Complicated Medical History Research Articles

Anesthesia for a Patient with Osteogenesis Imperfecta, Achondroplastic Dwarfism and History of Malignant Hyperthermia

A primary goal for anesthesia providers is to maintain patientsafety. This is an even greater concern when taking care of apatient with a complicated medical history. This case report,discusses the care of a 47 year-old female patient who presentedto a tertiary care center for an orthopedic procedure. Hermedical history included osteogenesis imperfecta (OI), achondroplasticdwarfism and suspicion of malignant hyperthermia (MH).There were multiple anesthetic implications to ensure safety forthis patient during the perioperative period. OI concerns includebone fragility and potential for multiple fractures even afterinoffensive trauma. Achondroplastic dwarfism concerns includeabnormalities of the upper airway and difficulty with visualizingthe glottic opening during direct laryngoscopy.1 MalignantHyperthermia is a life threatening disorder, which places thepatient at risk for a hypermetabolic reaction if exposed to selectanesthetic agents.

P-398 Lower ectopic pregnancy prevalence with natural endometrial preparation in single euploid frozen embryo transfers

Abstract Study question Does the endometrial preparation approach for an euploid-frozen embryo transfer have an impact on the incidence of an ectopic pregnancy? Summary answer The natural cycle endometrial preparation approach seems to have a lower incidence of ectopic pregnancies compared to a hormonal replacement therapy cycle. What is known already Ectopic pregnancy (EP) is an uncommon complication of pregnancy and is associated with significant morbidity. IVF pregnancies have been implicated as a risk factor, but this finding is mostly confounded by multiple embryo transfer and complicated medical history of women undergoing IVF treatment (tubal disease, surgery, endometriosis, etc.). Recent studies have suggested that frozen embryo transfer may reduce the risk of EP, but it is not yet known whether embryo ploidy status and different endometrial preparation regimens affect the risk of EP. Study design, size, duration Retrospective cohort of 1517 pregnancies from 2607 single euploid frozen embryo transfers. Comparator estimates were estimated using multiple large cohort studies in the literature including 58,203,239 pregnancies from unselected cohorts and 220,167 pregnancies from IVF-treated women with the transfer of non-tested embryos. Participants/materials, setting, methods The rate of ectopic per pregnancies were compared to ectopic rate derived from multiple cohorts of IVF-treated women and population level reports of unselected pregnancies (natural conception and IVF). Comparator estimates were obtained with proportion meta-analyses using generalized linear mixed models. Factors associated with ectopic pregnancies were investigated with mixed-effects logistic regression analyses. Main results and the role of chance EP rate in our cohort was 10/1000 pregnancies (95% CI: 5 to 16 per 1000) resulting from single euploid embryo transfers (1.1%, 16/1517). The observed prevalence of EP was 12/1000 pregnancies (95% CI: 6.8 to 21 per 1000) in unselected cohorts and 14/1000 pregnancies (95% CI: 13 to 15 per 1000) after IVF-treatment. Ectopic rate in our study was not significantly different than rates reported in the literature from unselected and IVF pregnancies (P = 0.579 and 0.223, respectively). There were no significant differences between women with ectopic pregnancies and those with clinical pregnancies in terms of age (33.6±5.5 vs. 35.1±5.2 years, P = 0.290), BMI (26.7±4.8 vs. 25.8±4.6 kg/m2, P = 0.475) and serum AMH levels (3.3±2.9 vs. 3.4±3.9 ng/mL, P = 0.854), nor between the quality of embryo transferred between top, good, fair and poor (1.8% vs 0.7% vs 1.9% vs 0.9%, p = 0.088, 0.997 and 0.508 respectively). Ectopic rates were also similar between women with history of cesarean section (1.1% vs 1.0%, P = 0.847) or isthmocele (1.0 vs 1.1%, P = 0.857). There were less ectopic pregnancies following transfers with natural endometrial preparation (0.5 vs 1.5%, natural vs programmed) and the effect showed statistical significance in multivariable analyses (OR: 0.28, 95% CI: 0.06 – 0.88, P = 0.049). Limitations, reasons for caution Small sample size as well as infrequent occurrence of the studied event reduces the power of our study to detect small but clinically meaningful effects with statistical significance. Wider implications of the findings We did not observe a lower than reported prevalence of EP among euploid embryo transfer. However, rate of EP was significantly lower in natural endometrial preparation cycles compared to preparation with exogenous hormones, indicating that a natural cycle might have a protective effect against the development of an ectopic pregnancy. Trial registration number Not applicable

