Episodes Of Vomiting Research Articles

812. INTRAOPERATIVE USE OF IMPEDANCE PLANIMETRY FOR RECURRENT ACHALASIA AFTER HELLER-NISSEN

Abstract Background Re-operations after Heller myotomy for esophageal achalasia is a challenging operation due to the fibrotic tissue surrounding the esophago-gastric junction (EGJ). The risk of both undertreatment or, on the other hand, esophageal perforation is significant. The impedance planimetry could guide the operation and assess whether the patients needs further dissection of adhesions, an extension of the previous myotomy and anti-reflux treatment. Methods A 70-year-old woman treated with Heller-Nissen in 1983 for type II achalasia was referred to our tertiary care center with absolute dysphagia for three days. In the past 41 years she reported occasional and self-limited episodes of dysphagia, regurgitation and chest pain. Aside from that, her medical history was unremarkable. An esophagogastroduodenoscopy (EGD) with airway protection was performed, showing retained solid food. A water-soluble swallow study showed a tortuous megaesophagus and a misaligned esophageal gastric junction (EGJ), which did not allow endoscopic dilation. Esophageal wall thickening and focal lesions were ruled out by a CT scan. Results A laparoscopy with impedance planimetry technology support was scheduled. The first EGJ distensibility index (EGJ-DI) measurement was 2.1 mm2/mmHg. Esophagus was freed, encircled and released from the hiatus. An EGD confirmed the reposition of the cardia in the abdomen and the previous anterior esophageal myotomy. The Nissen fundoplication was not detectable. At this stage, an EGJ-DI of 4,2 mm2/mmHg was found. To obtain a regular esophageal outflow an anterior myotomy of the EGJ and proximal stomach was carried out and the edge was everted with absorbable barbed suture. A posterior cruroplasty was then performed. The final EGJ-DI was 8,8 mm2/mmHg. Conclusion The postoperative course was uneventful and she was discharged on post-operative day 4 eating a soft diet. In conclusion, the intraoperative use of the impedance planimetry technology has been crucial for a correct decision-making process during complex redo operations for esophageal achalasia as it has helped to tailor the surgical treatment. https://www.dropbox.com/scl/fi/pednopcqnalooidynge3q/ISDE-Definitivo.mov?rlkey=8exx0oe6ompxoex8wqmlsgi0i&st=xgnfnjyt&dl=0

Isolated pulmonary valve endocarditis in a pediatric patient with down syndrome

BackgroundIsolated pulmonary valve endocarditis (IPE) accounts for less than 2% of all infective endocarditis patients. It is commonly associated with several predisposing factors, including intravenous drug use (IVDU) and congenital heart disease. The most common causative pathogens of IPE are Staphylococcus aureus and Streptococcus viridans. We report a Down’s syndrome patient with IPE and with no standard risk factors caused by the rare pathogen Acinetobacter spp. This led to respiratory failure and systemic infection due to septic pulmonary emboli. Early elective surgery was decided upon as the patient was no longer responding to medical therapy, and his clinical condition was worsening over time.Case presentationA 15-year-old male with Down syndrome and no underlying heart defect presented with a 3-month history of episodic fever, nausea, vomiting, and diarrhea. Transthoracic echocardiography (TTE) revealed large vegetation on the pulmonary valve leaflet, another mobile mass at the pulmonary artery bifurcation, and severe pulmonary regurgitation. Serial blood cultures isolated Acinetobacter spp. Despite initial antibiotic therapy, the patient continued to have sepsis, unresolved vegetations, and developed life-threatening complications and respiratory distress, which convinced us to perform a pulmonary valve replacement surgery with a homograft. After surgery, the patient recovered and was discharged on the ninth postoperative day (POD).ConclusionThis report highlights IPE’s diagnostic and therapeutic challenges, alongside the importance of a comprehensive cardiopulmonary workup in patients with unexplained fever, sepsis, and pulmonary symptoms, even without typical risk factors. Based on the patient’s aggravating condition despite medical treatment, early surgical intervention and pulmonary valve replacement were deemed crucial. However, there still needs to be a definitive guideline on when and how surgery should be performed in patients with complicated IPE, especially in pediatric patients.

Cannabis use patterns and association with hyperemesis: A comprehensive review.

