Extended Post Discharge Prophylaxis for Venous Thromboembolism Prevention After Bariatric Surgery.

PURPOSE: The utility of routine post-discharge VTE prophylaxis after bariatric surgery remains a matter of debate. While inpatient chemical prophylaxis decreases the risk of fatal pulmonary embolism, most thromboembolic events occur after discharge and carry high morbidity and mortality. To address this risk, apixaban was introduced as extended prophylaxis for 30 days after surgery. MATERIALS AND METHODS: The study ranges between 1/2014 and 7/2022. Apixaban was incorporated as routine extended prophylaxis protocol in 05/2017 and is dosed at 2.5 mg BID for 30 days. There were two study groups: those who received apixaban on discharge (n = 1443; 60%) and those who did not (n = 953; 40%). Patients with concern for postoperative bleeding (hypotension, unexplained tachycardia with hematocrit drop > 6%, hematocrit drop > 9%), or on preoperative anticoagulant/antiplatelet therapy (except aspirin), were not discharged on apixaban. Post-discharge VTE, readmission, transfusion, and reoperation rates were compared between groups. RESULTS: There were 2396 consecutive primary bariatric operations: sleeve gastrectomy (1949; 81%), Roux-en-Y gastric bypass (419; 18%), and duodenal switch (28; 1%). There were no post-discharge VTEs in patients treated with apixaban vs. five (0.5%) VTEs in patients who did not receive treatment; p = 0.02. There was a higher incidence in post-discharge bleeding events in the apixaban group (0.5 vs 0.3%; p = 0.75), mostly requiring readmission for monitoring without intervention or transfusion. In the apixaban group, one patient underwent EGD for bleeding while another required blood transfusion; there were no reoperations for bleeding. CONCLUSION: There were no post-discharge VTEs in patients who received apixaban. Treatment was associated with a higher risk of self-resolving bleeding events. This study adds to the increasing body of evidence supporting the benefit of routine, extended oral chemoprophylaxis after bariatric surgery.

Menstruation-Induced Psychosis in a Pediatric Patient: A Case Report.

Menstruation-induced psychosis (MIP) is a rare disorder with limited documentation in the medical literature. Most cases have been described in case reports, although multiple literature reviews have demonstrated the relationship between menses and psychosis. Here, we describe 2 episodes of rapid-onset psychosis in a healthy 15-year-old girl. Written informed consent was obtained from the patient and their father. On first evaluation, autoimmune encephalitis was the leading diagnosis of consideration. The patient received intravenous immune globulin, returning to baseline within 24 hours of administration. Extensive neurological workup was unrevealing, aside from mild cerebrospinal fluid pleocytosis, serum anti-thyroid peroxidase (TPO) antibodies, and a fluid-attenuated inversion recovery (FLAIR) splenial lesion on magnetic resonance imaging. Psychotic symptoms began around the start of the patient's menstrual cycle, and both episodes were less than 1 week in duration. This report reviews the characteristics of MIP, details a case of recurrent psychosis that fits these characteristics, and adds a well-documented case to the growing series of reports. Given the rarity of MIP, it is essential to thoroughly document such cases. This case provides an example of the clinical presentation and disease course for pediatric patients presenting with MIP, and may serve as a reference for future work in understanding MIP. MIP is characterized by psychotic symptoms of acute onset and short duration that occur in association with the menstrual cycle.1,2 MIP can present in any individual capable of menstruation, including those who do not identify as female. Per previous reports, patients generally have no history of mental illness prior to their first psychotic episode and completely recover their baseline functioning.1 In this case, the patient's presentation is consistent with the characteristics previously described for MIP.1.