Association Between Pancreatic Cancer and Dipeptidyl Peptidase-4 Inhibitors Use in a Case-Control StudyDipeptidyl peptidase-4 inhibitor is an incretin-based agent used to treat type 2 diabetes mellitus, which has been available in the Taiwan market since 2009.1 Pancreatic cancer was the eighth leading cause of cancer death in Taiwan in 2017.2 At present, no definite evidence is available on the association between pancreatic cancer and dipeptidyl peptidase-4 inhibitors in Taiwan. To evaluate this issue, a population-based case-control study was conducted using the database of the Taiwan National Health Insurance Program with 23 million citizens living in the independent country of Taiwan.
80-Year-Old Man With Massive Leg SwellingAn 80-year-old man was admitted to the hospital with a 2-month history of painful swelling of his right lower extremity. His medical history was remarkable for metastatic prostate cancer, radical prostatectomy, androgen deprivation therapy with goserelin acetate (a gonadotropin-releasing hormone analogue used to treat prostate cancer, breast cancer, and endometriosis), and radiation therapy for cancer recurrence with bony metastases. He had no history of claudication. The patient had undergone right total hip arthroplasty 6 months previously and lower back surgery 3 months later.
73-Year-Old Man With Increasing Abdominal Girth and DyspneaA 73-year-old man with a history of type 2 diabetes mellitus, hyperlipidemia, and obesity presented to the emergency department with a 3-month history of increasing abdominal girth and shortness of breath. He also noted some mild abdominal discomfort when he moved. He denied nausea, vomiting, diarrhea, constipation, chest pain, fevers, and significant alcohol use. His medications included amlodipine, aspirin, glyburide, and hydrochlorothiazide.
33-Year-Old Man With SyncopeA 33-year-old man presented for evaluation of syncope. A few weeks earlier, he had become light-headed and developed mild chest discomfort and visual changes while running from home plate to first base during a softball game. A few days before evaluation, he had been running on his treadmill when he became light-headed, lost consciousness, fell, injured his nose, and broke his glasses. Bystanders observed no seizure-like activity. He experienced no bowel or bladder incontinence, tongue biting, or postevent confusion.
26-Year-Old Man With Recurrent Urinary Tract InfectionsA 26-year-old male college student presented with 1 week of constant, right lower quadrant, throbbing abdominal pain that was worse after eating and accompanied by bilious emesis. He had experienced similar, albeit less severe and self-limited, episodes of abdominal pain during the preceding 6 months. He denied fevers or chills but had lost 4.5 kg (10 lbs) in the past 6 months. During the same time period, he was treated twice with antibiotics for urinary tract infections (UTIs) after reporting symptoms of dysuria and noting “bubbles” in his urine.
78-Year-Old Man With Nausea and Chest PainA 78-year-old man presented with a constant, substernal, sharp, nonradiating chest pain of 6 hours' duration; he rated the pain's severity as 5 on a 10-point scale. He denied previous chest discomfort. His chest pain was preceded by 1 day of epigastric abdominal pain and episodes of nausea and nonbloody emesis. He described the epigastric pain as constant, sharp, and band-like, noting that it was exacerbated by food. Findings were otherwise unremarkable on a complete review of systems. Before this illness, he had exercised daily by jogging on a treadmill.
85-Year-Old Man With EpistaxisAn 85-year-old man with a medical history notable for monoclonal gammopathy of undetermined significance (MGUS), prostate cancer, bladder cancer, and squamous cell skin cancer presented to the emergency department with periodic epistaxis of 3 to 4 weeks' duration. The bleeding was spontaneous without antecedent trauma. The episodes of epistaxis usually lasted for about an hour. Pressure to the nares would stop the bleeding. The patient noted prolonged bleeding of his gums after brushing his teeth.
51-Year-Old Hospitalized Man With a Painful LegA 51-year-old Somali man was admitted to an inpatient cardiology service at Saint Marys Hospital, a Mayo Clinic–affiliated hospital in Rochester, MN, with symptoms of fever and progressively worsening shortness of breath. Chest radiography demonstrated substantial pulmonary edema secondary to volume overload in the setting of acute worsening of chronic renal failure. Initial laboratory investigation yielded the following notable results (reference ranges provided parenthetically): leukocyte count, 30.3 × 109/L (3.5-10.5 × 109/L); blood urea nitrogen, 142 mg/dL (8-24 mg/dL); and creatinine, 12.6 mg/dL (0.9-1.4 mg/dL).
