Uncomplicated Course Research Articles

Stant restenosis in a patient with vazorenal arterial hypertension

Introduction. Up to 20% so-called secondary forms of hypertension are associated with vascular pathology of the kidneys (renovascular hypertension). The lack of effectiveness of drug therapy of this form of hypertension determined the invasive treatment tactics. Objectives. The purpose of this article was to observe the clinical course of renovascular hypertension and determine the tactics of treatment in the long-term period after a previous stenting of the renal arteries. Material and methods. Our patient is a woman, born in 1957. Since 2011, hypertension has been diagnosed, since 2014 - rhythm disturbances, since 2015 edema of the lower extremities, maximum blood pressure up to 250/120 mm Hg, in 2016 - stenting of the renal arteries (RA) was performed according to the angiography results, the patient's condition was satisfactory. Since 2018, due to deterioration, the patient was hospitalized. The main diagnosis: Secondary vasorenal arterial hypertension of the II stage, 3 degree. Bilateral renal artery stenosis (angiography 03.03.2016). Renal artery stenting (03.03.2016). Restenosis of the stent of the right renal artery up to 80% (angiography 15.11.2018). Ventricular extrasystole II gradation according to Laun-Wolf-Rayan. Hyperlipidemia type IIb-III. Very high cardiovascular risk. Complication: Hypertensive crisis (uncomplicated course) (01.1I.2018). HF II A stage, class II with preserved systolic function of the left ventricle (EF 69%). Conducted therapy: perindopril 15 mg, bisoprolol 5 mg, torasemide 5 mg; amiodarone 100 mg bid; indapamide 1.25 mg; amlodipine 5 mg, acetylsalicylic acid 150 mg; rosuvastatin 20 mg. Results. The patient underwent a standard examination at hospital. Identified deviations: laboratory: ESR 20 mm / h, basophils 1.3%, creatinine 83 μmol / L (CKD-EPI 77 ml / min / 1.73 m2), dyslipidemia IIb according to Fredrickson; instrumental: ECG – left axis deviation, signs of left ventricular myocardial hypertrophy (LVMH); Holter - single ventricular and supraventricular extrasystoles; echocardiography - sclerotic changes in the valvular apparatus of the heart, concentric LVMH; ultrasound of the abdominal cavity and retroperitoneal space – the right kidney is reduced in size, microcalculosis of both kidneys, signs of stenotic flow along the left RA at the level of the stent; RA angiography - restenosis in the stent of the right RA up to 80%. Stentoplasty with possible stent-to-stent DES stenting was recommended by an endovascular surgeon. Conclusions. This clinical case demonstrates the need for screening a category of patients with resistance to standard antihypertensive therapy for the presence of secondary arterial hypertension, which will improve the quality of life of the patient and reduce the number of drugs used, in some cases up to their withdrawal. Given the high likelihood of restenosis of stented vessels, it is necessary to carry out primary prevention of the restenosis occurrence.

Spontaneous unilateral twin tubal ectopic pregnancy: A case report

Unilateral tubal twin pregnancy is rare with an incidence of 1: 125,000 spontaneous pregnancies. Majority of cases that occur follow ovulation induction and assisted reproductive technology. A 38-year-old single primipara with a 9-week history of amenorrhea, 2-week history of lower abdominal pain, and a 3-day history of vaginal bleeding. Previous history of ectopic gestation with surgery, as well as repeated elective abortions and pelvic infections, was elicited. She was hemodynamically unstable with features of an acute abdomen. Pelvic examination revealed features suggestive of ectopic gestation. Spot serum pregnancy test was positive and the pelvic ultrasound revealed left tubal twin ectopic gestation with the significant peritoneal fluid collection. An emergency laparotomy with left salpingectomy was performed, with an un-complicated post operation course. The diagnosis was confirmed with histology. A high index of suspicion is required in the diagnosis of ectopic gestation in order to reduce the morbidity associated with it. Unilateral twin tubal ectopic gestation, although rare, has been reported with higher frequencies, and as such, the occurrence should be carefully sought on ultrasound in order to reduce its potential morbidity and mortality.

