11210 research outputs found
Sort by
Cameron lesion in the setting of a diaphragmatic hernia leading to occult bleeding
No full textIntroduction: Diaphragmatic hernias can present as symptoms that are similar in nature to acid reflux disease or even gastroparesis. Cameron lesions, which are uncommon ulcerations at the hiatus of a hernia, present themselves as occult bleeding. Case Presentation: A 65 y/o male with PMH of ESRD on HD, diaphragmatic hernia, HTN, and DM presented for an LUE AVF creation with plans for a supraclavicular block with sedation. During preoperative evaluation, the patient endorsed he was asymptomatic from his hernia diagnosis which was made several years ago. The case was uneventful until heparin administration, after which the patient had significant emesis requiring conversion to GA and removal of contents from the airway and gastrum. EGD was performed post operatively revealing an erosion at the hiatus of the hernia, identified as a Cameron lesion that was the likely source of his bleeding and emesis after heparin. These lesions are typically seen as a mucosal erosion or ulcer in the presence of a medium to large hiatal hernia. Unfortunately, they are not routinely diagnosed until after an occult bleeding event or chronic anemia. Conclusion: Preoperative evaluation is key in perioperative care to ensure patient safety. While some conditions present themself unexpectedly, proper post operative care and evaluation of patients moving forward should be taken into consideration. Patients with moderate to large hiatal hernias, particularly those with symptoms, should undergo GI evaluation and possibly endoscopic intervention before elective procedures. Cameron lesions, while they can be medically management if diagnosed, often require more invasive treatments to prevent episodes of occult or chronic bleeding. 1. Gray DM, et al. (2015) Dis Esophagus.28(5):448-5
Perioperative management and considerations of super-morbid patients in back surgeries
No full textIntroduction: Obesity is an increasingly common condition. ASA classifies obesity based on BMI, with class 3 being BMI \u3e 40. Class 3 obesity is associated with many comorbidities, thus increasing perioperative risk.[1] There are several recommendations for obese patients, however there are not many guidelines regarding super morbid patients. This case focuses on airway management and positioning. Case presentation: A 45 years female with medical history of asthma, thrombocytopenia, BMI of 89, 165cm of height came for lumbar-sacral ulcer debridement. She has been bedridden for 1 month after laparoscopic gastrectomy. She presented with decubitus ulcer that needed surgical debridement. Initially surgeon requested prone positioning. Due to concern for ischemic optic neuropathy and increased abdominal pressure, the final position determined to be right lateral decubitus. Airway examination showed good interincissor distance, mallampati score III, thyromental distance \u3e 7cm, good upper lip bite test. The patient was preoxygenated and the bed head was elevated to 30 degrees, as well as several blankets were placed to achieve adequate head extension. Given that previous endotracheal tubes were successfully placed with videolaryngoscope and masking was adequate, the decision was made to use videolaryngoscope with fiberoptic as a backup. Induction was done with sevoflurane, 12mcg of dexmetomidine and 120mg of propofol, after ensuring that we could mask ventilate, 80mg of succinylcholine was given and the tube was placed on first attempt. Patient desaturated to 90%. Throughout the case, a large amount of phenylephrine was used. For extubation, bedhead was placed at 30 degrees and patient was fully awake and following command, with VT \u3e 5ml/kg of ideal body weight. Conclusion: Morbid obesity is an important risk factor for difficult airway. Despite only fulfilling 2 criteria for difficult airway, backup plans should and was considered. Preoxygenation was also optimized with elevation of bedhead and use of blankets. If we look at the difficult airway algorithm[2], the safest way to have proceeded was with awake fiberoptic intubation, however, this can be a traumatic experience for the patient and about 7% of ASA closed claims are related to awake intubation.[1] Furthermore, we shouldn\u27t assume that all super morbid patients will be impossible to ventilate or intubate [2]. Adequate preoxygenation strategy that can be used include apneic oxygenation and elevating bed head. The surgicl position of the patient is also important because prone position is higher risk for ischemic optic neuropathy and increased abdominal pressure. This patient had several risk factors for decreased intraabdominal organ perfusion. Increased intraocular pressure is exacerbated by reduced venous return in prone positoning, leading to higher risk of underperfused optic nerve [3]. Large amount of phenylephrine used in the case prompted us to investigate whether larger volume of distribution affect use of vasopressors. Literature concluded that vasopressors should be titrated to cardiovascular goals however, other drugs, especially the lipophilic drugs have significant changes in pharmacokinetics. 1. Wan Jane, Liu. (2022) Saudi J Anesth 16: 314-321 2. Apfelbaum, Jeffrey. (2022) Anesthesiology 136: 31-81 3. Melissa, Kwee (2015). Int Surg 100: 292-30
Higher patient-reported percentage pain reduction than calculated pain score differences in chronic non-cancer pain patients
