Euglycemic Diabetic Ketoacidosis Presenting as Hypoglycemia in a Patient With Type 2 Diabetes and Von Gierke's Disease.

Von Gierke's disease (VGD) is rarely associated with type 2 diabetes mellitus (DM2). We present a case of VGD with DM2 that presented with hypoglycemia in the setting of diabetic ketoacidosis (DKA) in a young male with VGD using the sodium-glucose co-transporter 2 (SGLT2) inhibitor empagliflozin. The patient required resuscitation with fluids containing glucose prior to the administration of insulin for DKA protocol with significant clinical improvement. This case demonstrates a rare presentation of DKA with hypoglycemia.

Comparison of a Valveless Trocar System and Conventional Insufflation in Pediatric Urologic Surgery.

Background: Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods: A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal insufflation system (AIS) or conventional insufflation system (CIS) was utilized were obtained from hospital records. Data were compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal carbon dioxide, oxygen saturation, body temperature, positive inspiratory pressure, systolic blood pressure, and heart rate. Results: There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion: The AirSeal valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study, however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss, operative time, and perioperative complications.

Street Medicine: Barrier Considerations for Healthcare Providers in the U.S.

In the last decade, a movement known as "street medicine" has emerged. It is a relatively new medical field in which healthcare providers deliver medical care to homeless populations outside of traditional healthcare facilities, on the streets, and in various settings where unsheltered people live. Physicians essentially visit people living in camps, along riverbanks, in alleys, and abandoned buildings to provide medical care. During the pandemic, street medicine in the U.S. was often the first line of defense for people living on the streets. As the practice of street medicine continues to grow and expand across the country, there is an increasing demand to standardize patient care delivered outside traditional healthcare facilities.

The use of Tablo continuous veno-venous haemodialysis to rapidly remove lithium in a patient with severe lithium toxicity.

We report a case of severe, life-threatening lithium toxicity in a patient with bipolar I disorder who presented with altered mental status and acute renal failure. At admission, serum lithium level was well above toxic levels (>2 mEq/L). The signs and symptoms of lithium toxicity significantly improved after treatment with continuous veno-venous haemodialysis (CVVHD). The patient was discharged with no neurological or renal sequelae. Herein is the first case report using the Tablo CVVHD system to treat severe lithium toxicity.

Sphingomonas paucimobilis Bacteremia in a Patient With Retropharyngeal Abscess.

Sphingomonas p aucimobilis is a nonfermenting gram-negative bacillus that is widely distributed in both community environments and hospitals. Various infections have been identified in humans, but most have been limited to case reports. When reported, it is most commonly nosocomial infections associated with contaminated hospital equipment such as indwelling catheters, ventilators, hemodialysis devices, and very rarely upper respiratory tract infections. We report an unusual presentation of S . paucimobilis infection. This case report describes a 59-year-old immunocompetent man who presented with a retropharyngeal abscess. Blood culture was positive for S . paucimobilis. The patient was treated for a total of 21 days of intravenous (IV) cefepime and oral (PO) metronidazole. He showed significant improvement and was discharged home with no medical sequelae.

Platelet surface GPIbα, activated GPIIb-IIIa, and P-selectin levels in adult veno-arterial extracorporeal membrane oxygenation patients.

Our objective was to characterize platelet surface glycoprotein (GP)Ibα, activated GPIIb-IIIa, and P-selectin levels during and after extracorporeal membrane oxygenation (ECMO). We performed a single center cohort study of 10 adult patients on ECMO for cardiogenic shock. Patients had blood samples drawn on ECMO day 1 or 2, day 3, day 5, and 48-72 hours after ECMO decannulation. Platelets from untreated blood samples and samples treated with either adenosine diphosphate (ADP) or thrombin receptor agonist peptide (TRAP) had surface GPIbα, activated GPIIb-IIIa, and P-selectin levels measured using flow cytometry. Platelet surface GPIbα levels varied significantly by time on ECMO (p = .002) and were significantly higher on ECMO day 5 compared to ECMO day 1 (p = .01). GPIbα levels during ECMO did not differ significantly from levels after ECMO decannulation (p = .14). Activated GPIIb-IIIa levels did not change significantly during ECMO, but were significantly higher after ECMO decannulation (p = .04). There were no significant differences in P-selectin levels during ECMO (p = .87) or after ECMO decannulation (p = .41). Platelet surface GPIbα and P-selectin levels were similar during and after ECMO whereas activated GPIIb-IIIa levels were lower during ECMO, particularly in response to TRAP stimulation, potentially contributing to ECMO-induced coagulopathy.