Acute Borrelia burgdorferi infection in pregnancy

Introduction: There is a paucity of information regarding the potential complications and sequelae regarding intrauterine exposure to Borrelia burgderfori. Borrelia infection continues to be of increasing concern, with endemic regions now spanning the United States, and a continual increase in the number of documented cases of infection annually. Case Report: A 26-year-old gravida 1 para 0 who presented at 21 weeks 2 days gestational age to her primary care provider and was diagnosed and treated for a right knee Lyme monoarthritis. Antenatal course was complicated with fetal growth restriction and concern for a congenital cardiac malformation. The patient underwent induction of labor and delivered a viable male infant at 39 weeks. The patient had an uncomplicated postpartum course and was discharged home on postpartum day two. She followed up with her rheumatology providers at three months and showed improvement in her right knee Lyme monoarthritis. Her neonate underwent an echocardiogram following delivery which showed a small atrial septal defect, patent ductus arteriosus, patent foramen ovale, and a pericardial effusion. Repeat echocardiogram was performed at three months of age and showed resolution of those abnormalities and no evidence of any other cardiac abnormalities. The infant is currently meeting all expected developmental milestones. Conclusion: There remains a gap in knowledge regarding the potential adverse maternal, fetal, and neonatal outcomes that can result from acute infection with Borrelia burgdorferi. Given the potential for severe sequelae, providers must be aware of the appropriate treatment regimens for these patients during pregnancy, especially in endemic areas.

INTRAOCULAR PRESSURE CHANGES AFTER UNEVENTFUL PHACOEMULSIFICATION IN EARLY POSTOPERATIVE PERIOD IN HEALTHY EYES.

SUMMARYThe aim was to determine early changes in intraocular pressure (IOP) following uneventful phacoemulsification and intraocular lens (IOL) implantation in healthy eyes. This prospective interventional case series study was conducted at Ophthalmology Department, Kragujevac Clinical Centre, Kragujevac, Serbia. The study included 123 eyes of 123 cataract patients, 66 women and 57 men, age range 50-88 (mean 70.73±7.94) years having undergone phacoemulsification and in-the-bag implantation of a foldable IOL. The patients were treated at Kragujevac Clinical Centre between June 2015 and May 2016. IOP was measured by Goldmann applanation tonometry preoperatively, then 4-6 hours, 18-24 hours and 7 days postoperatively by the same examiner. The mean IOP preoperatively was 15.10±2.68 mm Hg. In three patients, maximum measured IOP was 22 mm Hg. At 4-6 hours postoperatively, the mean IOP was 24.29±7.56 mm Hg (p<0.001), at 18-24 hours it was 18.37±4.80 mm Hg (p<0.001), and 7 days after the surgery the mean IOP was 16.24±2.90 mm Hg (p<0.05). The measured IOP values were statistically significant in all measured times. However, at 4-6 hours and 18-24 hours, the mean IOP value was highly statistically significant (p<0.001). Although 7 days after the surgery IOP normalized, the mean IOP value was statistically significant (p<0.05). In conclusion, our research showed that even eyes with normal preoperative values and uncomplicated phacoemulsification course can show very high IOP values postoperatively, which can cause pain, blurred vision and, rarely, compromise visual function.

Primitive Umbilical Endometriosis in a Young Woman at the District Health Center (CSREF) in Commune II in Bamako

Umbilical endometriosis, also called Villar’s nodule, has rarely been described in the literature. It represents only 0.5% to 1% of all cases of endometriosis. We report a case in a 28-year-old nulligest, nulliparous woman who consulted at the CSREF CII in Bamako. The diagnosis was suspected with the presence of umbilical swelling with cyclic, painful, dark hemorrhage of firm consistency. We performed an omphalectomy with an uncomplicated postoperative course. She was released from the hospital three days post-surgery. Anatomo-pathological examination of the resected specimen confirmed the diagnosis of umbilical endometriosis.