A case of severe anaphylactic reaction after administration of diagnostic-dose ferumoxytol in a pediatric patient

We describe a case of anaphylaxis during administration of intravenous (IV) ferumoxytol as a magnetic resonance imaging (MRI) contrast agent in a 4-year-old patient with complicated past medical history including YARS genetic mutation with resultant liver failure and deceased donor liver transplantation, stage IV chronic kidney disease (CKD), and hypertension. The patient was noted to have labored breathing 4 min after initiation of ferumoxytol infusion and was subsequently rapidly intubated and returned to the intensive care unit (ICU) for monitoring. Anaphylactic reactions to therapeutic doses of ferumoxytol led to issuance of a black box warning by the FDA in 2015. Adverse reactions to lower-dose ferumoxytol used in diagnostic imaging, however, are rare and there has been a paucity of documented anaphylactic reactions in the literature.

Local intralesional talimogene laherparepvec therapy with complete local response in oral palatine mucosal melanoma: a case report

BackgroundMucosal melanoma, an aggressive type of malignancy different from the cutaneous melanomas commonly seen in the head and neck region, represents < 1% of all malignant melanomas. The pathogenesis of mucosal melanoma is unknown. Targetable mutations commonly seen in cutaneous melanoma, such as in the BRAF and NRAS genes, have a lower incidence in mucosal melanoma. Mucosal melanoma carries a distinct mutational pattern from cutaneous melanoma. Surgery with negative margins is the first-line treatment for mucosal melanoma, and systemic therapy is not well defined. Talimogene laherparepvec, an oncolytic viral immunotherapy, is United States Food and Drug Administration approved for the treatment of advanced malignant cutaneous melanoma, with local therapeutic benefits. Mucosal melanoma was initially excluded from talimogene laherparepvec’s initial phase III clinical trial.Case presentationWe present the case of a white female patient in her 40s with past medical history of systemic lupus erythematous, scleroderma, and estrogen-receptor-positive invasive ductal breast carcinoma. Following a bilateral mastectomy, the patient was found to have BRAF-negative mucosal melanoma of her hard palate with a soft palate skip lesion. Owing to the presence of a skip mucosal lesion as well as the anticipated defect and need for free-flap reconstructive surgery, nonsurgical management was considered. The patient was referred to medical oncology, where—based on the patient’s complicated medical history and the risk of immunotherapy possibly worsening her prior autoimmune diseases—local talimogene laherparepvec injections were chosen as the primary therapy for her mucosal lesions. Though talimogene laherparepvec is approved for the treatment of cutaneous melanoma, there are limited data available on the use of talimogene laherparepvec in mucosal melanomas.ConclusionThe patient had a complete local tumor response at both the primary lesion as well as the skip lesion with the local injections. She had no side effects and maintained a high quality of life during treatment.

Amyand&amp;apos;s hernia unveiled: a case report on perforated appendix within the inguinal hernia sac

Background: Acute appendicitis (AA) is still a common cause of lower abdominal pain, which frequently leads to emergency room (ER) visits. A case of perforated appendix within the inguinal hernia sac was presented. Case presentation: The clinical journey of a 30-year-old male patient with acute right iliac fossa pain suggestive of recurrent appendicitis was detailed in this case report. The patient\&amp;apos;s complicated medical history, which included dostinex-treated hyperprolactinemia and a previous episode of conservatively managed appendicitis in 2017, sets the stage for complex diagnostic challenges. The patient complained of acute localized tenderness and pain in the right iliac fossa, but no gastrointestinal symptoms, fever, or diarrhea were present. The admission laboratory results showed elevated white blood cells (WBC) (15.2), hemoglobin (Hb) (15.8), and platelet (PLT) (191) levels. Computed tomography scans exposed a perforated appendix within the right inguinal hernial sac surrounded by inflammatory changes. Laparoscopic appendectomy revealed a perforated appendix within the inguinal hernial sac, necessitating omental dissection and drainage. The postoperative course was uneventful, with a 7-day hospital stay and subsequent OPD follow-up. Microscopic examination confirmed acute suppurative appendicitis with periappendicitis aligning with clinical and radiological assessments. Conclusions: Amyand\&amp;apos;s hernia is a rare type of hernia that involves the appendix. A perforated appendix within a groin hernia is unusual and necessitates immediate source control to manage infection and prevent sepsis.

