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Risk Factors for Readmissions in Patients Undergoing Endoscopic Drainage for Peripancreatic Fluid Collections
No full textBACKGROUND: Pancreatic fluid collections (PFCs) are a frequent complication following acute pancreatitis and often necessitate endoscopic cystogastrostomy (EC) for drainage. Despite high technical and clinical success rates, unplanned readmissions remain common.
AIMS: This study aimed to evaluate readmission rates and identify associated risk factors in patients undergoing EC for PFCs.
METHODS: We conducted a retrospective review of 100 patients who underwent EC for symptomatic PFCs between June 2016 and August 2021. Demographic data, clinical characteristics, procedural details, and outcomes were analyzed. Univariate and multivariate logistic regression were used to identify factors associated with unplanned readmissions.
RESULTS: Clinical success was achieved in 95% of patients. However, 31% experienced unplanned readmissions, most commonly due to sepsis (47%), abdominal pain (28%), and gastrointestinal bleeding (14%). Univariate analysis identified intra-abdominal varices and paracolic gutter extension as significant risk factors. Multivariate analysis confirmed intra-abdominal varices as an independent predictor (OR 3.51, 95% CI 1.26-9.80, P = 0.016). Technical success was high (98%) with an overall adverse event rate of 14%.
CONCLUSION: Unplanned readmissions are common after EC for PFCs, with intra-abdominal varices emerging as a key risk factor. Enhanced follow-up and risk stratification may improve patient outcomes and reduce healthcare burden
Early diagnosis and tailored treatment in atypical idiopathic thrombocytopenic purpura: A CARE compliant case report
No full textRATIONALE: Idiopathic thrombocytopenic purpura (ITP) is a hematological disorder characterized by a decrease in platelet count due to increased destruction or decreased production. Although the pathophysiology and etiology remain largely unknown, understanding the typical and atypical presentations of ITP is crucial for early diagnosis and effective management. This case report highlights the rationale behind a comprehensive approach for the diagnosis and treatment of ITP, especially in cases with atypical presentations.
PATIENT CONCERNS: A 45-year-old woman presented with a mucocutaneous petechial rash spreading over the ocular and oral areas of the face, accompanied by similar manifestations in the limbs. While petechiae are a hallmark of ITP, the initial widespread distribution and specific involvement of these extensive mucocutaneous areas were considered atypical presentation patterns in this case. She also reported moderate gum bleeding, epistaxis, and spontaneous ecchymosis of the oral mucosa. These symptoms suggested a potential platelet disorder.
DIAGNOSES: Based on the clinical presentation and laboratory findings, the diagnosis of ITP was made. The patient\u27s symptoms and laboratory results were consistent with the typical features of ITP, including a decreased platelet count, petechiae, and manifestations of bleeding.
INTERVENTIONS: A thorough history and physical examination were conducted to rule out other potential causes of thrombocytopenia, including infections, medications, and underlying autoimmune diseases. Laboratory tests, including complete blood count, peripheral blood smear, and coagulation profile, were performed to assess platelet count, morphology, and clotting function. The diagnosis was initially followed by conservative management. Later on, the patient was also treated with corticosteroids and then intravenous immunoglobulin.
OUTCOMES: The patient responded well to intravenous immunoglobulin, thereby demonstrating the effectiveness of the treatment. She was then discharged with maintenance doses of corticosteroids and a close follow-up schedule.
LESSONS: This case report illustrates the importance of recognizing the diverse presentations of ITP, including its atypical manifestations. Early diagnosis and effective management are crucial for improving patient outcomes. A comprehensive approach, including thorough history, physical examination, and laboratory tests, is essential for the accurate diagnosis and effective treatment of ITP
Lifting the Veil: Delayed Diagnosis of Sheehan Syndrome Unmasked by Adrenal Crisis
No full textWe report a 28-year-old woman with refractory hypoglycemia, hypotension, and profound fatigue found to have panhypopituitarism secondary to Sheehan syndrome. Although she had a remote history of postpartum hemorrhage marked by agalactia and secondary amenorrhea, her diagnosis was delayed until she developed an adrenal crisis in the setting of acute pyelonephritis. Comprehensive endocrine testing confirmed secondary adrenal insufficiency, central hypothyroidism, hypogonadotropic hypogonadism, and lactotroph failure; Magnetic resonance imaging demonstrated a partially empty sella consistent with remote pituitary infarction. Prompt initiation of stress-dose glucocorticoids and thyroid hormone led to rapid hemodynamic stabilization and resolution of hypoglycemia. This case underscores the importance of early recognition of subtle hypopituitarism signs-particularly postpartum lactation failure-and the need to consider endocrine etiologies in critical care presentations that mimic septic shock
Advances in Non-statin Lipid Therapies: A Narrative Review of Evolving Strategies for Cardiovascular Risk Reduction