Cannabis use in the general population is prevalent and is rising because of increased acceptance of its use, legalization in most US states, and perceived health benefits. Cannabis product potency has dramatically increased with higher delta-9-tetrahydrocannabinol content. Cannabis has documented antiemetic properties and cannabinoid pharmaceuticals are used in disorders like chemotherapy-induced nausea and vomiting. Forty to eighty percent of cyclic vomiting syndrome (CVS) patients use cannabis products, which reportedly reduce stress as well as nausea and vomiting. Cannabinoid hyperemesis syndrome (CHS) has a presentation similar to CVS, but is associated with longstanding, high dose cannabis use, and is thought to be relieved by sustained cannabis abstinence. Most CHS patients have used cannabis on a daily or near-daily basis for more than 2 years. Compulsive hot-water bathing behaviors are reported by most CHS patients, but are not specific for this disorder as they are also noted by about half of CVS patients. Episodic vomiting associated with cannabis use contributes to extensive health resource use, including emergency department visits and inpatient hospitalizations, and impacts patients and their families negatively. Treatment for CHS overlaps with CVS although cannabis abstinence remains the cornerstone of its management. Challenges associated with cannabis use cessation in CHS include patient skepticism of the role of cannabis as a cause of symptoms, perceived benefits of cannabis, and a lack of other effective therapies. In this review, we highlight cannabis use patterns in the US and discuss diagnosis and management of CHS and gaps in knowledge about this disorder.

The use of intranasal sufentanil and/or s-ketamine for treatment of procedural pain in children in an ambulatory setting: A retrospective observational study.

Minor but painful medical procedures are often handled at the operating room. If safe and effective treatment options are available many procedures may be performed outside of the operating room. The objective of this study is to assess the adverse events of intranasal s-ketamine and/or sufentanil alone or as part of a multimodal analgesic regime for medical procedures outside of the operating room. Secondary outcomes included analgesic effect, doses and indications for use. Retrospective observational study. Tertiary care paediatric hospital. Children 1 year up till 18 years. Intranasal (IN) sufentanil (S), intranasal s-ketamine (K) or the free combination of the two drugs (SK). The frequency of adverse events including serious adverse events reported by intervention. Between 2004 and 2014, 2185 medical procedures were registered, including 652 procedures with IN SK, 1469 procedures with IN S and 64 procedures with IN K. The children's median age was 5.6 years (range 1.0-17.9). Medical procedures with at least one adverse event were 18% with IN SK, 25% with IN K and 18% with IN S. Common adverse events included episodes of vomiting (9%), nausea (8%) and dizziness (3%). In two patients receiving IN S, serious adverse events occurred. One patient had respiratory depression and bronchospasm and another patient with cerebral palsy had a seizure. Both were handled immediately and did not result in any sequelae. The median doses of intranasal sufentanil were 38% lower when combined with s-ketamine (IN SK free combination: sufentanil dose 0.5 μg/kg (range 0.2-1.3) and s-ketamine dose 0.5 mg/kg (range 0.2-1.5). IN S monotherapy, sufentanil dose 0.8 μg/kg (range 0.2-2.7)). Similar analgesic effect was reported for S and SK. Intranasal sufentanil and/or s-ketamine are feasible for the treatment of procedural pain in an ambulatory setting with appropriate per- and post-procedural observations and trained staff.

Neuraxial Analgesia for Scoliosis Correction: A Case Series in a Specialised Children's Centre.

Surgical correction of spinal deformities in children presents a challenge to the anaesthetist due to the extensive nature of the surgery, the co-morbidities of the patients and the constraints on aesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Patients undergoing scoliosis surgery are considered to suffer severe pain, which may lead to a negative impact on patient psychology and physical well-being. By using effective postoperative pain regimens to enhance recovery after surgery, pain can be significantly reduced, leading to patient satisfaction, facilitating early mobilisation, promoting oral intake, lowering postoperative pain and shortening the length of hospital stay. Thus, the primary objectives of this study were to assess the postoperative pain management andfirst rescue analgesic medications, by using preservative-free morphine 50 mcg/kg and dexmedetomidine 4 mcg along with normal saline 0.5 ml kg caudally, as well as to look for thesecondary objectivesside effects, including respiratory depression, nausea, vomiting and pruritis, timing of postoperative ambulation and length of hospital stay. Methods: In this study, we retrospectively included children under 14 years of age and above three years who underwent scoliosis surgery under a caudal epidural-general anaesthesia using caudal morphine and the dexmedetomidine technique in the period from January to May 2023 at the National Guard Health Affairs Hospital (NGHA), Riyadh. We collected the data of seven cases using the electronic chart system of the Best Care database to extract the specific cases that meet the inclusion criteria for the study, which are idiopathic scoliosis patients, aged 3-14 years, and primary correction procedures. Results: The pain-free duration was between seven hours and 48 hours (about two days). There were four female cases (57.14%), and three cases were male (42.85%). The patients' American Society of Anesthesiologists (ASA) status were II to III. In all the cases, there was no documentation of any episodes of postoperative nausea and vomiting (PONV), respiratory distress or pruritus, except for one case where the patient had an episode of PONV. Conclusion: In this study, our aim was to present our experience with dexmedetomidine as an efficient medication when coadministered with morphine to be used in the operating room. We found a high level of reliability in prolonging analgesia time and delaying the usage of rescue medication. We encourage more studies on caudal dexmedetomidine for patients undergoing scoliosis surgery.

