e-learning: the anesthesiology media lab of Yale University School of Medicine. A review

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Composite neuroendocrine carcinoma and squamous cell carcinoma with regional lymph node metastasis: a case report

Neuroendocrine cell carcinoma is a rare variant of esophageal carcinoma. The characteristic clinical features and diagnosis of superficial neuroendocrine cell carcinoma remain to be established. We report a ra...

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A 27-Month-Old Boy with Polyuria and Polydipsia

Psychogenic polydipsia is a well-described phenomenon in those with a diagnosed psychiatric disorder such as schizophrenia and anxiety disorders. Primary polydipsia is differentiated from psychogenic polydipsia by the lack of a clear psychotic disturbance. We present a case of a 27-month-old boy who presented with polyuria and polydipsia. Laboratory studies, imaging, and an observed water deprivation test were consistent with primary polydipsia. Polydipsia resolved after family limited his fluid intake and began replacing water drinking with other transition objects and behaviors for self-soothing. This case highlights the importance of water deprivation testing to differentiate between causes of polyuria, thereby avoiding misdiagnosis and iatrogenic hyponatremia. Secondly, primary polydipsia can result during the normal stages of child development without overt psychiatric disturbances.

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Case of acute paraspinal pyomyositis in an elderly diabetic secondary to spread from urinary tract infection

A 73-year-old woman with medical history of diabetes and hypertension presented with right-sided back pain and night sweats of 1 month duration. On physical examination, there was costovertebral angle tenderness and her urinalysis was indicative for urinary tract infection. She was admitted and managed with intravenous antibiotics. On initial imaging, there was a right-sided retroperitoneal mass adjacent to right kidney. This was investigated further with MRI, which showed diffuse inflammation of right paraspinal muscles with two loculated abscesses. The abscesses were aspirated and the culture sent grew Streptococcus agalactiae (Group B Streptococcus) and the patient was treated with 6-week course of intravenous antibiotics.

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Scrotal oedema: a misadventure of direct vision internal urethrotomy

Description 

A 30-year-old man presented with voiding lower urinary tract symptoms for 2 years due to bulbar urethral stricture. He had a history of appendectomy two and a half years ago during which he was catheterised. His retrograde urethrogram was suggestive of a short (<1 cm) bulbar urethral stricture (figure 1). After proper counselling, he was posted for direct vision internal urethrotomy (DVIU) under spinal anaesthesia. Immediately following the procedure, he developed scrotal oedema (figure 2). Perineal compression was given along with scrotal support. The patient was observed for 2 days in the ward; there was no increase in the oedema. He was subsequently discharged with an advice to keep a scrotal support and called on the 10th postoperative day. His oedema had completely resolved and his catheter was removed. He voided with a good flow rate of 27 mL/s and had a normal bell-shaped curve on uroflow...

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A deceptive presentation of Tuberculosis hip as Staphylococcal infection, its successful management and literature review

A 71-year-old man presented with septic arthritis of the hip with an initial culture growth of methicillin-sensitive Staphylococcus aureus (MSSA) masking the diagnosis of tuberculosis (TB). Based on joint aspirate culture and sensitivity results, the patient was first diagnosed with MSSA arthritis. He was started on intravenous antibiotics and underwent washout and debridement of hip. During the procedure, the surgeons observed characteristic tubercular changes and samples were sent for tubercular testing. The reports of cultures for acid-fast bacilli and synovial biopsies confirmed our intraoperative suspicion of TB. Antitubercular medication was started and it helped patient to improve quickly. He completed 9 months of tubercular treatment regimen and at completion total hip replacement was offered. At 8-year follow-up, the patient was doing fine with no recurrence of infection in his hip. High index of suspicion for skeletal TB was raised based on clinical and radiological signs especially if there was a delay or absence of response to appropriate therapy.

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Port site hernias following robotic colorectal surgery in people with obesity

Port site hernias are a rare complication following robotic surgery that can result in disastrous outcomes. We describe incarcerated port site hernias in two patients with obesity. Both patients required laparoscopic reduction. Following laparoscopic reduction, one patient's postoperative course was complicated by pneumatosis intestinalis, requiring exploratory laparotomy and subsequent small bowel resection. It is standard practice to not close the fascia of port sites less than 12 mm in robotic surgery. However, this allows for the rare possibility of small bowel herniation through the port site. We suggest that our patients' history of obesity and metabolic dysfunction contributed to difficult port retention during the case, and longer operating times which caused an increased amount of torque at the port site. Additionally, compared with laparoscopic surgery, robotic surgery is associated with increased torque at port sites. The combination of these risk factors extended the fascial defect, ultimately leading to the incarceration of small bowel in the port site.

