Successful Medical Management Research Articles

Ectopic Pregnancy in a Non-communicating Rudimentary Uterine Horn: A Case of Successful Medical Management and Literature Review

Ectopic Pregnancy in a Non-communicating Rudimentary Uterine Horn: A Case of Successful Medical Management and Literature Review

12533 A Rare Case of a Growth Hormone Releasing Hormone-Secreting Pulmonary Carcinoid Tumor: Clinical Presentation and Management

Abstract Disclosure: I. Yaseen: None. C. Woods: None. D.B. O'Shea: None. R.K. Crowley: None. D. O'Toole: None. H. Almeamar: None. We present a rare case of an ectopic Growth Hormone Releasing Hormone (GHRH)-secreting pulmonary neoplasm manifesting with acromegaly. A 62-year-old woman presented with Bell’s palsy. An incidental lung mass proved to be a 17.5cm carcinoid tumor, DOTATOC-avid, with bony and liver metastases, Ki67 1% on lung and bone biopsy. After pulmonary service referral to endocrinology, she was noted to have acromegalic features, the most troubling of which was macroglossia associated with mouth ulceration. IGF1 was 549ug/L (57-186), random growth hormone was 225. GHRH in serum was 1937ng/ml (reference < 60). MR Pituitary revealed hyperplasia.The multidisciplinary team discussion was that the lung lesion was unresectable, therefore she was commenced on somatuline autogel 120mg every 28 days and an opinion requested re suitability for Peptide Receptor Radionuclide Therapy. After 6 months of therapy IGF1 normalised to 90ug /L. GHRH reduced to 1056ng/L.Imaging at 8 months showed stability of lung primary and bone / liver metastases, with no benefit likely from PRRT at this time. This case highlights the importance of considering endocrine syndromes in the setting of a lung mass. The prevalence of acromegaly in Ireland is 69 per million people; this is the second Irish case known of GHRH-associated GH excess. Ectopic GH-secreting pulmonary tumors are a rare but important differential in patients presenting with acromegalic features. Complete surgical resection can be curative, underlining the significance of a multidisciplinary approach in management, encompassing endocrinology, thoracic surgery, and pathology. This case of successful medical management adds to the limited literature on such tumors and underscores the potential for non-pituitary neoplasms to cause systemic endocrinopathies. Presentation: 6/1/2024

S4837 Successful Medical Management of Intramural Duodenal Abscess

S4837 Successful Medical Management of Intramural Duodenal Abscess

Predictors of successful expectant and medical management of miscarriage: A systematic review.

15.3% of pregnancies result in miscarriage, management options include expectant, medical, or surgical. However, each patient has a range of variables, which makes navigating the available literature challenging when supporting individual patient decision-making. This systematic review aims to investigate whether there are any specific predictors for miscarriage management outcome. The following databases were searched, from the start of each database up to April 2023: PubMed, Medline, and Google Scholar. Inclusion criteria were studies interrogating defined predictors for expectant or medical management of miscarriage success. Exclusion criteria were poor quality, review articles, trial protocols, and congress abstracts. Data collection was carried as per PRISMA guidelines. Quality assessment for each study was assessed using the QUIPS proforma. Relevant predictors include demographics, ultrasound features, presenting symptoms, and biochemical markers. Across the 24 studies there is heterogeneity in miscarriage definition, predictors reported, and management outcomes used. Associations with certain variables and miscarriage management outcomes are described. Ten studies assessed the impact of miscarriage type on expectant and/or medical management. The majority found that a diagnosis of incomplete miscarriage had a higher success rate following expectant or medical management compared to missed miscarriage or anembryonic pregnancy. We conclude that there is evidence supporting the possibility to offer personalized miscarriage management advice with case specific predictors. Further larger studies with consistent definitions of predictors, management, and outcomes are needed in order to better support women through the decision-making of miscarriage management.

Successful medical management of a pituitary macroadenoma with features of resistant acromegaly and hyperprolactinemia using pasireotide.