Off-Label Sutureless Aortic Valve in the Failing Homograft

Homografts have been used in the aortic position as an alternative to xenograft or mechanical prostheses. With time, the leaflets and walls of the graft develop heavy calcification, making redo surgery hazardous. This study presented two patients who had successful sutureless bioprosthetic valve implantation into failing homografts, avoiding redo Bentall's procedure. It is believed that there has been one other report on the use of a sutureless aortic valve in this setting. The first patient is a 67-year-old male who underwent redo sternotomy, bioprosthetic aortic and mitral valve replacements and tricuspid annuloplasty. He initially underwent homograft aortic root, ascending aortic and hemiarch replacement in 1999 for a stenosed bicuspid aortic valve and aneurysmal aorta. He presented heart failure with pulmonary oedema. Transthoracic echocardiogram demonstrated a ruptured left coronary cusp, severe aortic, mitral, and tricuspid regurgitation, and pulmonary hypertension. Due to urgency and the extensive risk of a redo Bentall's procedure, he underwent a sutureless aortic valve implantation into the homograft. The patient was discharged home on postoperative day 10, after resolved delirium. Another 43-year-old male underwent homograft aortic root replacement in 1995 for bicuspid aortic valve and aortopathy. In 2018, he was diagnosed with severe aortic regurgitation secondary to perforated leaflets and redo surgery was planned with increased risk due to extensive calcification (“porcelain aorta”). After excision of the homograft leaflets, a large sutureless valve was inserted. The patient had an uncomplicated postoperative course. These two patients demonstrated that off-label use of the sutureless aortic valve in the failing homograft can be safely performed and offers an alternative strategy in management of these challenging patients.

Telemetric Monitoring of Intracranial Pressure

Background: We present the application of a modern telemetric method that records and monitors Intracranial Pressure (ICP) over long periods in patients with possible intracranial hypertension. Methods: A telemetric devise (Raumedic, Neurovent P-tel) was surgically implanted in six (6) patients. Three (3) patients with inconclusive diagnosis of idiopathic intracranial hypertension, two (2) patients with possible diagnosis of aqueduct stenosis and one (1) patient with Normal Pressure Hydrocephalus. All patients underwent a 3-day ICP recording within the nursing unit. Two more recordings were obtained over a period of 2-6 months at outpatient base. Results: All patients had an uncomplicated post-operative course. Analysis of the data excluded the diagnosis of idiopathic intracranial hypertension in two patients. Contrary in four patients data confirmed elevated ICP values and subsequently three of them underwent shunts implantation, while one patient refused further neurosurgical treatment. Conclusions: The telemetric device could be safely implanted in selected patients. It could provide long-term ICP recordings, which are necessary to confirm diagnosis and guide to the appropriate treatment.

Appreciation of the importance of pregravid preparation and reproductive attitudes of women of childbearing age in the city of Omsk

The aim of the study. Assess the importance of pregravid preparation and outcomes of pregnancy and childbirth, depending on the reproductive attitudes of women in the city of Omsk. Materials and methods. The study included 92 women who were divided into groups: group A (n=43) - women whose pregnancy was planned; group B (n=49) - women whose pregnancy occurred accidentally. Each group was divided into subgroups depending on age: from 18 to 30 and from 31 to 49 years. For each patient included in the study, a specially designed map was filled out. These patients were interviewed at the City Clinical Perinatal Center. Results. Comparative analysis revealed the relationship between the reproductive settings of women of childbearing age and the peculiarity of the course of pregnancy and childbirth in these patients. Summary. The majority of women of fertile age are married: in subgroup AA - 25 (96.2%), AB - 13 (76.5%), BA - 25 (92.6%), BB - 20 (91.0%). The predominant number of women of fertile age have one or more abortions: in subgroup AA - 12 (46.2%), AB - 6 (35.3%), in subgroups of comparison BA - 8 (29.6%), BB - 6 (27.3%). More than half of the women of fertile age surveyed have a history of untreated cervical pathology (from 40.8% to 64.7%). The course of pregnancy in women planning pregnancy in most cases proceeded without complications: in subgroup AA - 13 (50.0%), AB - 11 (64.7%). The most common cause of complicated pregnancy in women whose pregnancy occurred accidentally is the threat of spontaneous miscarriage: in subgroup BA - 15 (55.6%), BB - 16 (72.7%). The uncomplicated course of labor more often [subgroup AA - 19 (73.0%), AB - 12 (70.6%)] was observed in women whose pregnancy was planned and they were motivated to give birth to a healthy child.