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Blood culture-negative endocarditis presenting as altered mental status

Blood culture-negative endocarditis (BCNE) is difficult to diagnose because one of the major criteria to raise suspicion for endocarditis, a positive blood culture, is absent. BCNE accounts for 2.5% to 31% of all cases of endocarditis. Our report describes a 69-year-old woman with end-stage renal disease who presented with altered mental status. Physical examination and testing, including complete blood count, comprehensive metabolic panel, chest X-ray and head CT were otherwise unremarkable. Brain MRI revealed multiple areas of decreased diffusion concerning for cardioembolic stroke. A transthoracic echocardiogram demonstrated an abnormality on the mitral valve. Operative evaluation revealed a purulent mitral valve with vegetative clumps. Cultures of the vegetation and the blood grew no organisms. BCNE is a rare entity; neurological abnormalities may be the only presenting signs/symptoms. Endocarditis should be considered among the causes of altered mental status, even in the absence of positive blood cultures.

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Use of optokinetic chart stimulation to restore mobility and reduce ataxia in a patient with pseudo-Cushing ataxia

A 61-year-old patient was admitted to hospital after a fall. She presented with bilateral muscle weakness and severe ataxia. She was unable to maintain sitting balance or place feet on the floor and was unable to tolerate hoist transfers due to the severity of her ataxia. Nursing and physiotherapy staff found it difficult to sit her out of bed. Her physiotherapy intervention changed to optokinetic chart stimulation (OKCS) and sensory interaction for balance. After treatment for 5 days, her intention tremor fully resolved. At discharge, she was mobile with a wheeled zimmer walking frame and supervision of one person. At follow-up after 8 months, she was independently mobile without any walking aid in and around her house. She was going out shopping with her son. For recovery from ataxia, it is recommended that further research on restorative intervention at the nervous system level be carried out.

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Ictal cardiorespiratory depression: a real risk for sudden unexpected death in epilepsy (SUDEP)?

A 61-year-old woman affected by nocturnal hypermotor seizures since the age of 2 years complained of epigastric discomfort and chocking sensation before seizure onset for the last 25 years. Telemetry unit monitoring revealed several focal seizures with left frontotemporal onset complicated with ictal asystole and apnoea. After pacemaker (PM) implantation, video-EEG monitoring coupled with extensive respiratory montage confirmed the presence of ictal central apnoea. Despite this huge ictal autonomic imbalance which is claimed to be a risk factor for sudden unexpected death in epilepsy, the patient had a 25-year history of similar seizures, questioning the need to perform PM implantation and assisted ventilation.

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Physiological pituitary hyperplasia misinterpreted and treated as lymphocytic hypophysitis

Description 

A 19-year-old nulliparous eumenorrhoeic woman diagnosed with bilateral serous retinal detachment was referred for incidentally detected enlarged pituitary gland, seen on MRI of orbit. A focused MRI documented diffuse, symmetric enlargement of the pituitary gland having a convex superior surface abutting the optic chiasm (11.4 mm in antero-posterior x 16.9 mm in transverse x 9.3 mm in height) with marked homogeneous gadolinium enhancement with a thickened, non-tapering stalk (3.5 mm at infundibulum) and a conspicuous eutopic posterior pituitary bright spot (figure 1). A comprehensive work-up remained unremarkable (table 1). In view of symmetric, enlarged pituitary demonstrating intense homogeneous contrast enhancement and a thickened (>2–3 mm thickness is considered pathological), non-tapering pituitary stalk in this non-pregnant individual, a diagnosis of lymphocytic hypophysitis (LH) was considered, after ruling out the other possible differential diagnosis. Pulse therapy with intravenous methylprednisolone was initiated followed by maintenance therapy with daily prednisolone gradually tapered over 12 weeks....

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Feeding difficulty in an infant: an unusual cause

A 10-month-old girl, with spondyloepiphyseal dysplasia congenita and posterior cleft palate had presented at 23 days of life with history of feeding difficulties. A diagnosis of oropharyngeal dysphagia and gastro-oesophageal reflux disease was made, for which she was started on nasogastric tube feeding and oral ranitidine. However, she continued to have poor development of oropharyngeal skills, persistent reflux as well as poor growth and was planned for gastrostomy at 10 months of age. She underwent soluble upper gastrointestinal contrast study prior to gastrostomy placement to rule out anatomical causes of vomiting, which showed the greater curvature of the stomach to be lying above the lesser curvature, suggesting a diagnosis of gastric volvulus, likely chronic, given that she did not have a history of abdominal distension, irritability or recurrent vomiting. On diagnosis of gastric volvulus, our patient underwent laparoscopic gastrostomy creation and is doing well postoperatively.

