Incarcerated congenital transmesenteric hernia in an adult: a case report

Abstract

Transmesenteric hernia is a rare cause of bowel obstruction and strangulation. It can be due to iatrogenic injury, trauma, inflammatory and less likely congenital. We present a case of true congenital transmesenteric hernia in a 26-year-old male with no previous surgical history or trauma. The patient presented acutely with no prior symptoms. Investigations provided limited information towards the diagnosis of the hernia, but suggestive of mid-gut volvulus. Emergency laparotomy was performed to find >75% of small bowel herniating through a proximal jejunal mesenteric defect leading to incarceration and early strangulation. No resection was required and patient recovered well. This case presents yet another rare pathology and highlights the importance of keeping a low threshold for operative intervention in uncertain cases.

http://ift.tt/2uq894k

Traumatic diaphragmatic rupture with underlying lung laceration and tension pneumoperitoneum

Abstract

Tension pneumoperitoneum is commonly caused by gastrointestinal perforation and pulmonary causes are extremely rare. We present a case of a 47-year-old male post motor vehicle accident with a suspected left-sided haemopneumothorax on initial chest x-ray. CT of the chest post chest tube insertion showed a left-sided diaphragmatic rupture and an extensive diaphragmatic hernia. While en-route to the operating theatre, the intubated patient developed tension pneumoperitoneum with positive pressure ventilation and required immediate surgical intervention and repair. A review of the literature around tension pneumoperitoneum and diaphragmatic hernia in trauma is discussed.

http://ift.tt/2upTUMX

Hybrid approach to the management of infective endocarditis complicated by coronary artery embolism: a case report

Abstract

Septic coronary embolization in a patient with endocarditis is a rare and can be a devastating complication. The management of this clinical problem in the current era may be best served with a multi-modality approach. We present an interesting case of a patient with septic coronary embolization managed with the combined use of aspiration thrombectomy followed by surgical management of the infected valve.

http://ift.tt/2upVuyD

Endogenous endophthalmitis and osteomyelitis associated with interleukin 17 inhibitor treatment for psoriasis in a patient with diabetes

A 64-year-old man with type 2 diabetes mellitus and plaque psoriasis presented to the emergency room with 3 days of progressive right eye pain and decreased vision. After extensive workup and multidisciplinary team effort, the patient was diagnosed with and treated for unilateral endogenous methicillin-sensitive Staphylococcus aureus endophthalmitis, bacteraemia and osteomyelitis of the foot. The patient had been started on the interleukin 17 (IL-17) inhibitor secukinumab for his treatment-resistant plaque psoriasis 4 weeks prior to presentation. After treatment, his final vision was light perception and the foot infection resolved without sequelae. To our knowledge, this is the first reported case of both endogenous endophthalmitis and osteomyelitis associated with an IL-17 inhibitor.

http://ift.tt/2triYGu

An elusive ciliopathy: Joubert syndrome

The police brought a 65-year-old female patient to the EADU after being found 'roaming the streets' in an apparent state of confusion. This was her third admission under the same circumstances during the last 3 years. Neurological examination revealed (1) cognitive impairment, (2) oculomotor apraxia, (3) abnormal cancellation of vestibular ocular reflex, (4) mild ataxia and (5) mild hypotonia. Renal function was abnormal and liver function was normal. No retinal disturbance was found. The head CT on admission was normal for stroke and the lumbar puncture was negative for encephalitis. Her brain MRI showed 'molar tooth sign', suggestive of Joubert syndrome, which was confirmed by genetic testing showing anomalous NPHP1 gene

http://ift.tt/2s8jeq9

Anal herpes

Description

A 27-year-old man without significant past medical history presented to the emergency department with a 5-day evolution of abdominal and anal pain and haematochezia. Physical examination revealed perianal erythema and a painful digital anal examination without other findings. CT scans showed signs of proctitis (slight thickening of rectal wall and slight stranding of perirectal fat). Flexible rectosigmoidoscopy didn't reveal any pathological abnormalities. The patient was discharged with antibiotics and analgesics with the suspicion of proctitis. Three days later, the patient returned to the emergency department with worsening of the anal pain that irradiated to the buttocks and the physical examination revealed red bumps with ulceration (figure 1). Anal herpes was suspected and the patient was treated with an antiviral (brivudine) and carbamazepine for symptomatic relief. Seven days after treatment the patient had complete resolution of his symptoms and there were no cutaneous lesions.

