Introduction Gradual enlargement of multinodular goiter (MNG) may compress surrounding structures which may progressively cause complications of tracheal stenosis and airway compromise. Surgical resection remains the gold standard treatment in MNG patients presenting with respiratory distress. In the current global COVID -19 pandemic, compressive goiter should be a differential diagnosis in patients with stable benign thyroid goiter presenting with dyspnea. We present a case of MNG with life threatening airway obstruction during an active COVID-19 infection. Case presentation A 74-year-old female with a history of hyperthyroidism with multi-nodular goiter and recurrent atrial fibrillation status-post ablation, was transferred to the intensive care unit for treatment after being intubated for respiratory distress at a nearby hospital. She was diagnosed with hyperthyroidism about 40 years ago and managed with methimazole. Over the last two years, thyroid ultrasound and prior imaging showed MNG with patent but moderate tracheal narrowing; fine-needle aspiration (FNA) confirmed benign colloid nodules with cystic degeneration. She was pending cardiac clearance for surgery when symptoms acutely worsened two days before admission. On initial assessment, she was hemodynamically stable, afebrile, with oxygen saturation of 86% on room air. She was alert and able to follow commands. On physical examination, she had stridor and thyromegaly was evident with mild tenderness on palpation. Cardiopulmonary examination was remarkable for coarse breath sounds. Labs showed TSH 4.82 (Normal 0.3 - 4.5 ulU/mL), FT4 0.64 (Normal 0.5- 1.26 ng/dL). Respiratory panel test came back positive for SARS-CoV-2. Racemic epinephrine and albuterol nebulizers were administered to help with her symptoms. CT scan of the neck revealed a severe narrowing and mild rightward shift of the trachea by a large multinodular goiter, prompting the decision to intubate for airway protection. CT scan of the chest with contrast demonstrated the large MNG with tracheal stenosis. Her methimazole dose was adjusted. After cardiac clearance, she underwent thyroidectomy through a transcervical approach. Levothyroxine and calcium supplementation were started post-surgery. She was extubated two days after her thyroidectomy. Pathology results showed no evidence of malignancy. Discussion Acute airway obstruction by large MNG requiring emergent airway protection is rare. Typically airway compromise from large otherwise stable benign goiters results from sudden hemorrhage into a cyst, upper respiratory tract infection leading to tracheal edema, or worseningcomorbid conditions. During the COVID-19 pandemic, acute respiratory failure and shortness of breath is typical of worsening disease course. This case highlights the importance of maintaining wider differentials of respiratory failure even and we need to consider worsening of tracheal narrowing with a large goiter due to tracheal edema from SARS- CoV-2 Infection. Thyroidectomy before SARS-CoV-2 infection may have reduced her need for emergent intubation for acute respiratory failure by improving pre existing airway compression. Presentation: No date and time listed

Legionella is most known for causing pneumonia. However, it is a systemic disease that can directly cause severe multi-organ injury in what is sometimes referred to as "extrapulmonary Legionella." In this case report, a reasonably healthy 80-year-old man is found to have Legionella pneumonia complicated by rhabdomyolysis with acute, severe, non-oliguric acute kidney injury, uremic encephalopathy, transaminitis, and cerebellar dysfunction. With a 14-day course of azithromycin and prompt initiation of dialysis, the patient’s pneumonia and systemic sequelae improved. This case demonstrates the importance of considering Legionella in the differential diagnosis of patients who present with community-acquired pneumonia and multi-organ dysfunction. Prompt diagnosis and management may decrease mortality associated with this disease sequela.

Acute pancreatitis is a common reason for hospitalization in the United States and can have a high degree of morbidity and mortality if not treated appropriately. Establishing the diagnosis and following guidelinedirected medical therapy are both important. In the Western world, the most common causes include acute alcohol overuse, hypertriglyceridemia, gallstone pancreatitis, post-instrumentation including endoscopic cholangiopancreatography, and medication side effects. Our team describes the case of an 84-year-old male that was found to have acute pancreatitis secondary to repaglinide, a commonly used medication for the management of diabetes mellitus. The diagnosis was made based on the imaging findings, physical examination, and the corresponding laboratory markers. The patient was also found to have a blood-alcohol level at baseline and triglyceride levels within normal range. The patient's symptoms resolved with the cessation of repaglinide administration. Our team hopes to make the medical community more aware of the potential association between repaglinide and the potentially rapidly debilitating disease.

The aim of our study was to improve the dissolution of Tramadol hydrochloride (TH) via its semisolid filled lipid based capsules. Sustained release formulation is designed to achieve a prolonged therapeutic effect by continuously releasing medication over an extended period of time after administration of single dose. Semisolid matrixes of TH were prepared by melt-matrix method and were filled in hard gelatin capsule shell (size 0). In this experiment, a mixture of Glycerol monostearate (GMS) and lipid materials like different lipophilic oils and surfactants were used to improve the matrix integrity and drug release. The effects of different oils like Arachis oil, Soyabean oil, castor oil, neobee oil and olive oil and different surfactants such as Span 80, Tween 80, PEG 400, Chremophore RH 40, Cremophor EL were analyzed by formulating at various ratios. The matrices were subjected to the paddle dissolution method using 900 ml of phosphate buffer (pH 6.8). The dissolution test was performed at 100 RPM and the temperature was set at 37 ± 0.50C. The amount of drug was measured from the absorbance with a UV spectrophotometer at 270 nm. The release of drug was plotted in zero order-, 1st order- and Higuchi-release patterns. The correlation coefficients values of the trend lines of the graphs revealed that the formulations best fit in Higuchian release pattern. So it can be said that the pharmaceutical quality of Tramadol HCl capsules can be improved by using a semisolid lipophilic matrix filled in hard gelatin capsules. DOI: http://dx.doi.org/10.3329/dujps.v11i2.14572 Dhaka Univ. J. Pharm. Sci. 11(2): 137-145, 2012 (December)

Introduction Acute pancreatitis (AP) is a recognised rare complication in pregnancy. The reported incidence varies between 1 in 1,500 to 3 in 10,000 pregnancies and is higher in the third trimester.1 The commonest causes in pregnancy include gallstones, alcohol and hypertriglyceridaemia.1 2 Non-gallstone pancreatitis is associated with more complications and worse outcome1 2 with hypertriglyceridaemia-induced AP having mortality rates ranging from 7.5-9.0% and 10.0-17.5% for mother and fetus, respectively.3 4 Case History A 40-year-old, para 4 woman presented with epigastric pain and vomiting at 15+4 weeks' gestation. She was admitted with AP secondary to hypertriglyceridaemia in June and discontinued fenofibrate on discovering she was pregnant. Past medical history included Grave's disease with no risk factor for hypertriglyceridaemia. Initial investigations showed elevated amylase (475.0 u/l) and triglycerides (46.6 mmol/l). She was admitted to HDU for supportive management with antibiotics, sliding scale and parenteral nutrition commenced on day 8. Imaging revealed an inflamed pancreas without evidence of biliary obstruction/gallstones hence confirming the diagnosis of hypertriglyceridaemia-induced AP. Her laboratory tests gradually improved (triglyceride 5.2 mmol/l on day 17) but she required 2 units of blood for anaemia. Fetal heart was auscultated regularly, however, on day 18 ultrasound confirmed fetal demise (18+1 weeks) and a hysterotomy was performed as she had had 4 previous caesarean sections. Conclusion Management of AP in pregnancy requires a multi-disciplinary approach. Hypertriglyceridaemia-induced AP has poor outcomes when diagnosed in early pregnancy. Identifying those at risk pre- and antenatally can allow close monitoring through pregnancy to optimise care.