The somatostatin analog, pasireotide, is used for the treatment of acromegaly after the failure of surgery and/or first-line medical treatment. A 48-year-old male reported that during a workup for obesity in his home country, hyperprolactinemia was diagnosed and a 3.5 × 3.5 cm pituitary macroadenoma was identified on pituitary MRI. He received cabergoline for 6 months; then he was lost to follow-up. He presented at our Endocrine clinic 2 years later for treatment of obesity (BMI 49.5 kg/m2). Biochemical workup revealed that in addition to hyperprolactinemia (7,237 [normal: 85-323 mIU/L), he had acromegaly, evident by elevated insulin-like growth factor 1 (IGF-1) level (450 [normal: 88-210 µg/L]), and a positive growth hormone suppression test, secondary hypothyroidism, and secondary hypogonadism. Pituitary MRI showed that the adenoma encased parts of the left and right internal carotid arteries and encroached on the optic chiasm. Surgical excision was therefore not feasible. He was treated with cabergoline and later, long-acting release (LAR) octreotide. Prolactin levels were reduced with cabergoline, but IGF-1 levels did not respond to octreotide, and it was discontinued. The patient abandoned radiotherapy after two sessions. He was started on LAR pasireotide 40 mg every 4 weeks and continued on cabergoline 0.5 mg per week. His biochemical response was dramatic, with a near normalization of IGF-1 levels in 3 months. After 6 months from starting pasireotide, we increased cabergoline dose from 0.5 mg/week to 3 mg/week. Three months later, IGF-1 level was normalized. The patient developed type 2 diabetes as a side effect of pasireotide; however, this was well-controlled with medications. The case suggests that pasireotide can provide marked biochemical improvement in acromegaly after the failure of both cabergoline monotherapy and cabergoline plus octreotide. This further confirms a potentially efficacious treatment regimen in treatment-resistant acromegaly with hyperprolactinemia.

Successful medical management of giant prolactinomas: a comprehensive case report

Successful medical management of giant prolactinomas: a comprehensive case report

Perceptions and Experiences of People with Obesity and Type 2 Diabetes Around Appetite and Eating Behaviors: A Qualitative Study.

Chronic weight management and treatments for type 2 diabetes (T2D) involve a combination of lifestyle-based (diet, exercise) and pharmaceutical interventions. In people with obesity or T2D, understanding the impact of drivers/triggers on appetite and eating behaviors can be crucial to successful medical management. This study aimed to characterize perceptions and experiences regarding appetite and eating behaviors among people with obesity or T2D and identify drivers/triggers of food choices. This non-interventional, cross-sectional, qualitative study utilized semi-structured concept elicitation interviews to explore the perceptions of people with obesity and/or T2D around appetite, eating behaviors and drivers/triggers of food choices. Adult US residents (≥ 18years) with stable body weight (± 5kg) in the 3months preceding participation were included in the study. Forty-five participants (obesity: n = 15; overweight: n = 10; T2D: n = 20) were interviewed. Interviews were audio-recorded and transcribed verbatim for analysis. A subset of participants described eating behaviors on smartphone-based app tasks over 5days. Most (> 96%) discussed the influence of hunger, cravings and satiety on food choices. Participants identified 22 drivers/triggers (including health, 95.6%; culture/heritage, 93.3%; location, 91.1%; stress, 88.8%). Participants also discussed associations between drivers/triggers and eating behavior concepts (appetite, hunger, cravings, satiety, motivation/determination). A conceptual model illustrating eating behavior concepts and related drivers/triggers was developed. The concept elicitation interviews identified a multitude of drivers and triggers and characterized the association of such drivers/triggers with seven core patient-reported concepts encompassing eating behaviors. The findings build upon existing models of factors influencing food choices. Findings confirm prior research regarding impact of drivers/triggers on food choice in people with obesity and T2D and indicate underlying disease state does not appear to influence eating behaviors in people with stable body weight.