1032 Mixed sleep apnea management in a pediatric patient with Arnold Chiari type 1 and septo-optic dysplasia leading to hypopituitarism

Abstract Introduction Mixed Sleep apnea and Central sleep apnea are commonly noted in a patient with Arnold Chiari Malformation and definitive treatment of Arnold Chiari Malformation is surgical decompression. Report of case(s) The patient at the time of diagnosis of Mixed sleep apnea was 7 years old. She had already undergone tonsillectomy and adenoidectomy at the age of 4 years. Due to continued Sleep-disordered breathing, PSG was done in 2016 which showed predominantly mixed and central events. MRI was done which revealed Chiari 1 malformation with cerebellar tonsils extending 6 mm below the foramen magnum. The patient also due to septo-optic dysplasia and hypopituitarism followed with pediatric endocrinology and was on supplementation of Desmopressin, Hydrocortisone, Levothyroxine, and Somatropin. The mother at the time of pregnancy was a substance abuser, was incarcerated and the primary care was assumed by the patient’s legal guardian. The legal guardian was not interested in surgery for Arnold Chiari Malformation as she feared long-term outcomes and requested alternate treatment options. The patient underwent another split study and started on CPAP. The patient did not tolerate the CPAP and was transitioned to BiPAP. During her last clinic visit, the patient’s compliance had improved and she had achieved therapeutic AHI. The patient was also counseled on the effects of GH supplementation and untreated sleep apnea and is regularly followed by Sleep Medicine and Pediatric Endocrinology. The patient after transitioning to BiPAP has responded well to treatment for Mixed sleep apnea. Despite being on GH supplementation, with careful monitoring of hormone levels by Pediatric Endocrinology and symptom control by Sleep Medicine, the patient has shown remarkable improvement. Conclusion Mixed and central sleep apnea secondary to Arnold Chiari Malformation responds well to surgical decompression with improvement in sleep-disordered breathing. In a pediatric patient with complicated medical history with needing stress dose steroids, not a candidate for surgery, and intolerant to CPAP, BiPAP as a treatment modality showed good control of Sleep Apnea. Support (if any)

Acupuncture for Hindlimb Lameness in a Ferret

A geriatric ferret with a complicated medical history (adrenal disease, kidney disease, hindlimb lameness/weakness, chronic diarrhea, urinary incontinence) was presented for traditional Chinese veterinary medicine (TCVM) evaluation. A thorough conventional medical work-up had been performed but financial resources were unavailable for specialty referral. The owner, however, still wanted her pet to have a good quality of life for as long as reasonably possible. The ferret was a good candidate for acupuncture given that TCVM theory explained many of the clinical abnormalities. The owner’s most significant concern was the patient’s mobility and pain; therefore, the TCVM Patterns of Kidney Qi Deficiency and local Qi Stagnation were the focus of the initial TCVM visits. Aside from the deslorelin implant, the owner elected to discontinue all traditional medications. Improvements noted in the patient’s quality of life correlated with the acupuncture therapy received. Over a 2-month period and 5 acupuncture sessions, the patient’s mobility and urinary incontinence improved and complete resolution of the diarrhea occurred. At the conclusion of care for this patient, a recommendation for continuing TCVM was made with acupuncture treatments every 1-2 months along with disease monitoring with conventional diagnostics. This case is an excellent example of the medical benefits of acupuncture in an exotic companion mammal.

Free dental prosthetic treatment of patients with complicated medical history in Moscow region. Clinical case

Dental care is one of the socially important types of medical care and is highly demanded by the population. An important factor limiting the population’s possibilities for orthopedic rehabilitation is the financial situation of low-income and retired persons. The Government of the Moscow Region has approved more than 120 different measures of social support for residents of the Moscow Region. The social support program of making and repair dentures for Moscow region residents restores chewing efficiency and the budget of the Moscow region finances the performed treatment. The program includes main types of orthopedic constructions. Sometimes clinical cases may require more complex prosthetics due to concomitant pathology. For such cases some kinds of treatment so called ‘expensive’ exist in program. The article describes a clinical case of a patient with a stomatoneurological status who received orthopedic treatment using dental implants within the framework of free dental prosthetics.