P6 acupressure versus sham acupressure for prevention of intraoperative nausea and vomiting during cesarean delivery under neuraxial anesthesia: a randomized controlled trial

IntroductionIntraoperative and postoperative nausea and vomiting (IONV and PONV) are common during cesarean delivery (CD) with neuraxial anesthesia. Limited information exists on the antiemetic benefit of combined P6 acupoint stimulation with acupressure (P6 acupressure) and pharmacologic antiemetics on preventing IONV and PONV after CD. This study assessed the antiemetic efficacy of P6 acupressure compared to a non-P6 acupoint stimulation with acupressure (sham acupressure) in preventing IONV during CD. MethodsWe performed a randomized double-blinded trial comparing the efficacy of intraprocedural P6 acupressure versus sham acupressure in preventing IONV during CD after following the Society for Obstetric Anesthesia and Perinatology enhanced recovery recommendations. Subjects were instructed to apply additional pressure at the acupressure sites when they perceived nausea. The primary outcome was the incidence of IONV, and the secondary outcome was the need for rescue antiemetic treatment. ResultsNinety-nine P6 acupressure and 100 sham acupressure subjects were studied. There was no difference in the incidence of intraoperative nausea (67%), vomiting (17%), emesis episodes, or the need for rescue antiemetics intraoperatively. There were also no differences in the incidence of PONV and antiemetic treatment from PACU to discharge. At discharge, 70% of respondents reported experiencing nausea, but only 10% reported it affected self-care. Approximately 50% of the patients in both groups were satisfied with acupressure therapy. ConclusionP6 acupressure did not reduce the incidence of IONV or PONV when combined with antiemetic therapy per enhanced recovery recommendations. There does not appear to be sufficient evidence to support using P6 acupressure for IONV prevention.

Oesophageal squamous cell carcinoma in a blue‐fronted Amazon parrot (Amazona aestiva)

AbstractA 14‐year‐old, female, blue‐fronted Amazon parrot was referred for episodes of regurgitation. The differential diagnosis mainly included bornavirus infection, infectious or traumatic ingluvitis, gastro‐oesophageal reflux, gastritis/enteritis, heavy metal poisoning, metabolic disease (severe hepatic or renal disease), coelomitis, digestive neoplasia, extra‐digestive masses, organomegaly or foreign body. No improvement was noted with symptomatic treatment. Radiographs, avian bornavirus polymerase chain reaction and serology, biochemistry, haematology, crop cytology and ultrasonography failed to provide a definitive diagnosis. Lethargy, weight loss and crop stasis after 1 month motivated computed tomography, which revealed focal thickening of the oesophageal wall. Fine‐needle aspiration under computed tomography guidance of the mass was non‐diagnostic, and the bird died during recovery from anaesthesia. Oesophageal squamous cell carcinoma was confirmed by histopathology. This case illustrates the benefit of advanced diagnostic imaging to investigate chronic refractory regurgitations and describes the use of computed tomography‐guided fine‐needle aspiration in an avian patient.