Successful medical management of septic pericardial effusion in a dog

AbstractA 5‐year‐old, male, neutered cocker spaniel diagnosed with presumed immune‐mediated haemolytic anaemia 9 weeks previously, and treated with immunosuppressive medications with subsequent resolution of anaemia was presented for hyporexia, lethargy and tachypnoea of 48‐hour duration. Point‐of‐care thoracic ultrasonography revealed pericardial effusion causing cardiac tamponade. Cytological examination of the pericardial fluid showed an exudate with intracellular cocci chains and degenerate neutrophils, consistent with septic pericardial effusion. The culture of the effusion revealed a profuse growth of Staphylococcus pseudintermedius. Antibiotic and supportive therapy were instituted, immunosuppressant medications were tapered and stopped, the patient's clinical status progressively improved, and a full recovery ensued without need of further surgical and interventional procedures. Dual immunosuppression with prednisolone and ciclosporin was considered to be the most likely cause for the patient's clinical condition.

Medical Management of Acute Spinal Cord Injury with Aspiration pneumonia in a Kid

A two-month-old, non-descript female goat kid was brought to the Veterinary Clinical Complex, Veterinary College and Research Institute, Orathanadu, with a history of continuous high-pitched bleating, respiratory distress, and forelimb paresis over the past two days. The animal has appeared lethargic with an abnormal gait. Neurological examination revealed sluggish sensory and motor reflexes in the forelimbs and palpation elicited pain in the thoracic and dorsal spinal areas (C7-T2). Auscultation revealed exaggerated heart sounds and prolonged expiration. Radiographic examination ruled out spinal involvement but revealed left lung consolidation with pulmonary infiltration. Cerebrospinal fluid analysis showed an increase in neuron-specific enolase (NSE). The condition was tentatively diagnosed as acute spinal cord injury with aspiration pneumonia. Inj. Progesterone and intranasal Budesonide were administered along with a Progesterone patch applied to the lateral neck region. Successful medical management led to gradual clinical improvement observed from the seventh day and completely recovered after 15 days of treatment.

Mitral Valve Mass in a Patient with Positive Tuberculosis Wound Pathology: Successful Medical Management and Regression of Cardiac Mass

Introduction: Tuberculosis (TB) is a chronic granulomatous disease, ranking as the second cause of death by infectious agents in 2021. Tuberculosis affects millions worldwide, with valvular TB being a rare manifestation, accounting for less than 1% of extrapulmonary TB cases. Valvular TB is often diagnosed through imaging and laboratory evaluations, and the treatment involves prolonged antibiotic therapy and might require surgical intervention for damaged cardiac valves. Case Presentation: A 60-year-old female patient with diabetes mellitus and rheumatoid arthritis was referred for a cardiac assessment prior to hand wound debridement surgery. Transthoracic echocardiography (TTE) revealed a mass on the mitral valve, and subsequent transesophageal echocardiography (TEE) confirmed a large, mobile mass with abscess-like density. A blood culture study was negative for infective endocarditis, and a biopsy of the wound revealed necrotizing granuloma positive for Mycobacterium tuberculosis. Anti-TB medication was initiated, resulting in a significant improvement in the valve mass. No cardiac complications were reported during the follow-up. Conclusions: In suspected cardiac TB patients with a high risk of surgery or patients reluctant to undergo an operation, quadruple chemotherapy can serve as a diagnostic and therapeutic tool.

Healthcare Workers' Knowledge about the Segregation Process of Infectious Medical Waste Management in a Hospital.

Any hospital's primary goal is to restore human health and save lives through health services provided to patients, but at the same time, hazardous wastes are produced. Inconsistent management of unsafe wastes might cause adverse effects and other issues for workers, the environment, and public health. Segregation is considered the critical stage in successful medical waste management. Mixing hazardous medical waste with non-hazardous medical waste will be avoided by correctly applying practices at the segregation stage. This study aimed to assess personnel's knowledge about infectious medical waste and segregation practices used at six wards in Nicosia General Hospital. An analytical cross-sectional study was conducted, and data were collected through a structured self-administered questionnaire. The Statistical Package of Social Science (SPPS) version 25 was used with a minimum statistical significance of α = 0.05. The study population was nurses, nurse assistants, ward assistants, and cleaners working at the study wards. Out of 191 questionnaires, 82 were received, with a response rate of 42.93%. Most participants were female (72%) and nurses (85.4%). Participants had moderate knowledge about infectious medical waste management and good knowledge regarding segregation practices applied in their ward. Segregation was not carried out as it should have been, since most participants stated that infectious medical waste was mixed with non-hazardous medical waste. The number of correct answers the participants gave regarding the colour-coding of different medical waste categories was 67.5%, and only four answered correctly to all questions. Although participants knew segregation practices and the colour-coding process applied to medical waste, they did not use them satisfactorily. They applied methods regarding segregation without specific training, knowledge and guidance. Due to the issue's importance, training programs must be implemented and performed.