Hyperbaric oxygen treatment for paracentral acute middle maculopathy: a case study

A 47-year-old active-duty Navy diver with a complicated past medical history which resulted in his designation as not physically qualified (NPQ) for diving duty in 2016 presented on 07 May 2021 complaining of left-sided blurred vision. On exam by the attending undersea medical officer he was found to have a left upper inner and upper outer quadrant visual field defect along with a central scotoma. Urgent referral to ophthalmology ruled out retinal detachment but resulted in an initial diagnosis of a left branch retinal artery occlusion without embolus. Considering this a variant of central retinal artery occlusion, hyperbaric oxygen (HBO2) therapy was initiated approximately 12 hours after symptom onset, resulting in complete, though temporary, resolution of the visual field defect. He reported that after completion of his first HBO2 treatment, his visual field deficit began to return, but the deficit again resolved after initiating surface oxygen therapy between HBO2 treatments. After two days of continuous surface oxygen and daily HBO2 treatments, which kept his visual field defect minimized, his deficits changed to a persistent left lateral peripheral defect and a recurrent central nasal defect. At this time, his periodic ophthalmology evaluation revised his diagnosis to cilioretinal artery occlusion (CrAO). Further evaluation by ophthalmology revealed retinal changes consistent with a secondary diagnosis of paracentral acute middle maculopathy (PAMM), an ophthalmologic condition only recently defined in the literature (2013) [10] secondary to advances in retinal imaging technology. This case is presented to share the findings of this complicated case and to postulate a benefit from the use of HBO2 for cilioretinal artery occlusion with PAMM.

QLTI-13. FEASIBILITY OF SAMEDAY DISCHARGE AFTER BRAIN TUMOR RESECTION: A PROSPECTIVE QUALITY INTERVENTION STUDY

Abstract INTRODUCTION Cranial neurosurgery confers psychological stress, as well as the stress of being in the hospital rather than in one’s preferred surroundings. Compared with inpatient admissions, same-day discharges reduce patient exposure to nosocomial infection, thromboembolic complications, and medical error. Also, it reduces costs to the health care system. OBJECTIVE To report the results of a pilot study that prospectively evaluated for the first time in a United States hospital, the outcomes of patients that underwent brain tumor surgery and are discharged home the same day as surgery. METHODS A quality intervention study including patients who underwent outpatient craniotomy for brain tumors by a single neurosurgeon (R.J.K) at the University of Miami from August 2020 to August 2021 was performed. Patients included were between 16 to 85 years old, with a Karnofsky Performance Status score of ≥ 70, and with supratentorial tumors with a maximum diameter of 4 cm. Complete demographic and clinical data were collected prospectively for each patient. In all patients, the minimum observation period was 6 h after surgery. RESULTS 37 of 334 patients met the inclusion criteria for the outpatient protocol. Thirty-two patients were discharged on the same day as surgery. Five patients (14%) were considered eligible for outpatient surgery but were ultimately admitted to the hospital postoperatively and were discharged after overnight observation. No postoperative complications were noted at two-week follow-up. CONCLUSION With appropriate selection and postoperative monitoring, same-day discharge can be considered a safe and feasible option for certain craniotomy cases. Establishing a multidisciplinary team of physicians, nurses, radiologists, and physical therapists is critical to achieving this aim. Physicians should have a low threshold to admit a patient with concerning exam findings, complications, or complicated past medical history

PSUN193 Comparing Long-Term Outcomes of Children Diagnosed with New-Onset Type 2 Diabetes in an Outpatient vs Inpatient Setting