62-Year-Old Woman With Fever, Dyspnea, Pleuritic Chest Pain, and Weight LossA 62-year-old woman with rheumatoid arthritis (RA) presented for evaluation of chronic pleuritic chest pain, dyspnea, cough, odynophagia, fatigue, weight loss of 16.6 kg (30 lb), and migratory joint pains. Ten years earlier, RA had been diagnosed on the basis of polyarticular inflammatory arthritis. Rheumatoid factor (RF) had subsequently been positive and anticyclic citrullinated peptide (anti-CCP) antibodies negative. No signs or symptoms of underlying connective tissue disease (CTD) had been reported, and no serologic testing for CTD performed.
37-Year-Old Woman With Palpitations and FatigueA 37-year-old woman presented to the emergency department with palpitations, fatigue, and exertional dyspnea of 2 months' duration. The palpitations were persistent at rest and were not associated with anxiety. Review of the patient's medical history revealed that a prior pregnancy was complicated by postpartum cardiomyopathy. She was afebrile, had tachycardia (120 beats/min), and had a normal blood pressure of 118/64 mm Hg. Findings on physical examination were unremarkable, apart from trace bilateral lower extremity edema.
44-Year-Old Man With Shortness of Breath, Fatigue, and ParesthesiaA 44-year-old man presented to the Primary Care Internal Medicine clinic with a 1-month history of shortness of breath, fatigue, and paresthesia. He reported increasing shortness of breath while stocking shelves at work and recently stopped recreational jogging because of this symptom. He also described a new, painless numbness and tingling in his fingertips bilaterally.
51-Year-Old Man With Heart MurmurA 51-year-old man presented to the internal medicine clinic for a Department of Transportation medical examination to renew his commercial motor vehicle license. He denied any symptoms at the time of his visit. On detailed questioning, however, the patient reported progressive dyspnea on exertion of several months' duration. These symptoms were not particularly worrisome to the patient because he attributed them to deconditioning.
74-Year-Old Woman With New-Onset MyoclonusA 74-year-old female nursing home resident with Alzheimer disease was admitted to the hospital with a 5-month history of aggressive behavior, including physically striking other nursing home residents. She had been treated with quetiapine with mild improvement; however, she became tremulous while receiving this medication and so was switched to 0.125 mg/d of risperidone orally. Unfortunately, the patient continued to act aggressively and was brought to the emergency department, where she was unable to follow commands or answer questions appropriately.
82-Year-Old Man With Bilateral Leg SwellingAn 82-year-old man with a medical history remarkable for chronic heart failure, diabetes mellitus, benign prostatic hyperplasia (BPH), and degenerative joint disease presented to the outpatient clinic with bilateral lower extremity swelling of 1 month's duration. The lower extremity edema was bilateral but slightly worse on the right. The edema worsened during the day but transiently improved when the patient was in the supine position. He had no symptoms of paroxysmal nocturnal dyspnea, angina, or orthopnea.
52-Year-Old Woman With DysphagiaA 52-year-old woman presented with dysphagia, which started when she was 30 years old. Initially, the dysphagia was intermittent but had progressed to daily occurrences during the past 2 years. She had progessively more difficulty in swallowing solids, but not liquids. The patient described a spasmlike sensation in her chest, which occurred as soon as she started eating; this had become more prominent during the past 6 months. Almost once a week, food would “get stuck” in her esophagus, and she had to regurgitate it to relieve the discomfort.
38-Year-Old Woman With Hypertension, Headaches, and Abdominal BruitA 38-year-old woman presented to her local clinic for recurrent episodes of headache of several weeks' duration. Evaluation revealed a blood pressure of 202/136 mm Hg. The patient was prescribed 37.5 mg of triamterene with 25 mg of hydrochlorothiazide (1 tablet) twice daily and 50 mg of atenolol once daily.
52-Year-Old Man With Arthralgias, Fever, and FatigueA 52-year-old previously healthy man was admitted to an inpatient internal medicine resident hospital service with a 2-week history of profound generalized fatigue, nocturnal fevers (temperature as high as 39.4°C [103°F]), cold sweats, anorexia, and bilateral hand swelling and numbness. The swelling progressed to symmetrically involve his elbows, shoulders, knees, and ankles. He also reported arthralgias and profound weakness that had caused him to be confined to a wheelchair. He experienced joint stiffness of less than 30 minutes' duration in the morning that improved with activity.