Diverticulitis: A Review of Current and Emerging Practice-Changing Evidence.

Acute diverticulitis represents a common colorectal emergency seen in the Western world. Over time, management of this condition has evolved. This review aims to highlight recent evidence and update current recommendations. Notable evidence has emerged in certain aspects of diverticulitis. This includes disease pathogenesis, as emerging data suggest a potentially greater role for the microbiome and genetic predisposition than previously thought. Acute management has also seen major shifts, where traditional antibiotic treatment may no longer be necessary for acute uncomplicated diverticulitis. Following successful medical management of acute diverticulitis, indications for elective sigmoidectomy have decreased. The benefit of emergency surgery remains for peritonitis, sepsis, obstruction, and acute diverticulitis in certain immunocompromised patients. Routine colonoscopy, once recommended after all acute diverticulitis episodes, has been shown to be beneficial for cancer exclusion in a distinct patient population. Despite advances in research, certain entities remain poorly understood, such as smoldering diverticulitis and symptomatic uncomplicated diverticular disease. As research in the field expands, paradigm shifts will shape our understanding of diverticulitis, influencing how clinicians approach management and educate patients.

Case Report: Laparoscopy-assisted resection for intra-abdominal gossypiboma masquerading as a jejunal tumor (with video)

IntroductionIntra-abdominal gossypiboma, a cotton-based retained foreign body after an abdominal surgery, is associated with various clinical manifestations and complications. Its infrequent occurrence and unpredictability make its early diagnosis particularly challenging. We herein present an atypical case of intra-abdominal gossypiboma mistaken for a jejunal tumor.Case presentationA 33-year-old female presented to the emergency room with an acute episode of progressive abdominal pain and distention, nausea, and vomiting for 20 hours. She had undergone an urgent cesarean section due to fetal tachycardia seven years prior. The initial diagnosis of small bowel obstruction (SBO) due to a jejunal tumor was established by computed tomography. Subsequent to successful medical management of the SBO, a laparoscopy-assisted resection of the mass and the adherent jejunal segment was conducted, culminating in a primary side-to-side jejunojejunostomy. Examination of the excised tissue revealed an approximately spherical fibrous mass, 6 × 6 × 5 cm in dimension, embedded in the jejunal wall, housing a 20 × 20-cm gauze. Postoperative recovery and routine follow-up ensued without complications.ConclusionIn light of this case, the need for clinicians to maintain an elevated awareness and suspicion of gossypiboma should be accentuated when evaluating an intra-abdominal mass, especially in patients with a prior history of high-risk laparotomy. Laparoscopic surgery stands out as a technically proficient and minimally invasive strategy for diagnosing and treating intra-abdominal gossypiboma. Besides, it is imperative to emphasize the importance of meticulous surgical procedures and postoperative protocols to prevent such oversights, reaffirming the need for consistent intraoperative counts and checks of surgical items.

Abstract 17614: “Watchful Waiting” - Successful Medical Management of an Infected Watchman Device

Description of Case: A 68-year-old male with a past medical history of alcoholic cirrhosis, ischemic cardiomyopathy, atrial fibrillation, ventricular tachycardia, and sick sinus syndrome presented with exertional dyspnea and lower extremity edema consistent with acutely decompensated systolic heart failure. He had multiple implantable cardiac devices including a watchman device. He was subsequently found to have methicillin-sensitive staphylococcus aureus (MSSA) bacteremia and developed sepsis. A transesophageal echocardiogram (TEE) was done to evaluate for infective endocarditis and a 1 cm mobile echodensity attached to the anterior aspect of the watchman device was found. Given active bacteremia, the echocardiographic appearance was felt to be most likely consistent with a vegetation. Due to significant medical and cardiac comorbidities, device extraction was deemed very high risk and deferred in favor of antibiotic therapy by a multi-disciplinary team. The patient was treated with intravenous cefazolin and oral rifampin. Clinical defervescence and clearance of bacteremia were achieved. A follow-up TEE in 6 weeks showed complete resolution of the watchman device vegetation. Discussion: Cardiac implantable devices provide significant morbidity and mortality benefits to patients but incur the potential risk of infection. Watchman device infection, though rare, has been reported. The current guidelines recommend the removal of all hardware in patients with established device infection. However, percutaneous, or surgical extraction of the watchman device bears significant risk and may not be feasible in all patients. Our case demonstrates the potential role of antimicrobial therapy alone with close surveillance in treating high-risk patients with watchman device infection.

