Background: Approximately 1% to 2% of hospitalized patients get discharged or leave from the hospital against medical advice and up to 26% in some centers. They have higher readmission rate and risk of complications than patients who receive complete care. In this study we aimed to determine the rate of leave against medical advice (LAMA) and reasons for the same across different in-patient departments of a tertiary care hospital. Methods: Retrospective cohort study on patients admitted in all departments at our institute over a 1-year period. All patients who were admitted to an in-patient ward at the hospital and who left against medical advice by submitting a duly filled LAMA form were included. Univariate and multivariate logistic regression models with forward selection methods were employed. Revisit to hospital within 30 days; to clinic or emergency department was outcome variable for regression. Results: From June 2015 to May 2016 there were 429 LAMA patients, accounting for 0.7% of total admissions. Females were 223 (52%) compared to males 206 (48%). Finances were quoted as the most common reason for LAMA by 174 (41%) patients followed by domestic problems 78 (18%). Internal medicine was the service with the highest number of LAMA patients ie, 153 (36%) followed by Pediatric medicine with 73 (17%). Of the 429 patients, 147 (34%) patients revisited the hospital within 30 days. Sixty-one percent of these ‘bounced-back’ LAMA patients had worsening or persistence of same problem, or new problem/s had developed. In unadjusted bivariate logistic model, patients who were advised for follow-up during discharge against medical advice were four times more likely to revisit the hospital. Patients who were married had an increased odd of revisiting the hospital. Conclusion: Financial reasons are the most common stated reasons to LAMA. Patients who LAMA are at a high risk of clinical worsening and ‘bouncing back.’ This is the first study from our region on in-patient LAMA rates, to our knowledge. The results can be used for planning measures to reduce LAMA rates and its consequences.
Purpose Chemotherapy for advanced pancreatic cancer has limited efficacy due to the difficultly of treating established tumours and the evolution of tumour resistance. Chemotherapies for pancreatic cancer are typically studied for their cytotoxic properties rather than for their ability to increase the immunogenicity of pancreatic tumour cells. In this study Gemcitabine in combination with immune modulatory chemotherapies Oxaliplatin, zoledronic acid and pomalidomide was studied to determine how combination therapy alters the immunogenicity of pancreatic tumour cell lines and subsequent T-cell responses. Methods Pancreatic tumour cell lines were stimulated with the chemotherapeutic agents and markers of immune recognition were assessed. The effect of chemotherapeutic agents on DC function was measured using uptake of CFSE-stained PANC-1 cells, changes in markers of maturation and their ability to activate CD8+ T-cells. The effect of chemotherapeutic agents on T-cell priming prior to activation using anti-CD3 and anti-CD28 antibodies was determined by measuring IFN-γ expression and Annexin V staining using flow cytometry. Results These agents demonstrate both additive and inhibitory properties on a range of markers of immunogenicity. Gemcitabine was notable for its ability to induce the upregulation of human leukocyte antigen and checkpoints on pancreatic tumour cell lines whilst inhibiting T-cell activation. Pomalidomide demonstrated immune modulatory properties on dendritic cells and T-cells, even in the presence of gemcitabine. Discussion These data highlight the complex interactions of different agents in the modulation of tumour immunogenicity and immune cell activation and emphasise the complexity in rationally designing chemo immunogenic combinations for use with immunotherapy.
Nontraumatic liver herniation through diaphragm is a rare condition. We present a case of a 54-year-old female presenting with nontraumatic liver herniation mimicking a right lower lobe mass. Patient was noted to have growth of two right lower lobe lung nodules from 1.5 cm × 2.8 cm and 0.9 cm × 1.3 in August 2009 to 2.8 cm × 4.1 cm and 1.1 cm × 1.4 cm in March 2019 on computerized tomography (CT) scan. PET scan as well as the growth pattern was consistent with low-grade malignancy likely carcinoid tumor. CT-guided biopsy was not feasible because of location of the mass. We performed robotic thoracoscopy with plan for wedge resection, however gross inspection of the thoracic cavity revealed two masses on the dome of the diaphragm with appearance like liver and correlating with nodules seen on CT scan. A core needle biopsy showed that it was benign liver tissue.
