An unusual case of severe gastrointestinal bleeding.

We present the case of a 58-year-old female with a history of a bleeding duodenal peptic ulcer. Endoscopic hemostasis was unsuccessful; therefore, a transcatheter arterial embolization of a culprit vessel was performed. She was admitted to the hospital two months later because of obstruction of the common bile duct with cholangitis. Attempts to endoscopically place a biliary stent failed. The treating medical team opted for a surgical choledocho-jejunostomy. After 20 months, she presented with a melena and a severe anemia. Diagnostic work-up revealed portal vein thrombosis with portal cavernoma and bleeding choledocho-jejunostomy varices. The case presents and discusses rare complications of duodenal ulcer disease, as well as possible causes and treatment options.

Low-dose intravenous lipid emulsion for the treatment of severe quetiapine and citalopram poisoning.

The treatment of quetiapine and/or citalopram poisoning is mainly supportive and involves gastric lavage, activated charcoal, intubation, and mechanical ventilation. Recently, however, there were reports of successful treatment with intravenous lipid emulsion. Here we report a case of a 19-year-old Caucasian girl who ingested approximately 6000 mg of quetiapine, 400 mg of citalopram, and 45 mg of bromazepam in a suicide attempt. The patient developed ventricular tachycardia and epileptic seizures 12 h after admission to the hospital. As the patient's condition deteriorated, we combined standard therapy (intubation, mechanical ventilation, and vasopressors) with low-dose intravenous lipid emulsion (ILE) (a total of 300 mL of 20 % lipid emulsion) and normalised her heart rhythm and stopped the seizures. She was discharged to the psychiatric ward after 48 h and home after a prolonged (2-month) psychiatric rehabilitation. Intravenous lipid emulsion turned out to be effective even in the lower dose range than previously reported for quetiapine poisoning in patients presenting with seizure and ventricular arrhythmia. To our knowledge, there are no case reports describing the use of ILE in treating citalopram poisoning.

Ankle-Brachial Index and Long-Term (10 Years) Survival of Nondiabetic Hemodialysis Patients.

Low (<0.9) and high (>1.4) ankle brachial index (ABI) is associated with a higher cardiovascular (CV) mortality in the general and hemodialysis (HD) population. The aim of our study was to determine the impact of ABI on long-term survival of 52 non-diabetic HD patients. The ABI was determined using an automated, non-invasive waveform analysis device. Patients were divided into three groups: low (<0.9), normal (0.9-1.4) and high (>1.4) ABI. Patients were observed from the date of ABI measurement until their death or ten years. Survival analysis showed higher risk for CV death in HD patients with high ABI compared to normal ABI (log rank test P < 0.027). In Cox regression model adjusted for arterial hypertension, smoking, serum cholesterol and triglycerides, high ABI (P < 0.049) remained a predictor of mortality. The results indicate an association between ABI and long-term survival of non-diabetic HD patients and only high ABI was associated with higher CV mortality.

Intra-arrest percutaneous coronary intervention: a case series.

In patients with refractory cardiac arrest presumably from acute coronary occlusion, primary percutaneous coronary intervention (PPCI) may provide an opportunity for revascularisation and, subsequently, return of spontaneous circulation. We present our experience from a 24/7 primary percutaneous coronary intervention centre serving a population of approximately 800,000 individuals. A retrospective analysis was performed in patients with cardiac arrest treated from July 2011 to January 2014. Inclusion criteria were cardiac arrest and emergency coronary angiography performed during on-going external cardiopulmonary resuscitation (CPR). Course of treatment was analysed to outline the reasons for poor survival. Eight patients met the inclusion criteria; six (75 %) were male, and the mean age was 63 ± 16 years. Revascularisation under continuous cardiopulmonary resuscitation was achieved in all eight patients. Sustained return of spontaneous circulation was achieved in two patients (25 %). Both patients had poor neurological outcome (cerebral performance category 4), and both died within 3 months. We identified total duration of cardiopulmonary resuscitation (90.5 ± 33.3 min), lack of prehospital mechanical cardiopulmonary resuscitation devices and lack of extra-corporeal life support devices as the most likely reasons contributing to poor survival.

Ankle-brachial index and cardiovascular mortality in nondiabetic hemodialysis patients.

Atherosclerosis is a leading cause of morbidity and mortality in hemodialysis (HD) patients. Low (<0.90) and high (>1.40) ankle-brachial index (ABI) is known as a non-invasive diagnostic marker for generalized atherosclerosis associated with higher cardiovascular (CV) mortality in the general population. Less is known about associations between ABI and CV mortality in HD patients. The aim of our study was to determine the impact of the ABI on CV mortality in nondiabetic HD patients. Fifty-two nondiabetic HD patients (mean age 59 years, range 22 - 76 years) were enrolled in our study. Twenty-three (44%) were women and 29 (56%) men. The ABI was determined using an automated, non-invasive, waveform analysis device. All patients were divided according to the ABI into three groups: low ABI (<0.9), normal ABI (0.9-1.4) and high ABI (>1.4). The presence of arterial hypertension and smoking was established. Serum cholesterol (HDL and LDL) and triglycerides were measured by routine laboratory methods. Survival rates were analyzed using Kaplan-Meier survival curves. The Cox regression model was used to assess the influence of the ABI on CV outcomes. The model was adjusted for age, arterial hypertension, smoking, cholesterol and triglycerides. Mean ABI value was 1.2 ± 0.3 (range 0.2-2.2). Patients were observed from the date of the ABI measurement until their death or maximally up to 1620 days. Kaplan-Meier survival analysis showed that the risk for CV death was higher for HD patients with low and high ABI compared to normal ABI (log rank test: P < 0.006; P < 0.0001). In the adjusted Cox multivariable regression model low and high ABI (P < 0.011; P < 0.003) remained predictors of mortality in our patients. The results indicate a U-shaped association between the ABI and CV mortality in nondiabetic HD patients and showed that low and high ABI were directly associated with higher mortality of our patients.