Altered mental status and pronounced febrile response after second mRNA-1273 (Moderna) COVID-19 vaccine administration in a patient with previously documented COVID-19 infection.

A 54-year-old man who was previously found to be COVID-19 positive received two doses of mRNA-1273 (Moderna) vaccine 4 weeks apart, as recommended by the manufacturer. He was brought to the emergency department 1 day after second dose of the vaccine with altered mental status, headache and high fever. The patient was hospitalised for 2 days and managed with supportive care. He completely recovered with return of mental status to baseline and resolution of fever.

Meningitis secondary to disseminated gonococcal infection.

We report one of the unusual presentations of disseminated gonococcal infection. This case report describes a 24-year-old woman who presented with disseminated gonococcal infection manifesting as meningitis. Cerebrospinal fluid (CSF) and throat swab PCR were positive for Neisseria gonorrhoeae Blood and CSF cultures were negative for bacterial growth. The patient was treated with a total of 14 days of intravenous ceftriaxone. She was discharged with no neurological sequelae.

Community Medical Leadership Workshop: An Introduction to Physician Leadership for Resident Physicians.

Objective The Community Medical Leadership Workshop (CMLW) aims to prepare residents to become effective physician leaders through medical leadership lectures and case scenario discussions. By the end of the CMLW, participants will be able to define leadership in medicine, employ strategies to manage conflict and differences of opinions in the workplace, demonstrate effective communication skills while working with others, and describe the role of power in effective leadership. Methods A total of 32 resident physicians participated in our workshop that is based on the leadership practice inventory (LPI) and the Medical Leadership Competency Framework (MLCF). Our evaluation assessed communication strength, conflict resolution, time management, negotiation, delegation, teamwork, and community service. Results Most participants were satisfied with the course. They rated the workshop's contents the highest. In addition, over 90% of learners would recommend this workshop to others. We found a statistically significant increase in learners' ability to provide opportunities to include patients in quality improvements. Conclusion Our workshop was designed and tailored for resident physicians to introduce them to physician leadership. The workshop was well received and could serve as a model to promote qualities in residents that define effective physician leaders.

A Case Report of Schizoaffective Disorder with Pseudoseizures in a 42-year-old Male.

Psychogenic nonepileptic seizures (PNES), historically referred to as pseudoseizures or hysterical seizures, are sudden disturbances of motor, sensory, autonomic, cognitive, or emotional functions that can mimic epileptic seizures. PNES have a psychologic etiology related to dissociative disorders or conversion disorders, as opposed to the abnormally excessive neuronal activity found in epileptic seizures. Psychosocial conflicts are essentially converted into physical symptoms, resulting in seizure-like symptoms. This case report presents a 42-year-old male with a past history of child abuse, drug abuse, schizoaffective disorder, prior psychiatric hospitalizations, and diabetes mellitus type 2 who was admitted to the behavioral health unit with recurrent seizure-like episodes. These episodes were witnessed in the ED, however, appropriate workup failed to confirm abnormal neural activity or evidence of any brain injury. The patient was admitted to the psychiatric service where he was monitored for additional epileptic activity using long-term video-electroencephalogram (EEG) monitoring (LT-VEEG). While subsequent clinical events that resembled epileptic seizures were observed, the LT-VEEG failed to identify any epileptic activity. A diagnosis of PNES was established and a decision was made for the patient to remain on his current antiepileptic, psychiatric, and diabetes medications during his hospitalization. He showed gradual improvement during his stay and confirmed an understanding of his diagnosis. He was released three days later with instructions for follow-up and continued treatment with his outpatient psychiatrist. Early therapeutic counseling in patients who have a differential diagnosis of PNES should be considered to help identify and address the underlying causes of the seizure activity in an effort to curtail these seizure-like events.

Delusional Parasitosis in a Patient with Alcohol-induced Psychotic Disorder.

Alcohol-induced psychotic disorder is a rare complication of chronic alcohol abuse following abrupt alcohol cessation that is characterized by visual, auditory, or tactile hallucinations paired with intact orientation and stable vital signs, distinguishing the condition from delirium tremens and psychotic disorders. The condition, first termed alcoholic hallucinosis, has been described in medical literature for over a century, however, its nosologic classification and psychopathologic characteristics are less well-documented. One such case of alcohol-induced psychotic disorder with multimodal hallucinations of four months duration is described here.