Ahmad Al-Taee

Mobile‐based interpreter of arterial blood gases using knowledge‐based expert system

Purpose – An arterial blood gas (ABG) interpretation remains indispensable tool to assess and monitor critically ill patients in the intensive care unit or other critical care settings. This paper proposes a mobile‐based interpreter for ABG tests with the aim of providing accurate diagnosis in face of multiple acid‐base and oxygenation disorders. The paper aims to discuss these issues.Design/methodology/approach – A rule‐based expert system is designed and implemented using interpretation knowledge gathered from specialist physicians and peer‐reviewed medical literature. The gathered knowledge of ABG tests are organized into premise‐explanation pairs to deliver reliable evaluation with the appropriate differential in a timely manner.Findings – Performance of the developed interpreter prototype was assessed using a dataset of 74 ABG tests gathered from medical literature and clinical practice. The obtained results demonstrated that the identified acid‐base and oxygenation disorders and their differential d...

Smart Bolus Estimation Taking into Account the Amount of Insulin on Board

Self-management blood glucose (SMBG) and bolus calculations are pivotal components of evidence-based standard of care for young diabetics receiving multiple daily insulin injections. This paper aims at developing a smart bolus estimator that takes into account the amount of insulin on board (IoB), i.e. Insulin remaining in the patients body, to reduce fear of hypoglycemia and achieve goals of glycemic control. Design of the proposed bolus estimator follows the feed-forward multi-perceptron artificial neural network (ANN) with an input represents the time shift from last injection of quick acting (QA) insulin. The network output represents the amount of IoB. Calculation of the bolus required for a meal/snack is then carried out normally deducing the estimated IoB and thus the possibility of excess insulin administration and the risk of hypoglycemia can be averted. A functional prototype of the proposed system is developed and tested successfully on various mobile devices (i.e smartphones and tablet computers).

Metastatic signet ring cell carcinoma of unknown primary origin: a case report and review of the literature

In spite of the increasingly sophisticated diagnostic workup, detailed investigations fail to reveal a primary site of origin for about 3-5% of metastatic tumors. The most commonly reported subtype in cancer of unknown primary origin is adenocarcinoma. Signet ring cell carcinoma (SRCC) is a rare poorly differentiated aggressive subtype of adenocarcinoma that most commonly arise from the gastrointestinal tract. It usually presents late and is associated with poor prognosis. Treatment options remain limited to anecdotal reports. However, immunohistochemical studies can be useful in suggesting an origin and therefore may help guide investigations and treatment options. Here we present an unusual case of metastatic SRCC of unknown primary origin presenting as peritoneal carcinomatosis in a 73-year-old man. We also review the literature on metastatic SRCC of unknown primary origin and discuss the relevant findings. This work highlights the importance of collaboration between clinicians and pathologists as well as detailed histopathological, immunohistochemical, and molecular analyses which can help guide investigations and management options.

Autologous Graft-Versus-Host Disease of the Gastrointestinal Tract in Patients With Multiple Myeloma and Hematopoietic Stem Cell Transplantation

Multiple myeloma (MM) is the most common indication for autologous hematopoietic stem cell transplantation (HSCT) in North America. Despite occurring in up to 50% of patients undergoing allogeneic HSCT, the incidence of graft-versus-host disease (GVHD) after autologous HSCT is reportedly only 5-20%. Gastrointestinal involvement with graft-versus-host disease (GI GVHD) is a common and serious complication of allogeneic HSCT. GI GVHD after autologous transplant, which is referred to as autologous GVHD (auto-GVHD), has also been described. Auto-GVHD is usually less severe than allogeneic GVHD, and it can be one of the manifestations of engraftment syndrome with release of inflammatory cytokines and infiltration of auto-reactive T cells into affected tissue. Seventy-nine percent of patients respond well to corticosteroids without evidence of recurrence. However, cases of severe auto-GVHD lacking good response to corticosteroids have been reported, most notably in MM patients. Here we present two cases of autologous GI GVHD in recipients of autologous HSCT for treatment of MM. Our cases demonstrate two distinct clinical and endoscopic presentations of this uncommon entity. In the first case, the patient had more severe clinical symptoms accompanied by radiographic, endoscopic, and pathologic findings. The hospital course was complicated by cryptosporidium enteritis and acute cholecystitis in the setting of increased immunosuppression with a corticosteroid for presumed auto-GVHD. In contrast, the second case presented a patient with normal radiologic and endoscopic findings. Pathology revealing frequent apoptotic bodies led to auto-GVHD as a diagnosis. Both our patients received similar courses of chemotherapy prior to autologous HSCT (four cycles of a proteasome inhibitor, lenalidomide, and dexamethasone). Our work highlights the importance of maintaining a high level of clinical suspicion for auto-GVHD in patients presenting with GI symptoms after autologous HSCT, as it is a potentially treatable pathology that may be easily confused with other conditions. Health care providers should be aware of the potential complications of auto-GVHD after autologous HSCT and should be suspicious of auto-GVHD if GI symptoms occur, especially in patients receiving immunomodulatory therapy for MM, even in the absence of gross endoscopic findings.