The Effects of Dexmedetomidine on Pain-Related Outcomes in Craniotomy: A Systematic Review and Meta-Analysis

BackgroundCraniotomy is associated with several undesirable effects including postoperative pain. This systematic review and meta-analysis aimed to evaluate evidence on the efficacy and safety of dexmedetomidine (DEX) for pain management in patients undergoing craniotomy. MethodsWe followed PRISMA guidelines. The protocol was registered in Open Science Framework. We searched for existing randomized controlled studies (RCTs) published before June 2023 that used dexmedetomidine during the perioperative period in craniotomy in PubMed, Scopus, and the Cochrane Library. A meta-analysis was conducted in RevMan. Cochrane RoB2 and GRADE were used for quality assessment. ResultsA total of 19 RCTs comprising 3,153 patients were included. Pain intensity was lower in the DEX group than the control group at a mean difference (MD) [95% confidence interval (CI)] of –0.64 [–1.16, –0.13], p-value=0.01. The DEX group overall consumed less opioids in comparison with the control group at an MD=–4.00 [–6.16, –1.83], p-value=0.0003. However, heterogeneity was considerable for both outcomes (I2=81% and I2=96%, respectively). There was no difference between the DEX and control groups in the time to first post-analgesic requirement, hypertension, hypotension, or cough. ConclusionsThe results showed that the use of dexmedetomidine was associated with lower pain intensity and less opioid use. Patients in the DEX group experienced fewer episodes of nausea and vomiting, agitation, and shivering but more episodes of bradycardia. There was no difference between DEX and control groups in other adverse events.

A Systematic Review of Banded vs. Non-Banded Sleeve Gastrectomy Regarding Long Term Results

Abstract Background Laparoscopic Non-Banded Sleeve Gastrectomy (NBSG) is a widely popular weight loss procedure that has been around since the start of the millennium. Another variant, the Laparoscopic Banded Sleeve Gastrectomy (LBSG) started to emerge later. Questions have arisen on whether NBSG or BSG have better outcomes on the long run regarding weight loss, weight regain and reflux disease. This study aims to analyse previous studies performed on this subject and devise a conclusion regarding this matter. Obesity is a worldwide health issue with an unfortunate impact on an individual‘s quality of life. As of 2016, 39% of the world population suffered from obesity. Bariatric surgery is currently considered to be an effective and sustainable solution with increasing worldwide prevalence. Laparoscopic sleeve gastrectomy was first performed as the first step in biliopancreatic diversion with duodenal switch. Objective To scrutinize all English language papers written on the subject of comparing NBSG and LBSG as primary bariatric procedures and furthermore seeks to determine the superior surgery between them regarding weight loss, post-operative morbidity and complications like regurgitation, vomiting, reflux, dysphagia, and finally resolution of comorbidities like T2DM and HTN. Methodology This systematic review was carried out according to the updated PRISMA 2020 statement. A thorough search was executed in the Medline (PubMed) database, Elsevier‘s Scopus, Web of Science and the Cochrane Library in December 2022. Search was restricted to articles written in English. Search terms will be broad to encompass Banded Sleeve procedures. Results Our review revealed that the existing literature suggests increased weight loss following LBSG compared to NBSG; however, there‘s an increased risk of regular regurgitation episodes and of device related complications leading to revision surgeries (such as band removal). Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2023. Conclusion Laparoscopic banded sleeve gastrectomy provides apparent better outcomes than non- banded sleeve gastrectomy regarding sustainable weight loss results through 3-5 years of follow up as the studies we reviewed had demonstrated. Nonetheless, it poses a definite increase in the risk of regurgitation, vomiting and ring related complications that might require revision surgeries. More RCTs with longer follow up periods (>5 years) will significantly add to our understanding of the matter. Larger LBSG sample sizes are needed to further enhance our impression on efficacy and safety of the banded sleeve gastrectomy. Finally, larger T2DM and HTN patients‘ sample size is needed to form a conclusion on the relationship between banding and the resolution of these diseases.

Diagnostic Outcome of Rome IV Criteria in Infant Regurgitation

Abstract Background Infant regurgitation is the most prevalent functional gastrointestinal disorder (FGID) occurring in the first year of life. In 2016 Rome IV criteria was launched with criteria for diagnosis of infantile FGIDs including regurgitation. Objectives The aim of this study is to follow up cases of infant regurgitation diagnosed by applying Rome IV criteria among neonates and toddlers and reevaluate them to uncover any organic causes among them. Methods A prospective cohort study was conducted at the general outpatients’clinic, Children’s Hospital, Ain-Shams University included 280 cases fulfillingRome IV criteria with 3 months for recruitment of patients followed by 3 months follow of each case. Full history and clinical examination were performed with special focus on anthropometric measurements. Results from 280 cases 42.9% totally cured (stopped regurgitation), 49.6% partially improved (decreased number of regurgitation episodes per day) and 7.5% didn’t improve (still have the same number of regurgitations per day) with proper weight gain. However, only 3 cases showed failure to thrive which is not related to regurgitation. Conclusion None of our cases diagnosed as infant regurgitation by Rome IVcriteria developed any organic diseases during period of follow up indicating the accuracy of Rome IV criteria in excluding organic diseases.