Abstract Background Early identification and treatment of children and adolescents with Type 2 Diabetes (T2DM) is thought to improve long-term outcomes. However, it is unclear if severity of T2DM at presentation affects long-term clinical outcomes. Using the location of treatment initiation (inpatient compared to outpatient) as a proxy for severity of illness, we aimed to assess changes in dysglycemia and insulin requirements at diagnosis and after 3 years of follow-up. Methods We performed a retrospective chart review of children 8-18 years of age diagnosed with new onset type 2 diabetes and receiving diabetes care within a large tertiary care center between 1/1/2010 and 11/1/2021 for three consecutive years. Children were identified by ICD codes (ICD9 250.00, ICD10 E13.9 or E11.9). Charts were reviewed to confirm diagnosis. Exclusion criteria included medication induced diabetes, MODY, &amp;gt;1 positive diabetes autoantibody, BMI&amp;lt;85%, complicated medical history (genetic disorders, transplant, cancer, etc.), and &amp;lt; 3 visits in the study time frame. Chi-squared, t-tests, ANOVA, and linear regression were used for analyses. Results A total of 513 patients were identified by ICD code and, after exclusions, 116 were included in the analysis: 69 initially treated in an inpatient setting and 47 initially treated in an outpatient setting. The average A1C at presentation was higher in the inpatient group (11.02% ± 1.77) than the outpatient group (7.19% ± 0.72) (p&amp;lt;0.001). The BMI z-score at presentation was lower in the inpatient group (2.17%±0.58) than the outpatient group (2.41% ±0.35) (p=0.015), but at three years of follow-up the BMI z-score between the groups was not significantly different (2.05%±0.60) compared to (2.12% ±0.50) (p = 0.536). The average A1C remained higher in the inpatient group (9.58%±2.92) compared to the outpatient group (8.43% ±2.44) (p = 0.031). At treatment initiation the average total daily dose of insulin in the inpatient group (0.68±0.36 units/kg/day) was higher than the outpatient group (0.05±0.18 units/kg/day) (p&amp;lt;0.001). At three years of follow-up the average total daily dose of insulin remained higher in the inpatient group (0.50±0.46 units/kg/day) compared to the outpatient (0.29±0.36) (p=0.008 units/kg/day) group. Conclusion In conclusion, pediatric patients initially treated in the inpatient setting had poorer glycemic control and higher insulin requirements at baseline that persisted after three years of follow-up. These findings suggest that initial presentation may predict long-term clinical outcomes in children with T2DM. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

S3054 Interdisciplinary Management of a Complicated Pregnancy in a Patient With Cirrhosis

Introduction: We present a unique case of clotting disorder related cirrhosis leading to pregnancy complications. Case Description/Methods: A 29-year-old Caucasian female with a history of gastrointestinal bleeding, gastroesophageal reflux disease, epistaxis, and alcohol use disorder, goes for a routine gynecologic checkup when the physician notices a concerning enlargement of the caudate lobe on a computed tomography scan. Further evaluation reveals cirrhosis and Budd-Chiari syndrome. The patient starts enoxaparin and warfarin following this diagnosis. Eventually the patient is placed on the liver transplant list with a MELD (model of end-stage liver disease) score of 17 which improves to a score of 7 with sobriety. The patient attempts pregnancy and is unable to conceive. She is told she has early menopause at the age of 34. She undergoes reproductive endocrinology evaluation and achieves a successful in-vitro fertilization with a donor egg at age 36. This starts her high-risk pregnancy. The high-risk nature of this pregnancy revolves around the patient’s complicated past medical history of hemorrhagic stroke of unclear etiology, cirrhosis complicated by esophageal variceal bleeding, coagulopathy, Budd-Chiari syndrome, and thrombocytopenia. The patient has close variceal and hepatic vein thrombosis surveillance, labs, and routine checkup for vaginal bleeding with her increased risk of thrombosis during pregnancy. Endoscopy in the 1 st and 3rd trimesters shows small esophageal varices with no evidence of progression. Abdominal ultrasound displays vasa previa at approximately 28 weeks with velamentous umbilical cord insertion 2.3 cm from the internal os. After careful monitoring, the vasa previa is noted to resolve with umbilical cord insertion increasing to 4.8 cm from internal os in the following weeks. Repeated fetal echocardiograms present concern for the fetus being large for gestational age with estimated fetal weights ranging between the 95th-98th percentiles. The patient undergoes elective cesarean delivery and gives birth to a baby boy at 34 weeks with no labor complications. Discussion: We present a unique case of pregnancy during cirrhosis requiring management with multiple specialists. Although the physiologic changes in pregnancy are well understood, the way in which cirrhosis affects pregnancy and its outcomes are not yet well understood given paucity of published data. Certainly, there is complex interplay and physiology involved with increased potential for pregnancy complications.