Hepatic Collision Tumor of Metastatic Pancreatic Adenocarcinoma and Chronic Lymphocytic Leukemia: A Case Report.

A 70-year-old man with a past medical history of osteoarthritis and a long history of smoking and alcohol use presented to the emergency room after sustaining a fall at home and landing on his right hip. Vital signs on the presentation were notable for tachycardia. Laboratory testing revealed anemia (hemoglobin 11.9 g/dL, reference range: 13.5–17.5 g/dL) as well as leukocytosis (white blood cell count 53,600/μL, reference range 3500–10,500/μL) with lymphocyte predominance (an absolute lymphocyte count of 45,000/μL with 1% atypical lymphocytes). X-ray of the right hip revealed a right intertrochanteric fracture for which he underwent a successful operative repair on the next day. Workup for lymphocytosis and atypical lymphocytes included testing for infectious mononucleosis, CMV, HIV, and hepatitis B and C viruses with either enzyme-linked immunosorbent assay (ELISA) or polymerase chain reaction (PCR), all of which was unrevealing. Flow cytometry was performed on peripheral blood and confirmed the diagnosis of chronic lymphocytic leukemia (CLL). It demonstrated that 80% of the cells were in the small lymphocyte region. Within the small lymphocyte region, there was a monoclonal population of B-cells that co-expressed CD5, CD19, CD20, CD23, CD45, HLA-DR, and surface kappa light chain. In addition, ATM gene deletion was detected by fluorescence in situ hybridization (FISH) and was found in 23% of the cells. Workup for anemia revealed iron deficiency without any evidence of hemolysis. While awaiting flow cytometry results, abdominal ultrasonography (Fig. 1) was performed to assess splenic size and revealed a cystic lesion near the splenic hilum without any evidence of splenomegaly. Abdominal computed tomography with IV contrast (Fig. 2) was obtained and revealed a 5.0 × 3.5 cm multiloculated thick-walled cystic structure arising from the tail of the pancreas with an adjacent occlusion of the splenic vein and resultant gastric varices. Low-attenuation wedge-shaped lesions in the spleen l ike ly rep re sen ted sp len ic in fa rc t s were a l so demonstrated. Esophagogastroduodenoscopy with endoscopic ultrasonography revealed a 2 × 1 cm cyst-like structure in the pancreatic tail; the endosonographic appearance of which was highly suspicious for benign inflammatory changes likely representing a resolving pseudocyst. Pancreatic abnormalities were also suggestive of chronic pancreatitis in the setting of a long history of alcohol and tobacco use. Testing for vitamins A, D, E, K, and B12 levels as well as hemoglobin A1c was unremarkable. Fecal elastase was within normal limits but split qualitative fecal fat was elevated, so the patient started on pancreatic enzyme replacement. The hip fracture was thought to be mechanical although a pathologic fracture could not be ruled out. * Bassel Jallad jalladbm@slu.edu

Trigeminocardiac Reflex as the Presentation of Maxillary Sinus Adenocarcinoma

The trigeminocardiac reflex is a brainstem reflex that manifests as sudden hemodynamic dysfunction including bradycardia, hypotension, hypopnea, and gastric hypermotility due to mechanical stimulation of the trigeminal nerve. Here, the trigeminocardiac reflex was part of the initial patient presentation that led to the diagnosis of maxillary adenocarcinoma. A 54-year-old male presented to the emergency department with a two-month history of right upper jaw pain. Vital signs included blood pressure of 68/48 mmHg, heart rate of 55, and oxygen saturation of 85%. Physical examination showed a swelling on the right side of the hard palate and a right-sided abducens nerve palsy. MRI revealed a 2.8 x 2 x 3 cm enhancing right maxillary mass with retrograde extension along the right trigeminal nerve up to of the midbrain. Transoral biopsy of the mass revealed adenocarcinoma. The bradycardia resolved after successful surgical resection followed by radiotherapy. This case emphasizes the importance of considering brainstem reflexes such as trigeminocardiac reflex in the differential diagnosis of hemodynamic derangements in patients presenting with recurrent sinus symptoms and neurologic deficits.

Gallbladder Adenocarcinoma as the First Manifestation of Germline BRCA1 Mutation

Gallbladder adenocarcinoma (GBAC) is an uncommon, but highly fatal malignancy that follows an aggressive course and complete remission is rare. Germline mutations in BRCA1 genes have been associated with a significantly increased risk of breast and ovarian cancers as well as other malignancies. Here, we describe the first case of gallbladder adenocarcinoma as the initial presentation of BRCA1 mutation.

Acute Pancreatitis: Nothing to SPiT At.