INTRODUCTION: Spontaneous diaphragmatic herniation is a rare type of acquired diaphragmatic hernia without any history of trauma. (1) We describe a case where a non-traumatic liver herniation through diaphragm was observed mimicking a lower lobe lung mass. CASE PRESENTATION:A 54-year-old female without prior thoraco-abdominal trauma was seen in the clinic because of growth of 2 right lower lobe lung nodules. These nodules were initially noted incidentally on CT scan in August 2009 and measured 1.5 cm x 2.8 cm and 0.9 cm x 1.3. They remained stable on CT scan and PET performed in 2010. Patient was lost follow-up after that until she had a CT scan in March 2019 because of concern of pneumonia and it was noted that the lung nodules have increased in size to 2.8 cm x 4.1 cm and 1.1 cm x 1.4 cm. The patient was otherwise asymptomatic. A PET scan was obtained which showed hypermetabolic nodules with maximum SUV of 3.29 and 1.4 for the larger and smaller nodule respectively. Radiographic appearance as well as the growth pattern was consistent with low-grade malignancy like carcinoid tumor. We performed robotic thoracoscopy with plan for wedge resection and possible completion lobectomy. Gross inspection of the thoracic cavity revealed abnormal mass on the dome of the diaphragm with appearance like liver. It was noted to be lying in the oblique fissure and corelated with the position of larger nodule seen on CT scan. There was a second area of thinned-out area of the diaphragm where a small nodule was noted pushing on the diaphragm with appearance like liver consistent with location of smaller lesion on CT scan. A Tru-Cut needle biopsy showed that it was benign liver tissue. The decision was made not to proceed with any diaphragmatic repair or reinforcement with mesh as this was an asymptomatic herniation through diaphragm and the liver was fibrosed to the diaphragm protecting from any intestinal herniation.DISCUSSION: A review of literature revealed that there are 28 reported cases spontaneous diaphragmatic rupture (SDH) and of those only 10% had liver herniation. SDH is caused by events that increase intra-abdominal pressure like complicated labor, intense physical exercise, psychiatric illness, and cough secondary to pertussis. Another predisposing factor for SDH is congenital diaphragmatic defect which creates an area of weakness and increases the likelihood of herniation secondary to increased intra-abdominal pressure. SDH has also been described in association with other conditions like Ehler-Danlos Syndrome (EDS) and endometriosis because of weakness of diaphragmatic tissue. CONCLUSIONS: Our case was unique because the patient had asymptomatic SDH presenting as a lung mass without any history of etiologies leading to increased intra-abdominal pressure or weakness of diaphragm. Liver herniation through diaphragm can be managed without surgical repair if liver if fibrosed to diaphragm.
Background: Primary squamous cell carcinoma is a very rare entity and there are only 11 reported cases to date. We describe a case of primary SCC of the ampulla of Vater with microsatellite instability (MSI) and response to pembrolizumab immunotherapy. To the best of our knowledge, this is the first reported case of SCC of ampulla of Vater with MSI. We also performed a review of literature to determine the treatment modalities for this pathology.Case presentation: A 40-year-old male presented with direct bilirubinemia (total bilirubin: 10.7, direct bilirubin: 7.1) and was noted to have a pancreatic head mass which measured 6.6 x 5.5 x 5.5 cm. The patient underwent a pylorus preserving pancreatoduodenectomy with lymph node dissection. Pathology showed 5.5 x 3.5 x 3.5 cm squamous cell carcinoma of ampulla of Vater based on positive p40 and CK5 on immunohistochemistry. It was noted to be invading pancreatic head and duodenal mucosal. Surgical margins were negative. Adjuvant chemotherapy with mFOLFIRINOX (irinotecan, 5-fluorouracil, oxaliplatin) was not performed because of active Hepatitis C infection. Chemoradiotherapy with capecitabine and radiation therapy was initiated however patient had progression of disease despite that. The patient was transitioned to Pembrolizumab in context of MSI high tumour with palliative intent. He had an excellent response to immunotherapy. The therapy was stopped after 18 cycles on patient request because of persistent symptoms of dizziness and lethargy. At the eight-month follow-up after the last cycle of immunotherapy (2.5 years after surgical resection), the patient had no evidence of relapse on CT scan. Conclusions: Surgical resection is mainstay of treatment for primary squamous cell carcinoma of ampulla of Vater. Genetic testing for mismatch repair (MMR) genes should be performed for all patients and immunotherapy with Pembrolizumab should be considered in tumours with high microsatellite instability. Radiotherapy is not effective for this pathology.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
customersupport@researchsolutions.com
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.