ABSTRACT
Methadone is a synthetic full µ-opioid receptor agonist and N-methyl-D-aspartate antagonist given to patients who have recently stopped using illicit opioids or are tapering off chronic opioid pain medication. Maintenance treatment with methadone is today the most widespread and effective way to treat opiate addiction, which achieves abstinence, decreases morbidity and mortality, improves quality of life, and reduces crime genesis, among other benefits. It is also approved by the Food and Drug Administration for treating moderate-to-severe pain that remains unresponsive to nonopioid medications. Patients sometimes abruptly discontinue the medication for several reasons and sometimes suffer distressing but non-life-threatening withdrawal symptoms. More common withdrawal symptoms include anxiety, agitation, rhinorrhea, nausea, and vomiting, like other opioid agonist medications. Psychosis has been reported in some rare cases of methadone withdrawal. However, more research is required because, although psychotic symptoms have been described in different case reports after the reduction or withdrawal of methadone, they have not been sufficient. This case report contributes to the literature on rare manifestations of psychosis in patients who abruptly discontinue the use of methadone.
ABSTRACT
Tuberculosis (TB) remains a significant global health challenge. Miliary TB is a rare manifestation of TB that involves systemic lymphohematogenous dissemination of infection and presents diagnostic challenges due to its often asymptomatic or non-specific nature. This case report documents a rare occurrence of gastrointestinal (GI) bleeding secondary to miliary TB without pulmonary symptoms in an 81-year-old Filipino-American male living in the United States. Extensive imaging studies revealed a mass in the right colon with multiple bleeding vessels draped around it; it was not amendable to treatment with embolization and required right hemicolectomy with end ileostomy. The pathology report of the excised mass demonstrated miliary TB with necrotizing granulomas and granulomatous lymphadenopathy involving 23 lymph nodes. The patient was started on anti-tuberculosis medical management; however, the patient remained clinically unstable and expired on postoperative day 39. This case highlights the importance of the heightened clinical awareness required during times of globalization and in regions with dense immigrant populations. We aim to delineate the clinical understanding of gastrointestinal TB (GITB) and review possible indications for surgical management. We aim to help reduce diagnostic delay, therefore improving patient outcomes and limiting the spread of disease.
ABSTRACT
A direct sliding inguinal hernia descends through the superficial inguinal ring and encroaches on nearby organ structures, such as the bladder. This type of hernia is rare with a 2-5% incidence and occurs due to a weakness within the lower abdominal wall, usually associated with advancing age, that permits the distal colon to descend into the inguinal canal. Direct sliding inguinal hernias are a rare subset of inguinal hernias that require meticulous dissection due to their incorporation of nearby organs such as the bladder or colon. Few cases report repair of these hernias laparoscopically; however, the use of a hybrid laparoscopic/open approach has not been extensively documented and it may be beneficial to explore the use of this approach in inguinal hernia repair. We present a case of a robotic-assisted minimally invasive repair of a direct sliding inguinal hernia in an 85-year-old male. He initially presented to the emergency department with left-sided groin pain and imaging revealed he had a direct sliding inguinal hernia that incorporated the bladder wall. He was admitted to surgery for a robotic-assisted minimally invasive inguinal hernia repair with mesh. During the surgery, after seeing the extent at which the hernia sac incorporated the bladder wall, the procedure was converted to an open approach to perform the remainder of the reduction; however the robot was reintroduced for mesh placement. Post-operatively, the patient experienced mild incisional abdominal pain with return of bowel function on day four and was discharged that same day.
ABSTRACT
Calcium pyrophosphate deposition (CPPD) disease of the joints is a form of arthritis that can present in a severely debilitating form of pseudogout. Although mostly idiopathic, pseudogout has been reported following bisphosphonate therapy in only nine cases to date with a pathophysiology that remains unclear. We present the case of a 59-year-old postmenopausal woman who developed the rare onset of acute polyarticular CPPD disease following zoledronic acid infusion for the treatment of osteoporosis.
ABSTRACT
The social determinants of health (SDOH) are a complex web of factors that influence the health of individuals throughout their lifetime. There are many drivers of health inequities within the SDOH, such as socioeconomic status, education, employment, gender, and race/ethnicity. It is possible that mental illness may develop when these factors negatively affect health. However, current research primarily focuses on SDOH in cisgender individuals leaving a scientific gap in transgender individuals who require unique considerations when providing comprehensive medical care. We present the case of a 20-year-old transgender female who was admitted for suicidal attempts during a methamphetamine overdose, and who had been struggling with mental illness and suicidal gestures since she was a young teenager. The significance of our findings is discussed in the context of the substantial lack of current research on SDOH in transgender individuals to underscore the need for clinical awareness and promote future research.