ТАКТИКА СПЕЦИАЛИЗИРОВАННОЙ ПОМОЩИ РАНЕНЫМ С ОГНЕСТРЕЛЬНЫМИ ПЕРЕЛОМАМИ КОСТЕЙ ГОЛЕНИ

Огнестрельные переломы костей голени составляют более половины всех огнестрельных переломов длинных костей в условиях военных конфликтов.Цель: анализ тактики специализированного лечения раненых с огнестрельными переломами костей голени в учреждении гражданского здравоохранения третьего уровня в период локального военного конфликта.Материал и методы. Проведен ретроспективный анализ материалов лечения 83 раненых с огнестрельными переломами костей голени. Все раненые были мужчины, средний возраст 34,7±4,3 года (20-48). Пулевые ранения имели место у 29 (34,9%) пострадавших, взрывная травма – у 54 (65,1%). Изолированные повреждения сегментов опорно-двигательного аппарата установлены у 34 (41,0%) раненых, множественные – 31 (37,3%), сочетанные – 18 (21,7%). Открытые переломы IIIA типа – 34 (41,0%), IIIB – 46 (55,4%), IIIC – 3 (3,6%). По локализации преобладали переломы диафиза – 56 (67,5%), проксимального метаэпифиза – 12 (14,5%), дистального метаэпифиза – 15 (18,1%). Многооскольчатые (фрагментарные и полифрагментарные) переломы имели место у 74 (89,2%) раненых. На основании ретроспективного анализа результатов лечения материал историй болезней был разделен на две группы: 1 группа (n=53) с неосложненным клиническим течением, 2 группа (n=30) – с наличием осложнений. Результаты. В 1 группе число операций на одного раненого – 4,7±1,5, средний срок пребывания на койке – 47,5±8,2суток. У раненых с изолированными переломами IIIA типа и первичным окончательным остеосинтезом число оперативных вмешательств – 2,4±0,8, а средний срок пребывания на койке – 28,6±3,5 суток. Во 2 группе средняя длительность стационарного лечения – 74,5±10,2 суток, число оперативных вмешательств – 7,8±1,7.Заключение. Лечение огнестрельных переломов голени должно носить этапный комплексный дифференцированный характер, включая современные технологии закрытия раны и наружного внеочагового остеосинтеза.

Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis

The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. To investigate the association of the timing of colostomy reversal with operative outcomes. This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.

The 1, 2, 3, 4 of carcinoid heart disease: Comprehensive cardiovascular imaging is the mainstay of complex surgical treatment.

Carcinoid heart disease (CHD) is a rare complication of neuroendocrine tumors, most commonly involving the tricuspid and pulmonary valves. The mitral and aortic valves can also be affected, albeit rarely, in certain circumstances such as the presence of a patent foramen ovale. Transthoracic echocardiogram is generally considered the key imaging modality, but cardiac magnetic resonance can add valuable information, particularly in the assessment of pulmonary valve function or multivalvular disease. Previously, surgical management of CHD carried high mortality, as a result of less advanced surgical techniques and of late intervention, reserved for cases of severely symptomatic heart failure. Modern approaches are associated with significantly improved survival rates, even in multivalvular, complex cases. Valve replacement can provide survival benefits in patients with CHD, but the optimal timing for the intervention is uncertain, with data suggesting a trend of improved survival with earlier intervention. A comprehensive imaging assessment may contribute to establishing optimal surgical timing. This approach may shift the main driver of mortality from the cardiac involvement to the primary malignancy and lead to improved outcomes. We present a series of imaging findings in CHD patients who have successfully undergone simultaneous surgical replacement with bioprosthetic valves of 1 to 4 heart valves. The surgical decision in these patients was based on a multimodality cardiovascular approach, including transthoracic and transesophageal echocardiography and cardiac magnetic resonance. The patients had uncomplicated postoperative courses, significant symptomatic relief from heart failure symptoms, and there was no cardiovascular mortality. Early recognition of CHD with a multimodality approach may improve outcome, even in complex cases. Bioprosthetic valves are generally preferred in CHD due to decreased need for anticoagulation, despite concern for premature degeneration. A collaboration between the Oncology and Cardiology teams is essential for the long-term management of CHD patients.

