Calcium channel blocker ingestions remain one of the leading causes of death related to cardiovascular medication ingestion in both adults and pediatric patients. We report a case of a 17-year-old, ...103 kg female presenting after an intentional polypharmacy ingestion, including 500 to 550 mg of amlodipine. She presented with profound vasoplegia and cardiovascular collapse requiring high-dose inotropes and eventual life support with extracorporeal membrane oxygenation (ECMO). Current available treatments, designed for adults, including lipid emulsion and methylene blue, provided no sustained clinical improvement. This resulted in the initiation of single-pass albumin dialysis (SPAD). We aim to describe the clinical implications, amlodipine toxic dose effects, and clinical challenges associated with large pediatric patients and high-dose medications. We also discuss several challenges encountered related to dosing and concentration of medications, which led to fluid overload. Given the ongoing obesity epidemic, we routinely see pediatric patients of adult size. This will continue to challenge pediatric use of adult dosing and concentrations to avoid excessive fluid administration for high-dose medications, such as insulin and vasoactive agents. To our knowledge, this is the first successful case of using SPAD in conjunction with ECMO for salvage therapy after refractory life-threatening calcium channel blocker toxicity.
Highlights • Large study analyzing predictive factors of VP shunt revision in iNPH. • Baseline nausea showed a trend towards increased odds of revisions. • Baseline gait and cognitive symptoms ...associated with fewer shunt revisions. • Baseline headaches and urinary symptoms associated with greater time to first revision. • Baseline gait instability associated with shorter time to first revision.
Failure to Yield: Refractory Achalasia Ladizinski, Barry, MD; Rukhman, Erik D., BS; Sankey, Christopher, MD
The American journal of medicine,
2014, January 2014, 2014-Jan, 2014-01-00, 20140101, Letnik:
127, Številka:
1
Journal Article
Recenzirano
Ladizinski et al discuss the case of a 54-year-old man with refractory achalasia. He had a 10-year history of achalasia presented with nausea, emesis, and recurrent, nonradiating, crushing chest pain ...that worsened with food consumption. One month after presentation, the patient underwent minimally invasive Ivor-Lewis esophagectomy with gastric pull-through for end-stage achalasia. In spite of surgical intervention, he has remained symptomatic and manages ongoing symptoms with behavioral modification, eating small, frequent meals.
Abstract Current guidelines for treatment of diabetic ketoacidosis (DKA) recommend administration of an intravenous bolus dose of insulin followed by a continuous infusion. This study was designed to ...investigate whether the initial bolus dose is of significant benefit to adult patients with DKA and if it is associated with increased complications. This was a non-concurrent, prospective observational cohort study of adult patients who presented with DKA in a 12-month period. Charts were divided into two groups depending on whether they received an initial bolus dose of insulin. Data on glucose levels, anion gap (AG), intravenous fluid administration (IVF), and length of stay (LOS) were collected. Primary outcome was hypoglycemia (need for administration of 50% dextrose). Of 157 charts, 78 received a bolus of insulin and were designated the treatment group, the remaining 79 formed the control group. Groups were similar at baseline and received equivalent IVF and insulin drips. There were no statistically significant differences in the incidence of hypoglycemia (6% vs. 1%, respectively, p = 0.12), rate of change of glucose (60 vs. 56 mg/dL/h, respectively, p = 0.54) or AG (1.9 vs. 1.9 mEq/L/h, respectively, p = 0.66), LOS in the Emergency Department (8 vs. 7 h, respectively, p = 0.37) or hospital (5.6 vs. 5.9 days, p = 0.81). Equivalence testing revealed no clinically relevant differences in IVF change, rate of change of glucose, or AG. Administration of an initial bolus dose of insulin was not associated with significant benefit to patients with DKA and demonstrated equivalent changes in clinically relevant endpoints when compared to patients not administered the bolus.
Abstract Background Predicting survival after surgery for patients with metastatic spine disease can be challenging with multiple variables that can influence a patient's overall survival. Predictive ...models have been developed to assist clinicians in providing prognosis for patients. Recently, Ghori et al reported a composite model taking into account a modified Bauer score, pre-operative albumin and ambulatory status of patients with spinal metastasis. We sought to assess the reliability and validity of this composite model to predict one-year survival in patients diagnosed with metastatic cancer to the spine using an independent cohort. Purpose To assess the reliability and validity of the Ghori et al composite model to predict one-year survival in patients diagnosed with metastatic cancer to the spine using an independent cohort. Study Design/Setting Retrospective study Patient Sample 161 patients with spinal metastasis undergoing surgery Outcome Measures Patients' modified Bauer score, pre-operative albumin and ambulatory status were assessed. Methods Retrospective study of 161 patients with spinal metastasis who underwent surgical management from 2007 to 2013. The ability of this composite model to predict one-year survival was compared with actual patient survival using multivariable logistic regression to control for confounders, as well as post-regression diagnostics. Results Our analysis revealed significantly lower one-year mortality among patients with higher composite scores as compared to those with lower scores. Strong associations between scores and survival were appreciated in unadjusted analysis. The final model was able to account for 80% of the variation in the one-year survival and there was no evidence of lack of fit. Conclusion This study demonstrates, in an independent cohort of spinal metastases patients that a composite model taking into account the ambulatory status, serum albumin, and modified Bauer score is able to better predict post-operative survival. This data serves to validate the use of this predictive model in determining the prognosis of patients with spinal metastasis.
Category:
Ankle; Sports; Trauma
Introduction/Purpose:
Chronic ankle instability (CAI) is a commonly encountered condition amongst foot and ankle surgeons and is characterized by loss of function and ...stability of the ankle following multiple or poorly healed ankle sprains. The Brostrom- Gould procedure is a widely accepted method of addressing CAI and has been seen to produce favorable outcomes in terms of regaining ankle function and stability. While long-term clinical results of the Brostrom-Gould procedure exist in the literature, there is little published on long-term patient-reported outcomes.
Methods:
Patients that underwent the Brostrom-Gould procedure from 2011 to 2015 were identified. The electronic medical record was utilized to collect patient demographics, preoperative and postoperative diagnosis, and clinical outcomes. Patients were then surveyed to obtain PROMIS domain scores (physical function, pain interference, and depression), resiliency scores, foot and ankle ability measure (FAAM) scores, pain level, and ability to return to work postoperatively. Criteria for inclusion in our study was the successful collection of survey data.
Results:
50 patients were successfully surveyed for long-term postoperative patient-reported outcomes. Patients were surveyed at least 5 years after their original date of surgery with a median time of 6.7 (IQR 1.89) years. Four patients experienced complications including wound complications, sural nerve injury, and reflex sympathetic dystrophy. Four individuals had recurrence of instability with a median of 11.3 months (IQR 8.8) and six patients underwent reoperations. There was significant association of prior ankle instability surgery with PROMIS physical function scores (p=0.013) and being an athlete with PROMIS pain interference scores (p=0.042). Increased age was correlated with lower PROMIS functional scores (p=0.047) and lower FAAM ADL scores (p=0.044). Longer time to survey was significantly associated with an increased FAAM sports score (p=0.048). Longer time to survey was non-significantly associated with increased PROMIS functional scores (p=0.17), decreased PROMIS pain interference scores (p=0.52), and increased FAAM ADL scores (p=0.45).
Conclusion:
Patient-reported outcomes are important to measure to gain insight into the patient experience following the procedure and may be helpful in preoperative counseling. Our preliminary results suggest that longer time to follow up is associated with more favorable PROMIS domain and FAAM scores. We intend to conduct more surveys to add more power to our study.