Comparative Efficacy of Intermittent Bolus Doses of Phenylephrine and Norepinephrine in Preventing Maternal Bradycardia during Cesarean Section under Spinal Anesthesia: A Randomized Controlled Trial

Background and Aims: Maternal hypotension is a common concern during cesarean sections (CS) with spinal anesthesia and can have adverse consequences for both the mother and fetus. This study aimed to investigate the prophylactic effectiveness of intermittent boluses of phenylephrine and norepinephrine in preventing maternal bradycardia during maintenance of systolic blood pressure (SBP) within 90–100% of baseline. Material and Methods: Two hundred American Society of Anesthesiologists physical status -II parturients scheduled for CS with subarachnoid block (SAB) were randomly assigned to Group A (phenylephrine, 50 µg) or Group B (norepinephrine, 4 µg). The primary goal was to assess the incidence of maternal bradycardia (≤50 bpm) whilst SBP maintenance at 90-100% of baseline. The secondary objectives encompassed total boluses administered, episodes of hypertension (≥120% of baseline), Intraoperative nausea and vomiting (IONV), and neonatal APGAR scores. The time from intrathecal injection to fetal delivery (induction–delivery interval) was also evaluated. Results: Both norepinephrine and phenylephrine groups effectively prevented spinal-induced hypotension, with similar outcomes However, Group A (phenylephrine) experienced a significantly higher incidence of bradycardia (18%) compared to Group B (norepinephrine) with only 5% (P=0.016). Episodes of hypertension, IONV, and neonatal APGAR scores were comparable between the two groups. Conclusion: Intermittent boluses of norepinephrine and phenylephrine demonstrated equivalent efficacy in preventing spinal-induced hypotension during CS. However, norepinephrine exhibited an advantage over phenylephrine by significantly reducing the incidence of bradycardia. These findings support the consideration of norepinephrine as an effective alternative vasopressor for maintaining maternal hemodynamics during CS under SAB.

Novaluron and indoxacarb induced methemoglobinemia – unveiling a rare poisoning

Introduction and aim. In India, the utilization of agricultural pesticides for intentional self-poisoning is a prevalent method, and it is associated with substantially higher fatality rates compared to other self-poisoning approaches. Plethora, an agricultural insecticide containing novaluron (5.25%) and indoxacarb (4.5%), has recently been introduced and widely used in India and various other regions for its broad-spectrum lepidopteran control. While there have been documented cases of isolated self-poisoning involving indoxacarb, there is currently no literature reporting incidents of human poisoning specifically related to novaluron. Description of the case. An 83-Year-old male was presented to the emergency department (ED) with a history of consumption of 50 mL of an insecticide suspension concentrate called ‘PLETHORA’ to commit suicide. He had one episode of vomiting and dizziness after the ingestion. There was associated cyanosis, and the patient was put on high-flow oxygen at 10 L/min through a face mask. The patient was diagnosed to have methemoglobinemia and was successfully treated with methylene blue and ascorbic acid. One hour post methylene blue injection showed a methemoglobin level of 1%, and the patient gradually improved. Patients presenting with novaluron and indoxacarb poisoning require supportive treatment as there is no specific antidote. There should be a high index of suspicion for methemoglobinemia in such patients, and timely management is necessary to prevent further complications. The patient was successfully managed and discharged after the 3rd day of admission. Conclusion. The management of patients with novaluron and indoxacarb poisoning primarily involves supportive care, as there is currently no specific antidote available for these substances. Maintaining a high suspicion index for the development of methemoglobinemia and timely management of other complications is crucial for the best possible patient outcomes.

Development of a Digital Patient Assistant for the Management of Cyclic Vomiting Syndrome: Patient-Centric Design Study.