ОФЭКТ/КТ в послеоперационной диагностике функционального состояния аутотрансплантатов челюстно-лицевой области

Purpose: To evaluate the effectiveness of SPECT/CT for the assessment of graft viability following revascularized bone grafts in patients with mandibular (18) and maxilla (1) reconstruction. &#x0D; Material and methods: We investigated 19 patients with revascularized grafts from the fibula (16 patients), iliac crest (2 patients) and shoulder blade graft (1). For the follow up of all these patients, 99mTc-MDP bone scintigraphy and SPECT/CT was performed between 4–5 days postoperatively. The evaluation of the grafts was based on a comparison of tracer uptake between graft and the cranium.&#x0D; Results: 17 of 19 grafts had an uncomplicated clinical course. Complications in the graft occurred in two patients. In the analysis of planar scintigrams with uncomplicated healing were showed correct assessment in 10 of 17 patients and in 1of 2 patients with signs of necrosis of graft fragments. SPECT/CT was performed in addition to planar imaging.&#x0D; The increased uptake grafts were showed with SPECT/CT in all patients with uncomplicated clinical course. In the failed 2 grafts, decreased uptake was observed in both patients. In the analysis of SPECT/CT images the correct results were showed in all clinical cases.&#x0D; Conclusion: SPECT/CT performed within 6 days after the mandibular reconstruction is a useful tool to monitor the viability and early complications of revascularized mandibular and maxilla bone grafts. SPECT/CT is also recommended to interpretation of the bone scans and to precise assessment of graft viability.

MANAGING SEPTIC SHOCK IN A 28-YEAR-OLD POSTPARTUM FEMALE

SESSION TITLE: Critical Care 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Sepsis is the leading cause of death in the intensive care unit (ICU) and a common cause of morbidity and mortality worldwide. Sepsis is also recognized as one of the major factors accounting for admission of pregnant and postpartum patients to the ICU and for maternal death. Postpartum patients with sepsis may appear deceptively well before deteriorating with the development of septic shock, multiple organ dysfunction syndrome, or death. CASE PRESENTATION: In our case report, we present a 28-year-old female who had uncomplicated course of her first pregnancy. Her past medical history includes hypothyroidism. She had no surgical history, and no known allergies. She presented to labor and delivery with early labor at 39 weeks and 1 day. She had premature rupture of membranes, was started with Pitocin and subsequently had a vaginal delivery of a male infant weighing 3460g. Her delivery course was complicated by uterine atony, treated with Methergine and first-degree perineal laceration. Her postpartum course was complicated by persistent tachycardia (ranging from 120s-150s), shortness of breath, and dizziness. Her hemoglobin level dropped from 12 to 9 g/dL requiring two units of packed red blood cells. Her symptoms improved when she was discharged. Two days later, she presented to labor and delivery triage with worsening shortness of breath, orthopnea, right lower quadrant pain and foul smelling lochia. On physical examination, she was alert and oriented but in mild respiratory distress. She had bibasilar rales, fever, tachycardia, tachypnea and anascar.She was admitted to the hospital for severe sepsis with endometritis as a suspected source. Proper fluid resuscitation and broad spectrum antibiotics (Ampicillin, Clindamycin, and Gentamicin) were implemented. Blood and urine cultures were obtained and sent to the lab. Within 48-hrs of admission, she went into septic shock with multi-organ failure requiring intubation, renal replacement therapy, and vasopressors. By day four of her stay MICU, she started to show signs promising recovery and was later transferred to the hospital ward for continue recovery. She was discharged home on day 15 of her second hospitalization. DISCUSSION: Sepsis and septic shock are leading causes of intensive care unit admission as well as maternal and fetal morbidity and mortality.5 Risks factors for endometritis include: older age, untreated vaginal infection, low social economic status, poor hygiene, smoking, internal fetal monitoring, postpartum hemorrhage, chorioamnionitis, retained placental fragments and many others. Endometritis is a clinical diagnosis that is sort in a postpartum woman with fever that is unattributed to other causes. A culture of the endometrium is unlikely to be helpful, as culture results tend to be multi-microbial. CONCLUSIONS: Postpartum patients may appear deceptively well, which may delay their sepsis/septic shock diagnosis Reference #1: Karsnitz DB. Puerperal infections of the genital tract: a clinical review. J Midwifery Womens Health. 2013 Nov-Dec;58(6):632-42 Reference #2: Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol. 2012 Sep;120(3): 689-706 Reference #3: Chebbo A, Tan S, Kassis C, et al. Maternal sepsis and septic shock. Crit Care Clin. 2016 Jan; 32(1):119-35 DISCLOSURES: No relevant relationships by Kenneth Iwuji, source=Web Response