No full textDespite the well-established benefits of statin therapy in reducing atherosclerotic cardiovascular disease (ASCVD) risk, many patients fail to achieve recommended low-density lipoprotein cholesterol (LDL-C) targets or experience statin intolerance, necessitating alternative approaches. This review examines advances in non-statin lipid-lowering therapies, focusing on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies and inclisiran), bempedoic acid, and other non-statin lipid medications. We evaluate their mechanisms of action, clinical efficacy, and safety profiles on the basis of landmark trials. A conceptual framework for personalized lipid management is proposed, addressing residual cardiovascular risk, statin intolerance, and complex patient profiles. Clinical decision pathways are presented for high-risk patients, statin-intolerant individuals, and those with adherence challenges. We explore emerging therapies targeting novel pathways, including lipoprotein(a), apolipoprotein C-III inhibitors, angiopoietin-like protein 3 (ANGPTL3) inhibitors, cholesteryl ester transfer protein (CETP) inhibitors, and gene-editing technologies. Implementation barriers, including cost considerations, insurance challenges, and global access disparities, are discussed alongside solutions
When Gains Go Wrong: A Case of Selective Androgen Receptor Modulator-Related Liver Injury
No full textSelective androgen receptor modulators (SARMs) causing drug-induced liver injury is a rare, albeit inadequately described, potentially serious side effect for those in the fitness industry looking to maximize muscle growth, strength gain, and fat loss as quickly as possible. We present a case of a patient with drug-induced liver injury after starting Stenabolic, a newer SARM. We report a case of a 40-year-old male who presented with vague gastrointestinal symptoms. Before the presentation, he was relatively healthy but taking multiple over-the-counter supplements. Although he had been taking most of these supplements for a long time without notable side effects, he had recently started taking Stenabolic, a performance-enhancing drug under the SARM category. Laboratory and imaging studies confirmed hepatocellular injury. After ruling out infectious and autoimmune etiology, it was thought that the likely source was Stenabolic. The patient was treated with supportive care and was advised to discontinue Stenabolic. Upon discharge, he began to show clinical improvement. Although there is limited research about Stenabolic, other agents in the SARM class have been implicated in similar patterns of liver injury. Its structural and pharmacologic similarities to anabolic steroids raise concern for hepatotoxicity through an idiosyncratic immune-mediated mechanism. This case highlights the potential hepatotoxicity of performance-enhancing supplements like Stenabolic. With the growing popularity of SARMs and limited regulation, healthcare providers should maintain a high index of suspicion for supplement-induced liver injury. Further research is needed to clarify the safety and mechanisms of these agents. Until then, their use should be discouraged
Preanalytical variables and analytes in liquid biopsy approach for brain tumors: A comprehensive review and recommendations from the RANO Group and the Brain Liquid Biopsy Consortium
No full textThis review explores the pivotal role of preanalytical variables in bringing liquid biopsy approaches into the clinic for brain tumors. Preanalytical variables encompass a range of critical issues, from blood sample collection and handling to the impact of tumor heterogeneity and patient-specific factors. These variables introduce challenges such as false positives, false negatives, and variability in the analysis of tumor signals, which can hinder the diagnostic and prognostic utility of liquid biopsies. Understanding the nuances of preanalytical variables is essential for the successful implementation of liquid biopsy in clinical settings. This paper delves into strategies aimed at mitigating the influence of preanalytical variables by emphasizing the importance of standardized sample collection protocols, optimized sample processing and storage, quality control measures, and the integration of multiple liquid biopsy modalities
Fulfillment of patients\u27 expectations for reverse total shoulder arthroplasty for the treatment of rotator cuff tear arthropathy using the Exactech Equinoxe Platform
No full textBACKGROUND: Despite the increasing use of reverse total shoulder arthroplasty (rTSA), there remain limited data regarding perioperative expectations and fulfillment of expectations for patients undergoing rTSA for rotator cuff tear arthropathy (CTA). Thus, the purpose of this study was to determine the proportion of expectations that are fulfilled following rTSA and to determine which patient characteristics are associated with fulfillment of expectations at 2-year follow-up.
METHODS: Preoperatively, patients completed the Hospital for Special Surgery\u27s Shoulder Surgery Expectation Survey, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS) for pain, and a Single Assessment Numeric Evaluation (SANE) score for the affected shoulder. At 2-year follow-up, patients were asked to what extent each of their corresponding preoperative expectations that they had previously cited as very important were now fulfilled, and again completed the patient-reported outcomes. Demographic and range of motion (ROM) data were also collected.
RESULTS: Seventy-seven patients met all inclusion criteria and were included in this study. The expectations most frequently cited as being very fulfilled postoperatively were improvement in self-care (75%), improvement in ability to drive and put on seatbelt (77%), and relief of daytime pain (73%). Eighty-one percent of patients cited improvement in shoulder ROM as an important expectation preoperatively, but only 53% reported that this expectation was very fulfilled postoperatively. Patients with better postoperative ASES scores (P \u3c .001), better VAS scores (P \u3c .001), and better SANE scores (P \u3c .001) compared with the average patient had a greater proportion of expectations fulfilled.
