Should thrombolysis have a greater role in the management of pulmonary embolism?

Pulmonary embolism (PE) continues to be associated with significant mortality despite advances in the diagnostic techniques available for its detection. Anticoagulation remains standard treatment in PE although there is a consensus view that 'step-up' to thrombolytic therapy in addition to anticoagulation is indicated in those patients who are systemically shocked at presentation--a group defined as having suffered 'massive pulmonary embolism'. Considerable research has been directed at attempting to identify further groups of patients with PE who are at high risk of morbidity and mortality--notably those who are labelled as having suffered 'sub-massive pulmonary embolism' where this is defined as the presence of right-heart strain in the absence of systemic shock. In particular, the potential benefit of extending thrombolytic therapy to include those patients with sub-massive PE has been the subject of much enquiry and debate. This review examines the evidence for thrombolytic therapy and explores the potential for risk stratification in PE.

An unusual complication following radiological percutaneous gastrostomy.

INTRODUCTION: Intestinal malrotation is a condition, which is predominantly recognised in childhood. Because of the relative rarity, there is a possibility that it can be missed in the routine clinical care of adults. This case highlights the need for a high index of suspicion for malrotation when things go wrong in routine procedures. This can be the reason for catastrophic sepsis in patients who undergo minimally invasive procedures. CASE PRESENTATION: We present a patient with a malignant lesion of the tongue who went for elective placement of feeding tube who suffered unexpected complication as a result of malrotated large bowel. CONCLUSION: Malrotation of the intestine can make a relatively straightforward procedure fraught with complications. Clinicians should have a high index of suspicion about malrotation when performing procedures like percutaneous gastrostomy and radiologically guided entrostomy. If there is an index of suspicion they should be screened prior to the procedure.