Lung Herniation as a Result of Cardiopulmonary Resuscitation (CPR): A Case Report and Literature Review.

Lung herniation is a rare complication following cardiopulmonary resuscitation (CPR) and is defined as a protrusion of lung parenchyma through the thoracic wall. This article presents a case in which a patient presented to the hospital with sepsis secondary to community-acquired pneumonia. A 74-year-old female with a background of chronic obstructive pulmonary disease (COPD) suffered a sudden pulseless electrical activity (PEA) cardiac arrest while being managed in the acute medical ward. The CT following the return of spontaneous circulation (ROSC) demonstrated multiple bilateral anterior rib fractures and herniation of the right lung through the right lateral thoracic wall. She was managed in the ICU with ventilatory and cardiovascular support for four days until she suffered a second cardiac arrest, where resuscitation was unsuccessful. In addition to this case report, a literature review was carried out, given the rarity of this pathology. The literature provides only 13 articles on lung herniation due to CPR. The most common injury pattern was anterior rib fractures leading to anterior lung herniation. In our case report, the herniation was away from the fracture site at the lateral chest wall. A common complication was surgical emphysema in several of the articles, as was in our case. The surgical intervention appears to be indicated in large hernias, incarceration, or those causing pain and respiratory compromise. In our case, conservative management was elected, given the patient's significant persistent cardiovascular instability unsuitable for interhospital transfer. A high index of suspicion should be adopted for patients who undergo a prolonged period of CPR, including frail patients with underlying health conditions such as chronic lung disease.

Review of the Literature on Ocular Complications Associated With Aromatase Inhibitor Use.

Aromatase inhibitors (AIs), such as anastrozole, letrozole, and exemestane, are commonly used as adjuvant endocrine therapy in hormone-receptive breast cancer in postmenopausal women. Their adverse effects are well documented, except for visual disturbances. The purpose of this study was to review the current literature on ocular disease linked to AI use. Due to the scarcity of published data, any suggested ophthalmic adverse events were included to increase awareness of these drugs. The ocular side effects of tamoxifen use are well documented and were not included. Cases of rare side effects such as papilloedema, macular oedema, and uveitis associated with anastrozole and letrozole have been reported. Studies demonstrating retinopathy, in the form of crystalline retinopathy, hemicentral retinal artery occlusion, and retinal haemorrhages, are also noted. All three third-generation AIs can also lead to ocular surface diseases such as corneal epithelial changes, blepharitis, and keratitis. There is slightly more literature available regarding anastrozole-related ocular diseases. Although these are likely rare side effects, we recommend a high level of clinical suspicion when assessing patients with visual symptoms and on AIs. Larger prospective studies are necessary to further investigate these complications.

Cobb's Tufts: A Systematic Review.

Cobb's tufts, also known as iris vascular tufts (IVT) and iris microhemangiomas (IMH), are coils of tightly clustered, minute blood vessels at the iris pupillary border. This study aimed to analyze previous literature and provide an update on Cobb's tufts. A systematic literature review was carried out by interrogating PubMed, Google Scholar, Cochrane, and Embase databases. Full-text English language articles of any year were included in this study. A total of 38 articles fulfilled our inclusion criteria. A total of 115 reported cases of Cobb's tufts were incorporated into our review. The age of the patients ranged between 36 and 86 years. No sex or racial predisposition was noted. Most patients had no history of trauma, surgery, or blood dyscrasia. The majority of cases are asymptomatic and bilateral unless a spontaneous hyphema occurs, which most commonly presents as blurred vision. The etiology of this condition remains uncertain; however, a higher incidence has been shown in systemic conditions such as myotonic dystrophy and diabetes. Fluorescein angiography can be utilized to investigate tufts. Management includes treatment of raised intraocular pressure, observation for single bleeds, laser therapy for recurrent hyphemas, and lastly, iridectomy, which is considered in cases of recurrence following laser treatment.

Bowel Ischemia in a Patient With SARS CoV-2-Like Illness and Negative Real-Time Reverse Transcription Polymerase Chain Reaction Test Results During the Peak of the Pandemic.

An 83-year-old man presented to the emergency department (ED) during the peak of the first wave of the SARS CoV-2 (COVID-19) pandemic with severe abdominal pain, mimicking a severe abdominal pathology. He was found to have features suggestive of COVID-19 infection radiologically, with no leaking aortic aneurysm, bowel ischemia, pancreatitis, or perforation. With worsening symptoms, a repeat computer tomography (CT) scan four days later showed features of bowel ischemia, and he underwent a laparotomy and right hemicolectomy. Four real-time reverse transcription-polymerase chain reaction (rRT-PCR) tests were negative. He was still considered to be infected with COVID-19 and died from complications arising from multi-organ failure. This case highlights an atypical presentation of a possible COVID-19 infection, the urgency to have additional diagnostic tests apart from rRT-PCR, and the necessity to use the appropriate personal protective equipment (PPE) during the pandemic.

Role of Gastrografin in Patients With Small Bowel Obstruction.

Introduction Gastrografin (GGF) is a radiopaque contrast medium commonly used for diagnostic examination of the gastrointestinal (GI) tract. Available evidence suggests it has therapeutic and predictive value in the management of adhesional small bowel obstruction (ASBO). Thus, we investigated the use of GGF amongst patients who had a small bowel obstruction and audited the practice in University Hospital, Ayr. Methods Initial retrospective data of patients who had gastrografin for small bowel obstruction were extracted from April 2015 to August 2019 and analysed. After our local presentation and on implementing a GGF protocol, we prospectively collected data from February to June 2020 to close our audit. Results GGF showed a comparable therapeutic effect on ASBO in both audit cycles (72.2%-66.7%). Approximately 50% of unresolved cases were operated within 24 hours of GGF administration in both cycles. GGF consistently demonstrated a therapeutic benefit in refractory faecal impaction (100% in both cycles) and postoperative ileus (≥ 80%). Early use of computed tomography (CT) (less than 24 hrs) did not confer any added advantage (82.5% v 61.5%), however, it helped in making an appropriate diagnosis and the subsequent early gastrografin usage (78.3% v 92.3%) in ASBO. Conclusion GGF serves a very good therapeutic purpose in resolving ASBO, refractory constipation, and in rare non-resolving cases of postoperative ileus. Early CT diagnosis of ASBO is advocated before the administration of gastrografin. Unsuccessful resolution after 24 hrs of GGF is an indication for operative intervention.