CONCLUSIONS: Patients undergoing rTSA for CTA had greatest fulfillment of expectations for improvement in self-care, ability to drive, and relief of daytime pain at 2-year follow-up. Relatively few patients reported fulfillment of expectations for shoulder ROM. Better postoperative ASES, VAS, and SANE scores correlated with greater fulfillment of expectations. It is important to understand traditional objective metrics considered for success to surgeons may not be the same as a patient\u27s perspective. Using this information, surgeons can better tailor their preoperative discussions with patients to appropriately manage expectations
Periprosthetic Humeral Shaft Fracture about Total Elbow Arthroplasties Managed with Medial and Lateral Femoral Strut Allografts and Implant Retention: A Case Report
No full textINTRODUCTION: Expanding indications for total elbow arthroplasty in recent years have led to increased occurrence of complications, such as periprosthetic elbow fracture, which can occur in up to 12% of cases. Several management options for periprosthetic elbow fracture have been suggested in literature; however, there is currently no accepted guideline for treatment.
CASE REPORT: We present two cases of periprosthetic humerus fractures without implant loosening multiple years after the index procedures. They were treated with open reduction internal fixation (ORIF) utilizing a plate with medial and lateral cortical strut femoral allografting with implant retention.
CONCLUSION: Two cases of periprosthetic humerus fractures about total elbow arthroplasties were successfully treated with ORIF with medial and lateral cortical strut augmentation. Treatment for periprosthetic elbow fractures should be tailored to each patient based on factors, such as stability of implant, bone stock, and patient goals
Fulfillment of patients\u27 expectations for reverse total shoulder arthroplasty for the treatment of rotator cuff tear arthropathy using the Exactech Equinoxe Platform
No full textBACKGROUND: Despite the increasing use of reverse total shoulder arthroplasty (rTSA), there remain limited data regarding perioperative expectations and fulfillment of expectations for patients undergoing rTSA for rotator cuff tear arthropathy (CTA). Thus, the purpose of this study was to determine the proportion of expectations that are fulfilled following rTSA and to determine which patient characteristics are associated with fulfillment of expectations at 2-year follow-up.
METHODS: Preoperatively, patients completed the Hospital for Special Surgery\u27s Shoulder Surgery Expectation Survey, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS) for pain, and a Single Assessment Numeric Evaluation (SANE) score for the affected shoulder. At 2-year follow-up, patients were asked to what extent each of their corresponding preoperative expectations that they had previously cited as very important were now fulfilled, and again completed the patient-reported outcomes. Demographic and range of motion (ROM) data were also collected.
RESULTS: Seventy-seven patients met all inclusion criteria and were included in this study. The expectations most frequently cited as being very fulfilled postoperatively were improvement in self-care (75%), improvement in ability to drive and put on seatbelt (77%), and relief of daytime pain (73%). Eighty-one percent of patients cited improvement in shoulder ROM as an important expectation preoperatively, but only 53% reported that this expectation was very fulfilled postoperatively. Patients with better postoperative ASES scores (P \u3c .001), better VAS scores (P \u3c .001), and better SANE scores (P \u3c .001) compared with the average patient had a greater proportion of expectations fulfilled.
CONCLUSIONS: Patients undergoing rTSA for CTA had greatest fulfillment of expectations for improvement in self-care, ability to drive, and relief of daytime pain at 2-year follow-up. Relatively few patients reported fulfillment of expectations for shoulder ROM. Better postoperative ASES, VAS, and SANE scores correlated with greater fulfillment of expectations. It is important to understand traditional objective metrics considered for success to surgeons may not be the same as a patient\u27s perspective. Using this information, surgeons can better tailor their preoperative discussions with patients to appropriately manage expectations
Surgical Techniques to Address Patellofemoral Instability: An Individualized Approach
No full textPatellar instability involves complex decision making and an individualized approach. Often, patients with high-risk pathoanatomic features present after a single or recurrent dislocation events. Consideration of the patient\u27s osseous anatomy, age, dynamic examination findings, evaluation of soft-tissue tension, dislocation history, and goals are all integral to the treatment plan. With regards to surgical intervention, medial patellofemoral ligament reconstruction is the most commonly performed procedure to provide static stability to the patella. Concomitant proximal and distal realignment procedures can be performed, but consensus is lacking for whom these may be necessary. This Technique Note describes the order of operations and the author\u27s preferred technique for performing a medial patellofemoral ligament reconstruction using hamstring autograft concurrently with lateral retinacular lengthening, vastus medialis oblique advancement, native medial patellofemoral ligament imbrication, and tibial tubercle osteotomy or patellar tendon shortening through 2 main incisions, for a patient with high-risk pathoanatomic features and examination