No full textIntroduction: Pain relief is commonly evaluated through two derivatives of the numeric scale rating (NRS) and visual analog scale (VAS): patient-reported percentage pain reduction (PRPPR) and calculated percentage pain reduction (CPPR). A limited number of studies have examined the agreement between these two parameters in chronic pain patients and have generally focused on specific pain types or treatment methods. Methods: A retrospective analysis of 1,919 patients who sought medical attention for various pain conditions was conducted. Patients had to be seen for at least 6 months with no less than 4 clinic visits. At each visit, patients were asked to quantify both their pre and post-treatment pain scores on a numeric scale rating (NRS) as well as their subjective percentage improvement. IBM SPSS 27 software was utilized to analyze the data collected. Patients were first stratified based on the duration of their pain. To gauge the agreement between PRPPR and CPPR within each group, one-sample t-test was conducted to calculate the mean numerical values using the concordance correlation coefficient. Patients were further stratified into groups based on their treatment modality. The paired-sample t-test was used in order to calculate the mean PRPPR, mean CPPR and the correlation between them. Results: The mean PRPPR and CPPR for the entire population were 61.03 and 49.21 respectively, with a mean discrepancy of 11.81. The concordance correlation coefficient was 0.689. When grouped based on duration of treatment, the less than one year cohort had a PRPPR and CPPR of 60.87 and 56.26 respectively with a discrepancy of 4.61 and correlation coefficient of 0.822. In the 1–2-year group the PRPPR and CPPR were 61.76 and 50.29, respectively, with a discrepancy of 11.47 and correlation coefficient of 0.698. In patients treated for 2–3 years, the PRPPR and CPPR were 60.45 and 47.91, respectively, with an average difference of 12.54 and concordance correlation coefficient of 0.628. For patients treated for 2–3 years, the PRPPR and CPPR were 60.45 and 47.91, respectively. The average difference was 12.54, and the concordance correlation coefficient was calculated as 0.628. The PRPPR and CPPR for the 3–4-year cohort were 60.20 and 47.01, respectively, with a mean discrepancy of 13.19 and the concordance correlation coefficient was 0.657. Among patients treated for 4-5 years, the PRPPR and CPPR were recorded as 61.48 and 47.06, respectively. The average discrepancy among this group was 14.42, and the concordance correlation coefficient resulted as 0.675. For those that were treated for over 5 years, the PRPPR and CPPR were 61.23 and 50.23, respectively. The mean difference within this group was 11.00, while the concordance correlation coefficient was calculated to be 0.726. Conclusion: In this study, PRPPR overestimated CPPR. Due to the strong correlation between the two parameters, it can be concluded that changes in one can be predicted in the other with a high level of accuracy. However, it is unclear which one more accurately reflects an improvement in each patient\u27s underlying pain. Further research is needed to better understand the mechanisms behind the discrepancy between PRPPR and CPPR. 1. Fink A.B. et al. (2023) Neurology International. 15(2):560-568
Ethnic disparities in the management of chronic non-cancer pain
No full textIntroduction: Recent studies indicate a disparity in chronic pain management across different racial groups, particularly among Black, Indigenous, and People of Color. Additional findings highlight variations in pain prevalence and the response to both acute and chronic pain withing these groups. This study explores the demographic and clinical factors influencing pain management across various racial populations. Methods: We followed 1,662 patients in the greater Chicago area, who sought treatment for a variety of chronic pain conditions, for one year at minimum and had at least four different clinic appointments. Patients were stratified based on race, where they identified as White-non Hispanic, White-Hispanic, or Black. Analyses were performed to determine variations in pain intensity, duration, type of pain and treatment methods. IBM SPSS 27 was used to perform statistical analysis and the data was analyzed using independent t-tests, frequency tables, and crosstabs with χ2 analysis. Differences were considered significant with a p-value of p\u3c0.05; incomplete data was excluded from analyses. Results: From the 1,662 participants in this study, 47.8% identified as White-Non Hispanic, 32.6% as White-Hispanic and 19.6% as Black. Our findings revealed significant differences in mean age and BMI across all groups, where the Black population showed a higher average age and BMI (p=0.12 and p\u3c0.001, respectively). Low Back Pain was the most common reported ailment across all groups, especially among Black patients (70.6%, p=0.005). Steroid injections were the most common treatment method for all ethnicities, particularly among the Black patients (p\u3c0.001). However, after that, we found notable variations. White-Hispanic and Black patients were more likely to be prescribed gabapentin, while opioids were prescribed at higher rates to White Non-Hispanics and Black patients. White Non-Hispanic patients also had the highest rates of benzodiazepine prescriptions. The other treatment modalities, including NSAIDs, muscle relaxants and tricyclic antidepressants, revealed fluctuating usage patterns across our patient population. Conclusion: Due to its subjective nature, pain can be challenging to assess. Evaluating and managing pain requires clear and effective communication between patients and healthcare providers. Our findings reveal inconsistencies in pain management approaches and outcomes among different racial and ethnic groups, emphasizing the need for personalized pain management strategies to address these differences. It is crucial to explore effective methods for overcoming these challenges to implement appropriate techniques, ensuring all patients receive adequate and equitable healthcare. 1. Overstreet, D.S., et al. (2023) Curr Pain Headache Rep 27, 1–10. 2. Rahavard, B. B., et al. (2017) Pain Management, 7(5), 427–453
Post-procedural intensive care unit admission following middle meningeal artery embolization: A comprehensive analysis of morbidity, readmission, and healthcare expenditures: Abstract 408
No full text
Impact of diabetes on cardiovascular outcomes in PCOS patients: A retrospective database study
No full textPrediabetes in takotsubo syndrome: Impact on cardiovascular outcomes and mortality in a propensity-matched cohort study
No full text
