Hypertensive Emergency During Dialysis: A Paradoxical Physiologic Response.

Most end-stage renal disease patients experience a reduction in blood pressure during their hemodialysis session compared to predialysis. Surprisingly, a small subset of patients will experience an unusual physiological response to dialysis that results in a paradoxical increase in blood pressure. We discuss a case that involved an exaggerated elevation in blood pressure, ultimately requiring immediate cessation of dialysis and admission to the intensive care unit for intravenous treatment of a hypertensive emergency. This case serves as a framework to introduce the infrequently discussed concept of intradialytic hypertension. The underlying pathogenesis is poorly understood with multiple theoretical etiologies including activation of the renin-angiotensin-aldosterone system, imbalances in circulating levels of endothelium-derived mediators, clearance of antihypertensive medications, increased cardiac output, and changes in arterial thickness. It is important to be cognizant of this phenomenon as emerging evidence suggests that patients with any elevation in blood pressure during hemodialysis have increased rates of both short-term and long-term mortality.

Improving Discharge Rates to Home With the Help of Mobility Technicians: A Step in the Right Direction.

Background Early ambulation during acute hospitalization has been associated with improved clinical outcomes for patients. Despite the benefits of mobility in the hospital setting, physical therapists and nursing staff are often constrained by time. Mobility technicians (MTs) are individuals with specialized training who have emerged as a potential solution by providing safe ambulation for patients during their hospital stay. Objectives The purpose of this quality improvement project was to investigate the impact of MTs on clinical and financial outcomes for admitted patients at a high-volume tertiary institution. Methods A quality improvement project was implemented at Jersey Shore University Medical Center, Neptune City, from October 2022 to March 2023. The study was a prospective, single-institution cohort study and included patients admitted to two medical floors. Patients were divided into an experimental group that received services from MTs and a control group that did not receive this service but was eligible based on clinical status. The primary endpoint was the proportion of patients discharged to home. Secondary outcomes included the length of stay and financial impact. Results A total of 396 admitted patients were included, with 222 patients in the MT group and 174 in the non-MT group. Patients in the MT group were discharged home more frequently, at a rate of 79.7% compared to 66.1% for patients in the non-MT group (p = 0.002). MTs contributed to an average 2.4-day reduction in the length of hospital stay (7.8 days vs. 10.2 days, p = 0.007). The MT intervention led to an estimated net savings of $148,500 during the six-month study period. Additionally, 2.9 daily hospital beds were created. Conclusion Implementing an MT program significantly increased the discharge-to-home rates and decreased hospital length of stay. Preliminary analysis suggests that this intervention is cost-effective and can assist institutions in managing increased hospital capacity strain through the creation of additional hospital beds.

Rare Presentation of Stercoral Ulcer Spontaneous Perforation Without Preceding Radiographic Evidence of Colonic Inflammation and Fecal Impaction.

Stercoral ulcers are caused by persistent fecal impaction. A life-threatening consequence of stercoral ulcers is colonic perforation, which is rare. A high index of clinical suspicion should be held for patients with stercoral ulcer, as colonic perforation is a medical emergency, requiring immediate surgical intervention. Here, we report a case of a 45-year-old female admitted with sepsis of unknown picture and subsequently developed stercoral ulcer perforation (SUP), diagnosed intraoperatively, without prior radiographic evidence of colonic inflammation. She was successfully managed with emergency laparotomy and left colectomy with sigmoid colectomy.

Hemophilia B: A Pain in the Back.

This case report describes an unusual manifestation of hemophilia B, in the form of a lateral chest wall hematoma. A 27-year-old hemophiliac male was found to have a lateral chest wall hematoma after presenting with back pain associated with localized chest wall swelling. Even more unusual than the location of his hematoma was the absence of any preceding triggers such as a fall or trauma to the area. To our knowledge, this is the first reported case of its kind in a patient with inherited hemophilia B. We believe the reporting of such rare presentations increases awareness of these possibilities and thus aids in the prompt diagnosis and treatment of other similar cases when they are encountered.

COVID-19 Infection Presenting With Severe Hydrocephalus and Acute Stroke: A Case Report.

Hydrocephalus is the accumulation of cerebrospinal fluid (CSF) in the cerebral ventricles and is considered an emergency in acute presentation. Hydrocephalus typically presents with symptoms of headache, nausea, vomiting, lethargy, vision changes and seizure; furthermore, narrowing down the underlying etiology of hydrocephalus can aid in treatment and management options. We present a rare case of a patient that presented with a recent diagnosis of COVID-19 and was found to have acute hydrocephalus and stroke. The aim of this case report is to explore the link between COVID-19 and the development of hydrocephalus and stroke by delineating the underlying pathophysiology of COVID-19 as well as the etiologies of hydrocephalus and possible management strategies. We hope to highlight the importance of keeping an open differential for presentations of headaches and also emphasize the potential complications of COVID-19 infection to help better patient outcomes.

Underutilization of advanced presurgical studies and high rates of vagus nerve stimulation for drug-resistant epilepsy: a single-center experience and recommendations.

INTRODUCTION: Epilepsy surgery continues to be profoundly underutilized despite its safety and effectiveness. We sought to investigate factors that may contribute to this phenomenon, with a particular focus on the antecedent underutilization of appropriate preoperative studies. METHODS: We reviewed patient data from a pediatric epilepsy clinic over an 18-month period. Patients with drug-resistant epilepsy (DRE) were categorized according to brain magnetic resonance imaging (MRI) findings (lesional, MRI-negative, or multifocal abnormalities) and type of epilepsy diagnosis based on semiology and electroencephalography (EEG) (focal or generalized). We then analyzed the rates of diagnostic test utilization, surgical referral, and subsequent epilepsy surgery as well as vagus nerve stimulation (VNS). RESULTS: Of the 249 patients with a diagnosis of epilepsy, 138 (55.4%) were found to have DRE. Excluding the 10 patients with DRE who did not undergo MRI, 76 patients (59.4%) were found to be MRI-negative (non-lesional epilepsy), 37 patients (28.9%) were found to have multifocal abnormalities, and 15 patients (11.7%) were found to have a single epileptogenic lesion on MRI (lesional epilepsy). Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) were each completed in nine patients (7.0%) and magnetoencephalography (MEG) in four patients (3.1%). Despite the low utilization rate of adjunctive studies, over half (56.3%) ultimately underwent VNS alone, and 8.6% ultimately underwent definitive intracranial resection or disconnection surgery. CONCLUSIONS: The underutilization of appropriate non-invasive, presurgical testing in patients with focal DRE may in part explain the continued underutilization of definitive, resective/disconnective surgery. For patients without access to a high-volume, multidisciplinary surgical epilepsy center, adjunctive presurgical studies [e.g., PET, SPECT, MEG, electrical source imaging (ESI), EEG-functional magnetic resonance imaging (fMRI)], even when available, are rarely ordered, and this may contribute to excessive rates of VNS in lieu of definitive intracranial surgery.

Deciphering the surgical treatment gap for drug-resistant epilepsy (DRE): A literature review.

Patients with drug-resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy-related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.