An Adenoma with a Twist: Colonic Intussusception

Intussusception defined as invagination of the proximal intestine into a distal segment with most commonly affected population being children younger than two years old, although rare, is reported to occur in adults aswell. Commonly affected sites involve the terminal ileum at the ileocecal junction which accounts for 90% of the cases. In adults, small bowel intussusception is often reported on abdominal imaging. This finding is considered to be idiopathic and of no clinical significance in most cases. However, colonic intussusception is often the result of a lead point obstruction requiring further evaluation. We present a case of a 37 year old male with history of anxiety and depression, who presented with complains of intermittent abdominal pain ongoing for several weeks. The pain was located in the periumbilical region and described as sharp and spasmodic in nature. It occurred for a short duration in 2-3 hour intervals with complete resolution of pain between these periods. His symptoms were also associated with melena and hematochezia. At the time of his presentation, abdominal CT was performed which revealed colonic intussusception with telescoping of the hepatic flexure into the proximal transverse colon without evidence of masses or obstruction. Colonoscopy was pursued thereafter, which revealed a 7-8 cm polypoid mass in the proximal transverse colon causing partial obstruction and active torsion of colonic tissue, however the colonoscope was able to pass this area with moderate difficulty. Biopsies of the mass were sent for pathologic analysis and revealed features of tubulovillous adenoma with focal serrated architecture and surface inflammatory exudate. CEA tumor marker was obtained which was within normal limits. Patient underwent a laparoscopic assisted right hemi colectomy with partial omentectomy. The mass in the transverse colon was excised and confirmed tubulovillous adenoma. The patient had an uncomplicated post-operative course with resolution of symptoms. This is an unusual case of colonic intussusception in an adult male secondary to a large benign adenomatous lesion acting as a lead point. Although rare in adult population, pathologic intussusception of the colon should be considered in the differential of spasmodic or episodic pain in the mid or lower abdominal region and, radiographic findings of colonic intussusception should be investigated endoscopically to define the etiology

Volvulus of Ileal J Pouch - Rare But Yet Not Forgotten: A Rare Complication of Ileal Pouch Anal Anastomosis (IPAA) Leading to Small Bowel Obstruction

Surgical treatment of choice for refractory ulcerative colitis (UC) is ileal pouch-anal anastomosis (IPAA). Various complications related to the procedure are known, but volvulus of ileal pouch is an extremely rare complication with only few cases reported so far. We report a case of a 29 year old female with history of UC and IPAA who presented with intestinal obstruction, and was found to have an ileal pouch volvulus. A 29 year old female with history of refractory UC status post total proctocolectomy with IPAA 8 years ago was admitted with sudden onset of severe abdominal pain associated with constipation and inability to pass gas. She recently had an ileoscopy showing an ileoanal anastomotic stricture. Abdominal examination showed tenderness and hyperactive bowel sounds. Abdominal radiograph showed dilated small bowel loops. CT scan showed 11 cm dilatation of ileum proximal to the ileoanal anastomosis with a stricture at the anastomosis site. Differentials included pouchitis and de novo Crohn's disease of the ileal pouch. An ileoscopy was attempted but was aborted after findings of twisted IPAA site (spoke-wheel sign) with area of bluish discoloration suggesting ischemia and volvulus. She underwent urgent exploratory laparotomy. Intraoperatively ileal pouch volvulus was diagnosed with dilated proximal small bowel. Bowel was decompressed by enterotomy. No signs of necrosis were seen. She underwent loop ileostomy with uncomplicated postoperative course. UC refractory to medical management is surgically treated by proctocolectomy and IPAA with advantage of maintaining continence. Complications related to the procedure are pelvic infection (abscess/sepsis), pouch leak and bleeding occurring in the early postoperative period. Late complications are small bowel obstruction, stricture, pouchitis, de novo Crohn's disease of J-pouch and fistula formation. Volvulus of IPAA is a very rare complication. It should be included in the differential for postoperative patients presenting with abdominal pain and signs of bowel obstruction. Radiographic findings of the radial disposition of small bowel loops around the mesenteric root with abnormal right position of superior mesenteric artery and vein, and endoscopic finding of spoked-wheel sign are a clue to diagnosis. Delayed diagnosis can cause pouch ischemia and necrosis leading to pouch resection and end-ileostomy creation. Immediate surgical exploration and correction of volvulus is recommended to salvage the pouch.2541_A Figure 1. CT abdomen showing dilated ileal pouch with stranding in the mesentery2541_B Figure 2. Prior ileoscopy showing stricture at the ileoanal anastomosis site2541_C Figure 3. Ileoscopy showing twisted ileoanal anastomosis site (spoke-wheel sign) consisted with volvulus