Brain Protection in Patients with Aortic Dissection and Coronary Artery Disease

The aim. To compare the effectiveness of methods of protecting the brain and visceral organs during operations for aortic aneurysms combined with coronary artery lesions.&#x0D; Materials and methods. In the period from 2012 to 2020, 23 patients with Stanford type A and non-A non-B aortic dissection with damage to the coronary arteries were operated at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine using the brain protection techniques. Out of 23 surgical interventions, 16 were performed for Stanford type A acute aortic dissection, 3 for Stanford type A chronic aortic dissection, 1 for Stanford type A subacute aortic dissection, and 3 for Stanford non-A non-B aortic dissection. The main causes of aortic dissection were hypertension (16 patients), Marfan syndrome (3 patients), bicuspid aortic valve (4 patients).&#x0D; Results. The most threatening postoperative complication in this group of patients is neurological damage, which was observed in 4 (17%) patients after surgery, with gradual recovery of brain function. Also, the complications observed were respiratory failure in 3 (13%) patients, which required long-term artificial ventilation (more than 72 hours), and multiple organ failure in 1 (4.3%) patient, which caused a fatal outcome.Complications such as kidney and liver failure were not observed (most likely due to the small sample size). Heart failure was not noted as well. Hospital mortality was 4.3% (1 fatal case). In our study, among the entire group of operated patients, symptoms of neurological damage occurred in 4 (17.4%) patients, hemorrhagic stroke was present in 1 (4.3%) patient with a complicated medical history, 2 (8.6%) patients had hemiparesis and in 1 case (4.3%) there were cognitive disorders.&#x0D; Conclusions. Comparing brain protection techniques, taking into account the prolongation of aortic clamping time due to coronary artery shunting compared to isolated aortic dissection, it can be concluded that longer duration of selective brain perfusion (retrograde or antegrade) or duration of circulatory arrest more often lead to postoperative complications, namely neurological lesions.&#x0D; On the other hand, the small number of observations does not make it possible to fully assess the impact of each of the techniques. Further follow-up with a larger sample will provide opportunities for a more complete evaluation of brain protection techniques in operations for dissecting aortic aneurysms and coronary artery lesions.

Hyperaldosteronism and Renal Artery Stenosis in a Post-Abdominal Aortic Aneurysm Patient: A Case Report.

IntroductionPatients with history of abdominal aortic aneurysm (AAA) undergoing surgical repair can have a myriad of surgical complications including compromise to large arteries branching from the aorta. Secondary hyperaldosteronism, characterized by high levels of aldosterone and renin, can be due to a multitude of causes, including renal artery stenosis, and presents with nonspecific symptoms of fatigue, increased thirst, and muscle spasms. While it can initially be difficult to diagnose given its multitude of metabolic abnormalities, secondary hyperaldosteronism is important to consider in patients presenting with uncontrolled hypertension, hypokalemia, and metabolic alkalosis.Case ReportThis report explores the case of a 65-year-old male with a complicated medical history presenting to the emergency department with hypokalemia and hypertension six months after undergoing endovascular repair for an AAA and was found to have metabolic abnormalities including hypokalemia and metabolic alkalosis consistent with secondary hyperaldosteronism, likely secondary to renal artery stent stenosis. He was admitted to the hospital for four days and made a full recovery.ConclusionThis case highlights the need to understand, identify, and accurately diagnose hyperaldosteronism and recognize post-AAA repair complications of renal artery stenosis as a cause of this metabolic derangement.

Unusual Ulcer Bleeding in the Stomach

Emergency upper gastrointestinal endoscopy in a 45 years old man with a complicated medical history obtained a small ulcer in the gastric corpus bedded in a round impression of 4 cm in diameter and no active bleeding during investigation. We decided to perform an immediate angio-CT-examination of thorax and abdomen. Gastric ulcer and impression were induced by a partially thrombosed aneurysm of the splenic artery. Emergency angiography with percutaneous transluminal implantation of a covered stent into the splenic artery completely bridged the aneurysm. The patient resolved and left the hospital after 12 days. Literature review shows that currently an immediate switch from endoscopy to vascular surgery is the best option in such cases. Emergency endoscopists have to identify the so called herald lesion as what it is and to initiate further diagnostic steps at once, since the second bleeding is mostly fatal. This may increase the prognosis significantly to 20-90 % survival. Unfortunately, in a current survey 50 % of gastroenterologists felt themselves not good informed about this fact and would probably not have done the correct decisions.