68-Year-Old Woman With Chronic Cough and Recurrent Pleural EffusionsA 68-year-old woman with a history of hypertension, paroxysmal atrial fibrillation, and liver transplant for primary sclerosing cholangitis (PSC) presented with a 2-month history of cough and shortness of breath. Her cough, which had gradually worsened, progressed to dyspnea after several feet of walking. She denied fever, chills, sick contacts, chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea. She had taken levofloxacin for a presumed upper respiratory tract infection with no relief and was receiving oral immunosuppressive therapy with 1 mg/d of prednisone and 25 mg of cyclosporine twice daily.
77-Year-Old Woman With Back Pain and Shortness of BreathA 77-year-old woman presented to the emergency department with back pain, which began shortly after moving furniture 1 week before presentation. The pain was persistent, did not radiate, limited activities of daily living, and was unrelieved by conservative measures. Although there were no associated neurologic symptoms, the patient described intermittent fever and chills.
73-Year-Old Woman With Progressive Shortness of BreathA 73-year-old woman presented to our institution for evaluation of progressive shortness of breath that had gradually worsened during the previous year. Initially, her symptoms were mild and noticeable only with moderate exertion. By presentation, however, she reported severe dyspnea with only minimal exertion. Walking 3 to 6 meters resulted in such severe dyspnea that she had to discontinue activity. She also reported a harsh cough with occasional clear sputum production. A provisional diagnosis of asthma had been suggested before her presentation.
83-Year-Old Woman With Abdominal Distention and ConstipationAn 83-year-old woman with Alzheimer dementia presented to the emergency department with abdominal distention. Her husband provided the history. After having constipation for 1 week, she developed a progressively distended abdomen in the course of 2 days, with anorexia but no vomiting, melena, or hematochezia. She had no history of fever, rigors, dyspnea, or weight loss. Her medical history was remarkable for hypertension, coronary artery disease, and impaired fasting blood glucose levels. Despite the recent symptoms, she had no history of gastroenterologic symptoms, cancer, abdominal surgeries, or colon screening studies.
65-Year-Old Man With Persistent FeverA 65-year-old man was transferred to our institution for evaluation of fever. His symptoms included subjective fever, cough productive of creamy white sputum, and nasal congestion of 3 months' duration. He denied dyspnea, hemoptysis, weight loss, or night sweats. Approximately 10 days before admission, he had been seen by his primary care physician for worsening of symptoms and was treated empirically with an undefined antibiotic. Subsequently, palpitations and severe fatigue developed, and the patient was admitted to a local hospital, where he was noted to be febrile and hypoxic with pulse oximetry readings in the high 80% range.
42-Year-Old Male Methamphetamine User With Dysarthria and Facial DroopA 42-year-old man presented to the emergency department after the sudden onset of left hand numbness and tingling, dysarthria, and right-sided temporal region pain that began 30 minutes previously. On his way to the hospital, the patient had developed bilateral flank pain. He denied any significant medical history or history of similar symptoms and stated he had been in his usual state of health until the sudden onset of symptoms that brought him to the emergency department. He denied taking any medications and had no history of stroke, head trauma, recent bleeding, chest pain, back pain, palpitations, fevers, or chills.
60-Year-Old Man With RashA 60-year-old man presented with a rash that had developed during the previous 2 weeks. He had not experienced any symptoms of influenza or any other symptoms before the onset of the rash. The rash started on his scrotum and spread to his buttocks and then to his entire body. His face was spared, but he had pain inside his mouth. He first noticed a red, tender, pinpoint lesion on his scrotum, which became progressively larger with associated desquamation, pruritus, and worsening pain. An initial trial of topical hydrocortisone and then high-dose oral prednisone for 1 week was unsuccessful.
68-Year-Old Woman With ConfusionA 68-year-old woman with a history of chronic obstructive pulmonary disease and bipolar disorder presented to our medical center with a 1-month history of confusion. She was fatigued and confused and had poor oral intake. In the past 2 months, she had lost 10 kg. Two weeks before admission, she started to exhibit atypical behaviors, such as walking about her house undressed. The patient denied fever, headaches, seizures, nuchal rigidity, visual changes, weakness, dysarthria, dysphagia, and bowel or bladder incontinence.