Examining 30-Day Readmission Rate and Associated Factors in Patients Hospitalized for Diverticulitis Using Nationwide Readmission Database

Introduction: Diverticulitis is the third most common cause of hospitalization in the United States. While most have uncomplicated disease course, recurrence and complications can be a major source of morbidity and mortality. However, magnitude of 30-day readmission rate in patients with diverticulitis has not been studied. In addition to studying this, we aim to assess factors associated with 30-day readmissions in patients with diverticulitis. Methods: Nationwide readmission database (NRD), the largest all-payer database containing readmission data was interrogated for the years 2010-2014 to identify records of hospitalized adult patients (>18 years old) with primary hospital diagnosis of diverticulitis (ICD-9-CM 562.11 and 562.13). In patients who survived the index hospitalization, all-cause 30-day readmission (early readmission) rate was calculated. After a univariate analysis examining the differences in patients with and without early readmission, a multivariate survey logistic regression was performed to identify factors associated with early readmission. Results: N=303,346 hospitalizations with diverticulitis were identified, and of these 31.4% were readmitted within 30 days. Table 1 contains the results of univariate analysis comparing patients with and without 30-day readmission after presenting to the hospital for diverticulitis. In the multivariate analysis, age, teaching status of a hospital, payer type, disposition, length of stay, colonic resection, antibiotic use, placement of percutaneous drain, comorbidity index, and peritonitis were all factors associated with 30-day readmission (Table 2). Conclusion: Given that the average 30-day readmission rate for all-cause hospitalizations in the US was approximately 15% during this time, a 31% 30-day readmission rate for patients with diverticulitis is concerning and requires immediate attention. We have identified numerous factors associated with early readmission in these patients, and this can help inform national and local healthcare policy to help prevent early readmissions in these high-risk patient cohort. Specifically, given that surgical interventions (colorectal resection) and use of IV antibiotics use was associated with reduced readmission rate, further prospective research can focus on using these interventions in eligible patients to help reduce significant costs and morbidity associated with early readmissions.141 Figure 1. Examination of 30-day readmission rate in patients presenting with diverticulitis. Percentages displayed above are column percntages.

Xanthogranulomatous Pyelonephritis Causing a Renocolic Fistula Presenting as Symptomatic Anemia

Renocolic fistula is a rare clinical finding that is most commonly iatrogenic after surgical intervention. Herein, we present a case of spontaneous renocolic fistula secondary to Xanthogranulomatous pyelonephritis (XGP) with a subtle presentation as anemia. Given the subtle presentation in our case, colonoscopy findings were the trigger for further investigations.: This is a 40-year-old female was asked to go to the ED by her primary care physician (PCP) for low hemoglobin on routine labs. Patient had been complaining of fatigue, nausea, diarrhea, dysuria and urinary frequency for 7 days. Labs in the Emergency departement (ED) were remarkable for a hemoglobin of 6.5 g/dL (down from 10 g/dL 3 months prior) white blood cell count (WBC) of 18x103 cmm, creatinine of 1.87 mg/dL (baseline is 1 mg/dL) with blood urea nitrogen (BUN) of 24 mg/dL. Urinalysis was remarkable for too numerous WBC, positive bacteria and nitrite. Patient received 1 Unit of packed red blood cells and was started on Ceftriaxone for a urinary tract infection. No overt source of bleeding was identified. An esophagogastroduodenoscopy (EGD) was normal while colonoscopy showed a fistula with surrounding nodularity close to the splenic flexure of the colon (figure 1), a small amount of pus was also noted coming out from the fistula. Shortly after, the patient spiked a fever of 102.7F. C-Reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) were both elevated at 17 and 140 respectively which raised the concern of inflammatory bowel disease. A CT scan of the abdomen and pelvis with contrast showed findings of acute on chronic left kidney pyelonephritis with multiple contiguous abscesses in the inferior left kidney with a staghorn calculus concerning for XGP, it also showed the fistula between the left kidney and the splenic flexure of the colon (Figure 2,3). The patient underwent exploratory laparotomy, takedown and repair of renocolic fistula, partial omentectomy and left nephrectomy by urology and general surgery teams. Patient had an uncomplicated post-operative course and was discharged home on post-operative day 6 with a stable hemoglobin of 8 g/dL.1521_B Figure 2. CT scan of the abdomen and pelvis showing a renocolic fistula and xanthogranulomatous pyelonephritis1521_C Figure 3. CT scan of the abdomen and pelvis showing a renocolic fistula and xanthogranulomatous pyelonephritisIn conclusion, XGP is a rare type of chronic pyelonephritis that is usually a result of chronic obstruction by an infected stone. Spontaneous renocolic fistulas are rare nowadays with the advancement in antibiotics and renal stones management.1521_A Figure 1. Colonoscopy showing a fistula opening with surrounding nodularity