Cyclic vomiting syndrome (CVS) is an enigmatic and debilitating disorder of gut-brain interaction that is characterized by recurrent episodes of severe vomiting and nausea. It significantly impairs patients' quality of life and can lead to frequent medical visits and substantial health care costs. The diagnosis for CVS is often protracted and complex, primarily due to its exclusionary diagnosis nature and the lack of specific biomarkers. This typically leads to a considerable delay in accurate diagnosis, contributing to increased patient morbidity. Additionally, the absence of approved therapies for CVS worsens patient hardship and reflects the urgent need for innovative, patient-centric solutions to improve CVS management. We aim to develop a digital patient assistant (DPA) for patients with CVS to address their unique needs, and iteratively enhance the technical features and user experience on the initial DPA versions. The development of the DPA for CVS used a design thinking approach, prioritizing user needs. A literature review and Patient Advisory Board shaped the initial prototype, focusing on diagnostic support and symptom tracking. Iterative development, informed by the design thinking approach and feedback from patients with CVS and caregivers through interviews and smartphone testing, led to significant enhancements in user interaction and artificial intelligence integration. The final DPA's effectiveness was validated using the System Usability Scale and feedback questions, ensuring it met the specific needs of the CVS community. The DPA developed for CVS integrates an introductory bot, daily and weekly check-in bots, and a knowledge hub, all accessible via a patient dashboard. This multicomponent solution effectively addresses key unmet needs in CVS management: efficient symptom and impacts tracking, access to comprehensive disease information, and a digital health platform for disease management. Significant improvements, based on user feedback, include the implementation of artificial intelligence features like intent recognition and data syncing, enhancing the bot interaction and reducing the burden on patients. The inclusion of the knowledge hub provides educational resources, contributing to better disease understanding and management. The DPA achieved a System Usability Scale score of 80 out of 100, indicating high ease of use and relevance. Patient feedback highlighted the DPA's potential in disease management and suggested further applications, such as integration into health care provider recommendations for patients with suspected or confirmed CVS. This positive response underscores the DPA's role in enhancing patient engagement and disease management through a patient-centered digital solution. The development of this DPA for patients with CVS, via an iterative design thinking approach, offers a patient-centric solution for disease management. The DPA development framework may also serve to guide future patient digital support and research scenarios.

Severe amlodipine toxicity: A medical dilemma managed with therapeutic plasma exchange

Amlodipine poisoning is a nightmare for treating clinicians because of the intractable hypotension and bradycardia induced by the drug, which requires a balanced treatment algorithm. We encountered a case of severe Amlodipine toxicity (450 mg) who presented with complaints of nausea, multiple episodes of vomiting, and chest discomfort. On arrival at the EMD, the patient had significant hypotension (80/46 mmHg), bradycardia (40 beats/min), and a fall in oxygen saturation (75 %). He was symptomatically managed with inotropes, IV calcium, IV fluids, and oxygen supplementation. We decided to go forward with Therapeutic Plasma Exchange (TPE) in an attempt to remove the inciting agent. Two sessions of TPE were performed and the patient showed significant improvement post-procedure which led to the discharge of the patient within 10 days of admission. This case report highlights the noteworthiness of TPE in treating significantly high doses of drug poisoning.

Randomized Placebo-Controlled Trial of Topical Capsaicin for Delayed Chemotherapy-Induced Nausea and Vomiting.

We examined the efficacy of topical capsaicin in reducing delayed chemotherapy-induced nausea and vomiting (CINV). Adults on highly emetogenic chemotherapy regimens applied 2 g of capsaicin ointment (0.075%) or matching placebo four times a day to the abdomen for 5 days in addition to standard antiemetic regimen in this blinded randomized controlled trial. Patients were monitored for nausea and vomiting in the immediate (day 1), delayed (days 2-5), and extended phases (days 2-15). Self-reported incidence and daily episodes of CINV were compared between the groups. Onset, severity, need for rescue antiemetics, cumulative vomiting episodes, and safety were also compared. In total, 160 patients were enrolled. The final modified intention-to-treat population included 75 patients each in the capsaicin and placebo groups. Fewer patients experienced nausea (36.0% [n = 27] v 53.3% [n = 40]; P = .033) and vomiting (28.0% [n = 21] v 42.7% [n = 32]; P = .060) in the capsaicin arm during the delayed phase. During the extended phase, there was a significantly lower incidence of nausea (44% v 64.0%; P = .014) in the capsaicin arm. No difference in nausea (26.7% v 25.3%) or vomiting (22.7% v 18.7%) was evident in the immediate phase. The average daily episodes of nausea and vomiting were significantly fewer in the capsaicin arm during the delayed and extended phases. With capsaicin, no grade 3 nausea (9.3% v 0.0%; P = .007) was observed, and the time to first nausea and vomiting was significantly prolonged. There were no differences between the groups with respect to rescue antiemetics, unscheduled hospital visits, and adverse events. Topical capsaicin reduced the incidence of nausea and the average number of vomiting episodes during delayed and extended phases without increasing adverse effects.