An 18-year-old female patient was initially evaluated for a 3-day history of worsening epigastric pain, nausea, and vomiting. She had no known medical problems and no history of alcohol consumption, cigarette smoking, or marijuana use. Her only medication was levonorgesterol/ ethinyl estradiol for birth control. Physical examination revealed blood pressure 110/65 mmHg, pulse 91/min, temperature 36.6 C, and respiratory rate 16/min. Cardiopulmonary examination showed normal heart sounds and clear breath sounds. Abdominal examination revealed a flat abdomen with normal bowel sounds, dullness on percussion all over the abdomen, and tenderness on palpation of the epigastrium with local guarding but no rebound tenderness. Murphy’s and Carnett’s signs were negative. Complete blood count, metabolic panel, and liver function laboratory testing were normal with the exception of an elevated serum lipase (8369 U/L; normal range 12–70 U/L). Computed tomography (CT) of the abdomen (with intravenous contrast) revealed a 7 cm 9 9 cm 9 9 cm well-defined mass in the head of the pancreas (Fig. 1a). Magnetic resonance cholangiopancreatography (MRCP) demonstrated a complex cystic mass in the head of the pancreas with wall thickening that enhanced with contrast suggestive of a solid pseudopapillary tumor (SPT) (Fig. 1b). Based on these findings, an endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of the mass was performed, which revealed loose clusters of monotonous atypical cells with finely granular cytoplasm that formed papillary structures (Fig. 2). Immunohistochemical staining was positive for nuclear b-catenin (Fig. 3a), cluster of differentiation marker 10 (CD10) (Fig. 3b), estrogen (Fig. 3c), and progesterone receptors (Fig. 3d). Based on these findings, a diagnosis of an SPT of the pancreas was made. Staging CT scans showed no evidence of metastasis. The acute pancreatitis was managed conservatively with fluid replacement using crystalloid solution (0.9% NaCl) at a rate of 8 mL/kg, and the pain was controlled by fentanyl using a patient-controlled pump. The patient fully recovered and was discharged home on the fourth hospital day. Two weeks later, the patient underwent an uneventful laparascopic pancreaticoduodenectomy, from which she fully recovered.

Hepatic Dysfunction in Renal Cell Carcinoma: Not What You Think?

A 55-year-old Caucasian male, with history of type 2 diabetes mellitus and benign prostatic hyperplasia, was initially evaluated in emergency department with a 2-month history of worsening jaundice, pruritus, and right upper quadrant abdominal pain. His gallbladder had previously been removed. Medications included insulin and tamsulosin. He had a 20 pack-year history of smoking. He denied ever drinking alcohol to excess or using illicit drugs. On presentation, his vital signs were within normal limits. Physical examination revealed only scleral icterus, diffuse skin excoriations on the extremities and torso, and abdominal tenderness to palpation over the right upper quadrant. The liver span was normal; the spleen was not enlarged, and there was no lymphadenopathy or peripheral edema. Results of laboratory tests showed a hemoglobin (Hgb) 18 g/dl (13–17 g/dl), white blood cell (WBC) count 10 K/ mm (4–10 K/mm), platelet count 300 K/mm (150–400 K/mm), blood urea nitrogen (BUN) 20 mg/dl (8–21 mg/dl), and serum concentrations of creatinine 1.0 mg/dl (0.8–1.3 mg/dl), total bilirubin 20.9 mg/dl (0.3–1.9 mg/dl) [(conjugated bilirubin 12.5 mg/dl)], alkaline phosphatase (ALP) 327 units/l (50–100 units/l), gamma glutamyl transpeptidase (GGTP) 185 units/l (6–50 units/l), prothrombin international normalized ratio (INR) 1.6 (0.9–1.2), albumin 2.5 g/dl (3.5–5.5 g/dl), aspartate aminotransferase (AST) 29 units/l (5–30 units/l), and alanine aminotransferase (ALT) 34 units/l (5–30 units/l). Urinalysis was positive for urobilinogen and glucose, with 1 red blood cell/hpf on microscopic examination. Although an ultrasound examination of the right upper quadrant was unremarkable, abdominal computed tomography (CT) using intravenous contrast revealed an enhancing, 2.5 cm diameter, exophytic mass arising from the lower pole of the left kidney (Fig. 1). Magnetic resonance cholangiopancreatography (MRCP) was normal. The patient first underwent an ultrasound-guided liver biopsy, which revealed portal and periportal neutrophilic inflammatory infiltrates, with bile duct and ductular proliferation and centrilobular zone v3 hepato-canalicular cholestasis, findings consistent with cholestatic hepatitis. Serum concentrations of liver enzymes were unchanged during the entire hospitalization. Under the direction of the genitourinary surgical service, the patient underwent uneventful surgical resection of the renal mass. Histologic examination of the mass revealed the presence of tumor, a clear cell renal carcinoma with no vascular or capsular invasion. No obvious metastases were present, and the liver appeared grossly normal. Three months post-nephrectomy, serum concentrations of liver tests had returned to within normal limits (Fig. 2).