Оптимізація лікувально-діагностичного підходу до проведення мануальної вакуум-аспірації при післяпологових гнійно-запальних захворюваннях

The problem of postpartum pyo-inflammatory diseases requires the introduction of new approaches to its solution and optimization of diagnostic and therapeutic developments. The objective: was to determine the optimal time for manual vacuum aspiration of the uterus in postpartum endometritis, correction of therapeutic tactics and control of patients in the framework of the method of fluorescence spectroscopy. Materials and methods. The main group – 170 women with postpartum pyo-inflammatory diseases, control group – 40 women with uncomplicated course of the postpartum period. Their blood serum was examined using the method of fluorescence spectroscopy, in particular after manual vacuum aspiration of the uterus. Results. Fluorescence spectra were studied for 40 women of control group and 170 women of the main group, among them in 44 (25.8%) – in the dynamics during the treatment after manual vacuum aspiration of the uterine cavity. In 93.2% of the patients in the main group after it an increase in fluorescence intensity and max displacement in the short-wave region were recorded, which was a reliable sign of improving the condition of the patients. Conclusion. The use of the method of fluorescence spectroscopy in postpartum endometritis after manual vacuum aspiration of the uterus significantly helps to improve the monitoring of the process of treatment and, if necessary, to correct it in order to recover the patients in time. Key words: endometritis, manual vacuum aspiration of the uterus, the method of fluorescence spectroscopy.

Home treatment of acute pulmonary embolism: state of the art in 2018.

Historically, because of the necessity of parenteral anticoagulation, patients with acute pulmonary embolism are hospitalized until stable oral anticoagulation is achieved. Despite improvements in prognostic risk stratification and the introduction of the direct oral anticoagulants, home treatment is still not widely applied. Main advantages of home treatment involve improvement of quality of life and significant healthcare cost reduction. In this review, we summarized recent published data on home treatment of patients with acute pulmonary embolism. Although a significant decrease in mean duration of hospital admission for pulmonary embolism has been demonstrated over the last decade in Europe, most pulmonary embolism patients are currently hospitalized while they might be treated in an outpatient setting. In recent years, five major studies have been performed, in which the decision to initiate home treatment was based on the Hestia criteria in most patients. Over 98% of patients treated at home had an uncomplicated course. Home treatment of acute pulmonary embolism is suggested to be feasible and safe in 30-55% of all patients. Results of ongoing trials will provide more insight in the optimal strategy to select patients with pulmonary embolism who are eligible for home treatment and likely will result in more widespread application of this practice.

Atrial septal defects and pulmonary arterial hypertension.

Atrial septal defects (ASD) are a common congenital heart defect. The majority of patient with ASDs often follow an uncomplicated course of events. However, a proportion of patients with ASDs, may have their condition complicated by pulmonary hypertension (PH), with a subsequent significant impact on management, morbidity and mortality. The presence of PH, influences the suitability for defect closure. In this review we describe the different types of ASDs, the classification of PH related to congenital heart disease (CHD), when ASD closure is contraindicated and the management of patients who develop pulmonary arterial hypertension (PAH), including the most extreme form, Eisenmenger syndrome (ES).