Secondary Adrenal Insufficiency : A Case Report

Introduction: Insufficient pituitary hormone output is referred to as hypopituitarism. Individuals experiencing lethargy, dizziness, orthostatic hypotension, hypoglycemia, nausea, vomiting, or generalized abdominal pain may be diagnosed with acute adrenocorticotropic hormone (ACTH) insufficiency. This report detailed a unique instance of hypopituitarism in a patient who complained of nausea, vomiting, hypotension, hypoglycemia, and overall abdominal pain and soreness. Case presentation: A 65-year-old male presented to the outpatient department with complaints of a cough of 1-day duration on August 9/03/21 associated with 4 to 5 episodes of vomiting and pain in the abdomen, in addition to that whole body darkening, fatigue, and appetite loss of 6 months. weight loss intermittent sweating, and eyebrow and axillary hair loss. SOB with mild activity and also bilateral breast pain but no mass. Discussion: The diagnosis of hypothyroidism and inexplicable fatigue made us believe that there was an adrenal deficiency, which might be treated with cortisol around eight o’clock. Even though the patient with a high stress level the cortisol was immeasurable; so the diagnosis, of adrenal insufficiency, could be made. Other tests including ACTH and Imaging are usually needed to discover the subtype of insufficiency. The follow-up after 1 month showed no signs or symptoms left and a much better condition. Conclusion: When treating individuals who have fatigue that cannot be attributed to anything else, especially when weight loss and muscle weakness are present, adrenal insufficiency should be taken into consideration. A secondary adrenal insufficiency may exist even in the absence of skin pigmentation, which frequently triggers anxieties and ideas about Addison’s disease. If it is not identified promptly, it may potentially result in an adrenal crisis in situations with high-stress levels. Our patient presented with vague and largely mild symptoms related to early secondary adrenal insufficiency. These included nausea and vomiting, as well as fatigue. Laboratory studies indicated new hyponatremia and urine studies showed inappropriately normal urine sodium and osmolality. His morning serum cortisol was low, with borderline low ACTH, consistent with a secondary cause.

Case Report: Surgical management of petrous face meningioma

Petrous face meningioma presents a significant difficulty in neurosurgery because of its complex anatomical position near cranial nerves, brainstem, and important blood vessels. This case report describes the clinical course and successful surgical treatment of a 50-year-old female patient who had a two-month history of ataxia, along with a one-week episode of severe headache and vomiting. An MRI verified the existence of a petrous face meningioma after a thorough diagnostic assessment. Following that, the patient had a left retro-sigmoid craniotomy, which led to the complete excision of the tumour and relief of symptoms. A thorough one-month follow-up examination showed no recurring symptoms, suggesting a positive result and successful clearance of the meningioma. This case highlights the need of timely diagnosis and surgical treatment in dealing with petrous face meningioma, focusing on attaining complete tumour excision. This case demonstrates the success of complete removal of a tumour and the possibility of full return of neurological function in individuals with similar symptoms. This article enhances the current literature by offering insights into the management of petrous face meningioma and recommending a thorough surgical strategy to improve patient outcomes.

Outcome of antiemetic prophylaxis among pediatric cancer patients receiving moderate to highly emetogenic chemotherapy at pediatric hemato-oncology ward of Tikur Anbessa specialized hospital: A prospective observational study.

Chemotherapy-induced nausea and vomiting (CINV) is a major issue for chemotherapy pediatric patients, especially in developing countries due to limited access to essential antiemetics. This study aimed to assess antiemetic prophylaxis outcomes in pediatric cancer patients at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia. A longitudinal prospective observational study design was conducted among 201 pediatric cancer patients followed up to 120 h post-chemotherapy. The majority of patients (75.1%) received combination prophylactic antiemetics in the acute phase. Complete response (CR) was the highest in the acute phase (71.1%). Emesis episodes occurred most frequently on the first day of treatment (28.4%) and gradually decreased over time. History of motion sickness, platinum-based chemotherapy, and prior chemotherapy-induced vomiting (CIV) were associated with emesis during the acute phase whereas multiple-day chemotherapy, prior CIV, receipt of antiemetics, and a history of motion sickness in the delayed phase. However, the odds of CIV were reduced with steroid presence in the chemotherapy regimen. A considerable number of participants could not achieve a CR. It is important for clinicians to be cognizant of risk factors that influence the outcome of antiemetic prophylaxis to achieve better control of CINV among pediatric cancer patients.