Successful Medical Management of Bilateral Pneumothorax Due to Nasogastric Tube Misplacement in a Cat.

A 7 yr old female spayed domestic shorthair was evaluated for suspected lily ingestion and acute vomiting. The cat had vomited suspected lily plant material before presentation, and a nasogastric tube (NGT) was placed to continue to administer activated charcoal. The NGT was passed with sedation and limited restraint. To confirm placement, a single lateral radiograph was taken, which showed that the tube was in the trachea, bronchus, through the pulmonary parenchyma, and extending into the region of the craniodorsal retroperitoneal space. The tube was subsequently removed, resulting in a tension pneumothorax. Bilateral thoracostomy tubes were placed and attached to continuous suction. The pneumothorax resolved after 2 days, the thoracostomy tubes were removed, and the cat was discharged on day 3 after admission. To the authors' knowledge, this is the first described pneumothorax complication with successful medical management secondary to routine nasogastric tube placement in a cat. This case report underscores the importance of preparedness for thoracostomy tube placement before removal of any NGT that has been confirmed to be placed through the pulmonary parenchyma.

Successful antibiotic management of Staphylococcus epidermidis endophthalmitis after implantable collamer lens implantation

PurposeWe report a case of successful medical management of endophthalmitis post implantable collamer lens (ICL) culture-positive of Staphylococcus epidermidis.Observations: A 18-year-old female presented with decreased visual acuity in the left eye 20 days after ICL implantation. A diagnosis of postoperative endophthalmitis was made based on examination and ultrasonography. A vitreous tap was taken, and intravitreal antibiotics (vancomycin 1 mg/0.1ml and ceftazidime 2 mg/0.1ml) were administered twice (every 72 h), and peribulbar injection of triamcinolone acetonide after four days of the second intravitreal injection. The vitreous culture was confirmed for Staphylococcus epidermidis. The endophthalmitis was resolved, and visual acuity improved from 6/20 to 12/20 on day 7 and 22/20 on day 38. This is the first successful medical resolution of Staphylococcus epidermidis endophthalmitis post ICL surgery without ICL explantation and vitrectomy in the V4c model.Conclusions and importance: In antibiotic therapy, the excellent compliance and close follow-up of this endophthalmitis patient enabled careful postoperative surveillance on the effect of antibiotic therapy, avoiding the removal of the ICL or the loss of the integrity of the eye. The risk of potential infectious endophthalmitis post-ICL surgery should be fully emphasized during preoperative counseling.

Successful echocardiography-guided medical management of severe early post-implant right ventricular failure in a patient with left ventricular assist device support: a case report

BackgroundPost-implant right heart failure (RHF) has been recognized as a crucial prognostic factor in patients receiving left ventricular assist devices (LVADs), and its management has long attracted attention from cardiologists and surgeons.Case presentationThis report described an 18-year-old female with acutely deteriorating heart failure due to dilated cardiomyopathy who underwent paracorporeal pulsatile-flow LVAD and developed early post-implant RHF. At postoperative day (POD) six, she was almost asymptomatic at rest on 2.5 mg/kg/min of dobutamine; however, the echocardiogram, performed as part of the daily postoperative care, revealed a severely enlarged right ventricle with a decompressed left ventricle, implying the development of post-implant RHF. Bolus infusion of saline and reduction of pump flow (6.0 L/min to 3.0 L/min) led to normalization of both ventricular shapes in 30 s, suggesting that RHF could be managed without surgical interventions. Milrinone was started on POD six, followed by sildenafil administration on POD seven. Fluid balance was strictly adjusted under the close observation of daily echocardiograms. Milrinone and dobutamine were discontinued on PODs 18 and 21, respectively. The patient was listed for a heart transplant on POD 40. Despite reduced right ventricular function (right ventricular stroke work index of 182.34 mmHg*ml/m− 2, body surface area 1.5 m2), she was successfully converted to implantable LVAD on POD 44 with no recurrence of post-implant RHF thereafter for four years.ConclusionsIn post-implant RHF management, early detection, together with proper and prompt medical management, is crucial to avoiding any surgical intervention. Close observation of daily echocardiograms might be helpful in detecting subclinical RHF and is useful for post-implant medical management.