Figure...

http://ift.tt/2sqpWab

Cardiogenic shock from coronary vasculitis in granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a systemic vasculitis characterised by necrotising inflammatory changes in small-sized and medium-sized vessels and granuloma formation. It most commonly involves the kidneys and respiratory tract, but it can present with widespread manifestations involving any organ system. Rarely, it causes coronary vasculitis which can precipitate a severe cardiomyopathy. Here, we report a patient who presented in cardiogenic shock requiring vasopressors and was found to have extensive myocardial ischaemia secondary to coronary vasculitis. Further investigation led to a diagnosis of GPA, and he responded to treatment with corticosteroids, cyclophosphamide and plasmapheresis.

http://ift.tt/2sV3KIN

Large prostatic stones with staghorn renal calculus in a 61-year-old man: an unusual presentation of uncommon disease

Prostatic parenchymal calculi are common in ageing men who are evaluated for benign prostatic hyperplasia or prostate cancer. Giant prostatic calculi are very rare, usually associated with local predisposing factors for urinary stasis and infections, and traditionally managed by open surgery. We present the first case of its kind to be associated with a concurrent staghorn nephrolithiasis, and removed successfully by endoscopic approach using an access sheath through the urethra.

http://ift.tt/2sqBkTD

Gangrenous digital infarcts in a severe case of cutaneous polyarteritis nodosa

Cutaneous polyarteritis nodosa (CPAN) is a rare diagnosis which is distinct from polyarteritis nodosa (PAN). PAN is a medium-vessel vasculitis which can affect multiple organs and classically produces microaneurysms in the vasculature. CPAN is limited to the skin mainly affecting small vessels. There is an absence of microaneurysms in CPAN and it does not affect internal organs. However, the histopathological findings on the skin are similar to PAN. CPAN rarely progresses to PAN but relapses more often. We will illustrate a challenging case of a patient with CPAN who developed gangrenous infarcts despite initial immunosuppressive treatment with high-dose steroids and azathioprine. His treatment had to be escalated to intravenous cyclophosphamide which induced disease remission

http://ift.tt/2sUYXHu

Case 20-2017: A 48-Year-Old Man with Weight Loss, Confusion, Skin Lesions, and Pancytopenia

Presentation of Case. Dr. Robert H. Goldstein (Medicine): A 48-year-old man was seen in the emergency department of this hospital because of confusion. The week before this presentation, the patient, who was a lawyer, had traveled alone to Mexico for vacation. His family reported that he seemed to…

http://ift.tt/2s5siMj

Intelligent dynamic clinical checklists improved checklist compliance in the intensive care unit

Abstract

Background. Checklists can reduce medical errors. However, the effectiveness of checklists is hampered by lack of acceptance and compliance. Recently, a new type of checklist with dynamic properties has been created to provide more specific checklist items for each individual patient. Our purpose in this simulation-based study was to investigate a newly developed intelligent dynamic clinical checklist (DCC) for the intensive care unit (ICU) ward round.Methods. Eligible clinicians were invited to participate as volunteers. Highest achievable scores were established for six typical ICU scenarios to determine which items must be checked. The participants compared the DCC with the local standard of care. The primary outcomes were the caregiver satisfaction score and the percentages of checked items overall and of critical items requiring a direct intervention.Results. In total, 20 participants were included, who performed 116 scenarios. The median percentage of checked items was 100.0% with the DCC and 73.6% for the scenarios completed with local standard of care (P<0.001). Critical items remained unchecked in 23.1% of the scenarios performed with local standard of care and 0.0% of the scenarios where the DCC was available (P<0.001). The mean satisfaction score of the DCC was 4.13 out of 5.Conclusions. This simulation study indicates that an intelligent DCC significantly increases compliance with best practice by reducing the percentage of unchecked items during ICU ward rounds, while the user satisfaction rate remains high. Real-life clinical research is required to evaluate this new type of checklist further.

http://ift.tt/2tnqPVI

Postoperative delirium in elderly patients is associated with subsequent cognitive impairment

Abstract

Background. We examined the risk for postoperative delirium (POD) in patients with mild cognitive impairment (MCI) or dementia, and the association between POD and subsequent development of MCI or dementia in cognitively normal elderly patients.Methods. Patients ≥65 yr of age enrolled in the Mayo Clinic Study of Aging who were exposed to any type of anaesthesia from 2004 to 2014 were included. Cognitive status was evaluated before and after surgery by neuropsychological testing and clinical assessment, and was defined as normal or MCI/dementia. Postoperative delirium was detected with the Confusion Assessment Method for the intensive care unit. Logistic regression analyses were performed.Results. Among 2014 surgical patients, 74 (3.7%) developed POD. Before surgery, 1667 participants were cognitively normal, and 347 met MCI/dementia criteria. The frequency of POD was higher in patients with pre-existing MCI/dementia compared with no MCI/dementia {8.7 vs 2.6%; odds ratio (OR) 2.53, [95% confidence interval (CI) 1.52–4.21]; P<0.001}. Postoperative delirium was associated with lower education [OR, 3.40 (95% CI, 1.60–7.40); P=0.002 for those with <12 vs ≥16 yr of schooling]. Of the 1667 patients cognitively normal at their most recent assessment, 1152 returned for postoperative evaluation, and 109 (9.5%) met MCI/dementia criteria. The frequency of MCI/dementia at the first postoperative evaluation was higher in patients who experienced POD compared with those who did not [33.3 vs 9.0%; adjusted OR, 3.00 (95% CI, 1.12–8.05); P=0.029].Conclusions. Mild cognitive impairment or dementia is a risk for POD. Elderly patients who have not been diagnosed with MCI or dementia but experience POD are more likely to be diagnosed subsequently with MCI or dementia.

http://ift.tt/2s4ERHH