It's Not Cyclic Vomiting Syndrome Until Dietl's is Ruled Out: A Case for Point of Care Renal Ultrasound

BackgroundAbdominal pain and vomiting are frequent complaints for pediatric patients presenting to the Emergency Department (ED). When a diagnosis such as chronic abdominal pain, cyclic vomiting, or abdominal migraine has previously been made, it can lead to diagnostic momentum and confirmation bias on behalf of the treating physician. Dietl's crisis is a commonly missed diagnosis in the pediatric population that presents with intermittent episodes of pain and vomiting. It can be readily diagnosed at the bedside by the emergency physician (EP) through the employment of point of care ultrasound (POCUS). Case SeriesWe present two cases of pediatric patients with episodic abdominal pain and vomiting who were previously diagnosed with cyclic vomiting syndrome. In both cases, pediatric gastroenterology evaluations had occurred with negative diagnostic testing having been performed. Both patients also presented to their primary pediatrician and the ED multiple times with each encounter resulting in treatment of symptoms and discharge. Each patient eventually presented to the ED when an EP was present who performed a renal POCUS. In each patient, the POCUS revealed severe unilateral hydronephrosis. Subsequent workup confirmed the diagnosis of Dietl's crisis as the etiology of symptoms. Why Should an Emergency Physician Be Aware of This?In pediatric patients, EPs should be wary of the diagnosis of cyclic vomiting syndrome until ureteral obstruction has been ruled out. A bedside POCUS can rapidly establish this diagnosis and potentially preclude recurrent health care visits, unnecessary diagnostic testing, and permanent loss of renal function.

CARDIOGENIC SHOCK IN A PATIENT WITH SEVERE AORTIC VALVE STENOSIS AND MULTIVESSEL CORONARY DISEASE: ADVANCED THERAPEUTIC STRATEGIES

Abstract We describe a case of a 58 years old man. He was referred to emergency room for episodes of vomiting and epigastric pain for about a week. Upon admission he was confused with systolic–diastolic blood pressure values ​​70/40 mmHg, heart rate 120 bpm, sinus rhythm. pO2 was 80 mmHg and SO2 in air 97%. Lactate values 10, blood sugar > 300 mg/dl. The electrocardiogram showed sinus tachycardia with the results of antero–septal necrosis and incomplete left bundle branch block. The fast echocardiogram showed a dilated left ventricle with severe depression of the ejection fraction (EF about 10–15%), severe low flow–low gradient aortic valve stenosis (AVA bidimensional was approximately 0.9 cm²), severe mitral valve insufficiency due to a dual mechanism. The dimension of Inferior vena cava was 1.5 cm, collapsible. There was thrombotic stratification in the apex of the left ventricle and VA coupling was 2. The patient was admitted to the ICU with stage C cardiogenic shock according to SCAI classification. We found a value of PVC 3 mmHg. After fluide challenge there was an increase in blood pressure values to 100/60 mmHg. Noradrenaline vasopressor was started and subsequently a low dose of adrenaline. Blood pressure values maintained around 90/60 mmHg and undergo a sudden drop after increasing the dosage of the vasopressor. Diuresis was approximately 50 ml/h, lactates clear completely after approximately 4 hours. After 6 hours, due to a new sudden reduction in blood pressure, the patient was referred for IABP and coronary angiography control. In the context of multivessel coronary artery disease and cardiogenic shock he was therefore a candidate for urgent cardiac surgery of aortic valve replacement, by–pass and mitral anulovalvuloplasty. This case gave us the opportunity to analyze how to proceed in such a critical conditions with the below conclusions: a) the choice of vasopressors and inotropes is limited in case of severe aortic valve stenosis b) the presence of left ventricular intracavitary thrombosis limits the choice of ventricular assistance system c) in case of cardiogenic shock and severe aortic valve stenosis the patient must be a candidate for valve replacement surgery as soon as possible.