Spontaneous rupture of the common hepatic duct associated with acute pancreatitis: a case report

Rupture of the common bile duct is a life-threatening condition, usually observed after a trauma or in association with choledocholithiasis or an obstructive tumor of the bile duct. However, a spontaneous rupt...

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Treatment of Severe Refractory Hematuria due to Radiation-Induced Hemorrhagic Cystitis with Dexamethasone

Treatment of pelvic neoplasms with radiotherapy may develop sequelae, especially RHC. An 85-year-old male patient was admitted to a hospital emergency with gross hematuria leading to urinary retention and was diagnosed with RHC. The urinary bladder was probed, unobstructed, and maintained in continuous three-way saline irrigation. During 45 days of hospitalization, the patient underwent two cystoscopic procedures for urinary bladder flocculation, whole blood transfusions, and one platelet apheresis. None of these interventions led to clinical resolution. As the patient hematological condition was deteriorating, dexamethasone (4 mg i.v., bolus of 6/6, 12/12, and 24 h during five days) and epoetin alpha (1000 IU, 1 ml, s.c., for four weeks) were administered which led to the remission of the urinary bleeding. Dexamethasone therapy may be considered for RHC, when conventional treatments are not effective or are not possible, avoiding more aggressive interventions such as cystectomy.

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Surgical emergency: rupture of infected brachial artery pseudoaneurysm

Description

A 53-year-old right hand dominant man with a significant medical history of intravenous heroin abuse for over 10 years. He admitted to last injecting heroin this morning into his right arm. Surgical history is significant for traumatic right-hand amputation 10 years ago and multiple right-arm debridements for chronic wound infections from active heroin use. Patient presented to the emergency department with a brisk pulsatile right upper arm bleed. On initial surgical consultation, the patient was found to be hypotensive and tachycardic. Manual pressure was held over a pseudoaneurysm that was noted to be bleeding (figure 1 and video 1). Blood pressure cuff was applied proximal to the bleeding site, and the patient was taken to the operating room for exploration.

Figure 1

Note the chronic infected wounds and deformed upper extremity from multiple surgical procedures and pre-existing trauma.

Video 1

Pulsatile...

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A retrospective observational cohort study investigating the association between acute kidney injury and all-cause mortality among patients undergoing endovascular repair of abdominal aortic aneurysms

Abstract

Background

Acute kidney injury (AKI) has been found to be associated with short- and long-term mortality and morbidity in various clinical settings. However, it is unknown whether AKI after endovascular repair of abdominal aortic aneurysms (EVAR) is associated with postoperative mortality.

Methods

This observational study analyzed patients who underwent EVAR. The primary outcome was all-cause mortality. The outcomes of patients with and without postoperative AKI were compared using the Kaplan–Meier method and log-rank test. Factors with P < 0.05 on the univariate analysis were entered into the multivariate Cox regression model. Predictors of AKI were also determined using Cox univariate and multivariate analysis. The identified predictors of AKI were excluded from multivariate analysis for all-cause mortality because these factors could intermediate outcome.

Results

There were 490 eligible patients. After a follow-up of 28.3 (16.8) months [mean (standard deviation)], 62 patients (12.7%) died. AKI occurred in 59 patients (12.0%). AKI was found by the log-rank test to be associated with a significant increase of all-cause mortality (P < 0.001). Preoperative estimated glomerular filtration rate, preoperative peripheral vascular disease, and emergency surgery were found to be independent predictors of AKI and these variables were excluded from the main analysis. Multivariate analysis showed AKI [hazard ratio (HR) = 1.19, 95% confidence interval (CI) 1.01–3.60, P = 0.045] and transfusion (HR = 1.05, 95% CI 1.01–1.09, P = 0.011) were independent predictors of mortality.

Conclusions

In the present study, AKI and transfusion were associated with significant increases in all-cause mortality after EVAR.

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An Unexpected Cause of Bradycardia in a Patient with Bacterial Meningitis

Sinus bradycardia which is a sinus rhythm with a resting heart rate of less than 60 bpm is caused by intrinsic cardiac disorders like sick sinus syndrome or inferior myocardial infarction, metabolic and environmental causes (such as hypothyroidism and electrolyte disorders), medications (such as beta-blockers and amiodarone), infection (such as myocarditis), increased intracranial pressure, and toxic exposure, while it can sometimes be a normal phenomenon, especially during sleep, in athletes, and during pregnancy. Symptomatic sinus bradycardia should warrant a thorough work-up in order to identify any reversible causes; otherwise, placement of a permanent pacemaker could be needed. We present the case of a patient who was admitted due to confusion and fever and was found to have pneumococcal meningitis and bacteremia, and during his hospital stay he developed symptomatic sinus bradycardia that was of intractable cause and persistent. Placement of a permanent pacemaker was chosen until the night staff of the hospital discovered by chance the neglected cause of his bradycardia.

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POEMS syndrome: a rare cause of exudative ascites and chronic peripheral neuropathy

POEMS syndrome (Peripheral neuropathy, Organomegaly, Endocrinopathy, M protein, Skin changes) is a rare plasma cell disorder with multisystem involvement

A 40-year-old man with a chronic history of unexplained peripheral neuropathy , presented with exudative ascites.He was found to have an incidental osteolytic lesion of the sacrum proven to be a plasmacytoma. Immunoelectrophoresis for monoclonal protein was negative.

In addition, the patient was found to have hepatosplenomegaly, erectile dysfunction, hyperprolactinaemia and hypothyroidism.

The patient, was given steroid along with lenalidomide, and showed a good clinical response.

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Successful conservative management of a permanent pacemaker pocket infection: a less invasive approach

We present a successful conservative management strategy for a frail elderly patient with a cardiac resynchronisation pacemaker who presented with evidence of an Enterobacter cloacae pacemaker pocket infection. A device washout and debridement procedure was performed, with reburial of the device in a new prepectoral pocket and creation of a closed-loop continuous antibiotic infusion into the infected pacemaker pocket. This was followed by a 6-week course of ambulatory intravenous antibiotic therapy. This conservative management strategy avoided the need for a more invasive and high-risk full device extraction, which the patient clearly stated he did not wish to have. Up-to-date consensus management guidelines recommend extraction of the entire implanted system in this situation; however, in this case we demonstrate an alternative conservative management option, which may be suitable for frail elderly and comorbid patients or for patients who decline device extraction.

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