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Left shoulder pain in patients with old myocardial infarction could be a neuropathic pain from spinal epidural haematoma

Description 

A 66-year-old Japanese man with medical history of old myocardial infarction and on daily aspirin presented to the emergency department with sudden onset of severe left shoulder pain. He reported no prior trauma and denied cold sweat, vomiting, chest or back pains. At the time of initial evaluation, cardiac and neurological examinations were normal and there was no tenderness over the shoulder joints or the spine. A diagnosis of acute myocardial infraction or aorta dissection was first suspected. However, ECG, serum troponin T concentration and contrast-enhanced CT of the chest showed negative results.

The patient was admitted to the emergency department under the diagnosis of possible acute coronary syndrome. But, several hours later, he suddenly developed mild weakness of the left upper and lower extremities without facial muscle involvement. Urgent MRI revealed cervical spinal epidural haematoma (SEH) with spinal cord compression mainly to the left side (

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Fungal bezoar in an immunocompetent patient: a rare complication of forgotten double J stent

Description 

A 38-year-old man presented with intermittent right flank pain, dysuria, passage of turbid urine and low-grade fever for the last 1 year. He revealed a history of right-sided laparoscopic Anderson-Hynes dismembered pyeloplasty with double J (DJ) stenting performed for right pelviureteric junction obstruction 5 years back at other centre. The discharge card given to the patient advised for DJ stent removal, but the patient was lost to follow-up and never underwent DJ removal. His medical history was unremarkable for diabetes, HIV or steroid intake. On physical examination there was tenderness present in right flank on deep palpation. Blood serum chemistries revealed mildly deranged renal function tests (blood urea nitrogen 56 mg/dL; serum creatinine 1.5 mg/dL) with normal random blood sugar (92 mg/dL) and liver function tests. Urine analysis showed 40–50 pus cells/high power field (HPF), 20 red blood cells/HPF and presence of fungal hyphae and spores. Urine culture revealed >10⁵ colony counts of Candida albicans per...

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Rapid hair depigmentation in patient treated with pazopanib

Pazopanib is multitargeted tyrosine kinase inhibitor used for the treatment of metastatic renal cell carcinoma. Hair colour change is a common side effect of pazopanib therapy which usually develops gradually during few months of therapy. We report a case of the patient who developed multiple pazopanib side effects followed by rapid overnight hair and eyebrow depigmentation after only few weeks of therapy. In our research, we found no literature data of rapid loss of hair pigment due to therapy with any of listed multitargeted tyrosine kinase inhibitors. To the best of our knowledge, this is the first such case being reported. We presume that summation of different mechanisms probably led to rapid hair depigmentation. Considering the fact that pazopanib treatment was very effective in our patient, this side effect could be a good predictor of therapy success, although it presents very stressful event for patient and his family.

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Asymmetric Omphalopagus in a Triplet after In Vitro Fertilization: A Rare Case of Conjoined Twinning

Introduction. Asymmetric omphalopagus is a rare situation of conjoined twinning, in which a grossly defective twin is attached to the thorax and upper abdomen of the main twin. We describe a case of an asymmetric omphalopagus accompanied by a normal triplet after assisted reproductive technology (ART) and tried to further characterize the all aspects of the conjoined twins. Case Presentation: Perioperative diagnostic imaging was carried out followed by an autopsy to evaluate all aspects of the parasite accompanied by histological, immunohistochemical, and molecular biological evaluation. The parasite had well-developed lower extremities as well as upper extremities with a cleft hand syndrome. The sex was nondeterminable, but DNA fingerprinting revealed that both parasite and autosite are monozygotic, so are females. There was no sign of any axial skeleton or central nervous system. We found a rudimentary rectum with a nonpervious anus, a kidney, ureter, urinary bladder, and a blind-ending urethra. The blood supply of the parasite was connected to the vessel system of the autosite. Conclusions. To our knowledge, only two cases of parasitic omphalopagus after ART have been described to date. Altogether, 52 cases have been reported, and in most of them, the parasites were successfully separated.

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