obesity as well as between obesity and cortisol. Conclusion: Thus it can be concluded that obese individuals had increased chances of accelerated biological ageing due to an increase in cortisol, and a weakened grip strength is an indicator of it.

Long-standing, heavy alcohol use can lead to alcohol dependence, which predisposes to alcohol withdrawal if alcohol consumption is suddenly decreased or stopped. Alcohol withdrawal syndrome is characterized by a hyperadrenergic response, with symptoms ranging from mild tremulousness to delirium tremens. We report a 55-year-old male presenting with hyperthermia, tachycardia, tachypnea, altered consciousness, tremors, rigidity, diaphoresis, elevated creatinine kinase, and myoglobinuria. The diagnosis of alcohol withdrawal was made due to a history of alcohol use disorder with the last drink two days ago and no history of any medication or drug intake prior to admission. He was treated with benzodiazepines with an improvement in his condition.