Early pregnancy loss medical management in clinical practice

ObjectivesThis study aimed to review clinical practice outcomes of early pregnancy loss (EPL) medical management using mifepristone and misoprostol outside of a clinical trial setting. Study designIn this retrospective cohort study, we reviewed a deidentified database of patients who received mifepristone-misoprostol for EPL from May 2018 to May 2021 at our academic center–based clinic, which was a study site for a multicenter mifepristone-misoprostol EPL trial completed in March 2018. All patients received mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, with clinic follow-up typically scheduled within 1 week. The primary outcome was successful medical management, defined as management without the need for aspiration, and the secondary outcomes included additional interventions and indications, follow-up ultrasonography findings, and adverse events requiring treatment. ResultsWe treated 90 patients with a median ultrasound-measured gestational size of 49 (range 30–80) days and median time from mifepristone to misoprostol of 24 (range 8–66) hours. Follow-up was completed in clinic by 80 (88.9%), completed remotely by five (5.6%), and not completed by five (5.6%) patients. Overall, 76 (95% CI 82.9%–96.0%) of 85 patients (89.4%) with follow-up were successfully managed without uterine aspiration. Eighty patients had initial follow-up ultrasonography interpreted as gestational sac expulsion; seven (8.8%) of these ultimately underwent aspiration, including one patient who had a previously undiagnosed cesarean scar ectopic pregnancy. Two patients had significant safety outcomes: one pelvic infection and one blood transfusion during aspiration in the patient with a cesarean scar ectopic pregnancy. ConclusionsOutside of a clinical trial setting, medical management of EPL with mifepristone and misoprostol remains effective and safe. ImplicationsMedical management of EPL with mifepristone and misoprostol is effective and safe outside of a clinical trial setting. A standardized protocol based on the best available clinical trial evidence can be used in clinical practice for the medical management of EPL.

Recent advances in understanding brain cancer metabolomics: a review.

Regardless of the significant progress made in surgical techniques and adjuvant therapies, brain tumors are a major contributor to cancer-related morbidity and mortality in both pediatric and adult populations. Gliomas represent a significant proportion of cerebral neoplasms, exhibiting diverse levels of malignancy. The etiology and mechanisms of resistance of this malignancy are inadequately comprehended, and the optimization of patient diagnosis and prognosis is a challenge due to the diversity of the disease and the restricted availability of therapeutic options. Metabolomics refers to the comprehensive analysis of endogenous and exogenous small molecules, both in a targeted and untargeted manner, that enables the characterization of an individual's phenotype and offers valuable insights into cellular activity, particularly in the context of cancer biology, including brain tumor biology. Metabolomics has garnered attention in current years due to its potential to facilitate comprehension of the dynamic spatiotemporal regulatory network of enzymes and metabolites that enables cancer cells to adapt to their environment and foster the development of tumors. Metabolic changes are widely acknowledged as a significant characteristic for tracking the advancement of diseases, treatment efficacy, and identifying novel molecular targets for successful medical management. Metabolomics has emerged as an exciting area for personalized medicine and drug discovery, utilizing advanced analytical techniques such as nuclear magnetic resonance spectroscopy (MRS) and mass spectrometry (MS) to achieve high-throughput analysis. This review examines and highlights the latest developments in MRS, MS, and other technologies in studying human brain tumor metabolomics.

Case Study: Successful Medical Management for Klinefelter's Syndrome with HCG Injection

Case Study: Successful Medical Management for Klinefelter's Syndrome with HCG Injection