Diagnostic and Therapeutic Ambiguities in Diabetic Ketoacidosis With Overlapping Acute Pancreatitis and Hypertriglyceridemia.

This case report discusses the diagnostic challenges and management complexities in a patient presenting with symptoms of diabetic ketoacidosis (DKA) and severe pancreatitis, complicated by concurrent hypertriglyceridemia (HTG) and superior mesenteric vein (SMV) thrombosis. The presence of DKA in acute pancreatitis suggests very severe impact on the pancreas. Hence, it calls for screening with CT imaging for complications like hemorrhagic pancreatitis, necrotizing pancreatitis, or even thrombus. Despite typical reliance on clinical presentation and serum lipase for diagnosing pancreatitis, this case emphasizes the necessity of contrast-enhanced CT imaging in ambiguous cases to identify critical complications like thrombosis and necrotizing pancreatitis. Furthermore, the patient's management involved insulin therapy for DKA and HTG-induced acute pancreatitis, deferring plasmapheresis and anticoagulation due to the risk of hemorrhagic transformation in pancreatitis. This approach highlights the need for individualized treatment strategies, especially in complex presentations with overlapping pathologies. The case also explores the potential for insulin as a first-line treatment in HTG-induced pancreatitis over plasmapheresis, contributing to evolving guidelines.

PCI vs. CABG in left main with multi-vessel coronary artery disease and diabetes: Case report.

This case challenges the conventional preference for coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in patients with diabetes, left main coronary artery disease (LMCAD) and multivessel disease. Current guidelines generally recommend CABG, especially in the context of LMCAD. However, our case involves a male patient with diabetes with LMCAD and extensive multivessel disease who was successfully treated with PCI, demonstrating a favorable outcome. Despite the high-risk profile, including a SYNTAX score of 28, the PCI approach was selected. This decision was supported by evidence suggesting comparable outcomes between PCI and CABG in similar patients. Our case highlights the potential of PCI as not just a viable, but potentially superior alternative in specific high-risk patients with diabetes, contrary to the prevailing belief in favor of CABG for all patients with left main involvement.

Besieged in the Bronx: Lessons from an in-hospital mass casualty.

BACKGROUND: An active shooter in a hospital is an emergency extraordinaire. We report a single institution's response to the largest active shooter mass casualty event in American History. METHODS: Review of notification, flow of prioritized patients, and key elements of the day's dynamic after a hospital attack by a lone gunman were commenced. The review includes outcomes on seven victims and assailants. RESULTS: "Code Silver" announced: open display of a weapon. Concise, known, and published chain of command implemented. All house staff to the Emergency Department (ED) via text blast. Operating room (OR) notified. Injured to ED, then triaged to OR. Armed NYPD stationed throughout OR. Senior surgeons controlled key triage during attack with flow controlled from the ED and OR control desk. One fatality plus shooter. CONCLUSION: Success favors the prepared. The response to attack, readiness of medical personnel, mitigation, and recovery have brought the following recommendations: (1) single entrance access; (2) armed, professional guards at all entrances; (3) camouflage metal detectors; (4) mandatory, recurrent hospital-wide active shooter training, mock, and table top; (5) published physician chain of command; (6) intercom code system known to all hospital personnel indicating a weapon is openly displayed; (7) a "no fly" list of former employees who are prohibited on premises; (8) stop the bleed training with kits on every floor; (9) one voice, one face to disseminate information. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level I.