Is Hemodialysis So Efficient in Removing Phosphate?

A 16-year-old girl with a complicated medical history including cystic fibrosis, double lung transplant, and end-stage renal disease presented for intermittent hemodialysis 3 times a week. The patient was on a low-phosphorus diet and prescribed the phosphate binder sevelamer carbonate (Renvela) to address hyperphosphatemia. On January 5, 2022, there was a large increase in her pre-dialysis phosphorus concentration, which showed linearity on serial dilution (Table 1). The Kidney Disease Improving Global Outcomes 2017 guideline recommends that treatment of chronic kidney disease-mineral and bone disorder should emphasize maintaining serum calcium while lowering circulating phosphate (1). Phosphate is removed less efficiently than urea and creatinine by hemodialysis because the mobilization of intracellular phosphate is slower (2, 3). Common causes of pseudohyperphosphatemia include hemolysis, lipemia, phosphate-containing heparinized saline contamination, and interference from liposomal amphotericin B or paraproteins (4). This patient had falsely increased phosphorus due to contamination from phosphate-containing tobramycin/alteplase catheter lock solution (5).

Acquired Methemoglobinemia in a Ketamine-induced Ulcerative Cystitis Patient: A Case Report.

IntroductionAs ketamine gains traction as an alternative to opiates in the treatment of chronic pain, ketamine-induced ulcerative cystitis is now being recognized as a complication of its use. The first-line treatment is phenazopyridine, an over-the-counter medication for dysuria that historically has been known to cause methemoglobinemia. This report details the case of a patient presenting to the emergency department (ED) with methemoglobinemia.Case ReportA 66-year-old woman with a complicated medical history presented to the ED with anemia and hypoxia after extended use of phenazopyridine for treatment of ketamine-induced ulcerative cystitis. She was found to have methemoglobinemia secondary to phenazopyridine used to treat her ketamine-induced ulcerative cystitis, a previously undocumented sequelae of chronic ketamine use. She was admitted to the hospital for three days and made a full recovery.ConclusionThis case highlights the need to suspect ketamine-induced ulcerative cystitis in patients who use ketamine chronically and be judicious in the use of phenazopyridine for symptom management to prevent life-threatening complications.

Same-day discharge after brain tumor resection: a prospective pilot study.

PurposeOutpatient brain surgery has many advantages for the psychological and physical wellbeing of patients, as well as reduced costs to the health care system. Compared with inpatient admissions, same day discharges reduce patient exposure to nosocomial infection, thromboembolic complications, and medical error. We aim to establish a prospectively collected quality outcomes database to examine the outcomes of patients that undergo brain tumor resection and are discharged home the same day as surgery.MethodsWe have established a prospectively collected quality outcomes database to examine the outcomes of all patients that underwent brain tumor resection by a single neurosurgeon (R.J.K) at our institution from August 2020 to August 2021 and were discharged home the same day as surgery.ResultsOver the one-year period this study was conducted, 37 of 334 patients met inclusion criteria for the outpatient protocol. Thirty-two patients were discharged on the same day as surgery. Five patients (14%) were considered eligible for outpatient surgery but were ultimately admitted to the hospital postoperatively and were discharged after an overnight observation. No postoperative complications were noted at two-week postoperative follow-up.ConclusionIn select patients undergoing brain tumor surgery, same day discharge should be considered. Establishing a multidisciplinary team of physicians, nurses, radiologists, and physical therapists is critical to achieving this aim. Physicians should have a low threshold to admit a patient with concerning exam findings, complications, or complicated past medical history. Once discharged, open communication with the patient and their family is critical to detect complications that should trigger rehospitalization and intervention.

Возможности протонной терапии при повторном облучении диффузной опухоли ствола мозга у детей

Currently, there is no cure for pediatric diffuse brain stem (BS) tumors. Radiotherapy, including proton therapy, is an important component of combination treatment for this cancer, especially in children with a complicated medical history. The article addresses the issues of therapy for pediatric BS tumors and reports the use of proton re-irradiation in a 9-year-old boy with unverified diffuse BS tumor. Proton re-irradiation is an effective treatment option that can sustain and improve the quality of life and prolong survival in children with diffuse BS tumors.