Cardiac arrest caused by accidental severe hypothermia and myocardial infarction during general anesthesia.

Therapeutic hypothermia is often used for traumatic brain injury because of its neuroprotective effect and decreased secondary brain injury. However, this procedure lacks clinical evidence supporting its efficacy, and adverse outcomes have been reported during general anesthesia. A 61-year-old man with a history of percutaneous coronary intervention (PCI) was admitted with traumatic brain injury. Immediately after admission, he underwent mild therapeutic hypothermia with a target temperature of 33.0°C for neuroprotection. During general anesthesia for emergency surgery because he developed a mass effect, hypothermic cardiac arrest occurred following an additional decrease in the core body temperature. Moreover, myocardial infarction caused by restenosis of the previous PCI lesion also contributed to the cardiac arrest. Although the patient recovered spontaneous circulation after an hour-long cardiopulmonary resuscitation with rewarming, he eventually died of subsequent repetitive cardiac arrests. When anesthetizing patients undergoing therapeutic hypothermia, caution is required to prevent adverse outcomes that can be caused by unintentional severe hypothermia and exacerbation of underlying heart disease.

Hemodynamic changes following accidental infiltration of a high dose of vasopressin.

Vasopressin local infiltration is useful in gynecological surgery because it can reduce hemorrhage. Depending on the activities of the sympathetic system and the renin-angiotensin system, reactions to vasopressin may differ and predicting its systemic effects is difficult. Because life-threatening complications can occur, infiltration with vasopressin should be administered with caution. A 42-year-old female patient was diagnosed with uterine leiomyomas. During a robot-assisted laparoscopic myomectomy, 50 U of vasopressin, which is ten-times the recommended dose, was accidentally infiltrated. Subsequently, bradycardia with a heart rate of 25 bpm occurred, which recovered within 3 minutes. Peripheral perfusion indices and the diameter of the radial and brachial arteries also decreased markedly and recovered within 1 hour. The surgery was concluded without additional events. The patient was discharged 2 days later with no abnormal findings. Because vasopressin infiltration can cause life-threatening complications, it is necessary to determine the extent of patient reactions to vasopressin using measures such as the peripheral perfusion index or radial and brachial artery diameters. These measures may also help to predict the occurrence of complications.

Upper gastrointestinal bleeding caused by direct invasion of diffuse large B-cell lymphoma into the stomach in a patient with HIV infection: A case report.

RATIONALE: Diffuse large B-cell lymphoma (DLBCL) is the most frequent human immunodeficiency virus (HIV)-related Non-Hodgkin's Lymphoma of the stomach. Although gastrointestinal (GI) bleeding due to primary gastric lymphoma has been previously reported in the literature, there have been no reports of stomach wall involvement of intra-abdominal lymphoma presenting as GI bleeding. PATIENT CONCERNS: We present a rare case of direct invasion of DLBCL to the stomach wall that presented as upper GI bleeding in a patient with HIV. DIAGNOSIS: Upper endoscopy showed a large ulcerofungating mass in the lesser curvature of upper stomach body. The computed tomography scan showed an about 22 × 12 cm sized huge mass that invades into the stomach wall in the abdominal cavity. A diagnosis of DLBCL was established after histological examination. INTERVENTION: The patient was treated with 6 courses of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). OUTCOMES: The patient achieved a complete response with 6 courses of R-CHOP treatment. No recurrence was observed during the 4-month follow-up period. LESSONS: Because of the high incidence of lymphoma in patients with HIV, if such patients complain of dyspepsia, epigastric soreness, or melena, malignant tumors, such as lymphomas or stomach cancers, should be suspected. As in this patient, doctors should be aware that intra-abdominal lymphoma can invade into the stomach wall and cause bleeding.

The Colonoscopist's Expertise Affects the Characteristics of Detected Polyps.

BACKGROUND/AIMS: The influence of the endoscopist on the polyp detection rate (PDR) is underappreciated in clinical practice. Moreover, flat lesions or lesions of the proximal colon are more difficult to detect. Here, we evaluated the differences in the PDR and the characteristics of detected polyps according to the experience of the colonoscopist. METHODS: We collected data on 2,549 patients who underwent screening colonoscopy performed by three fellows. The PDR was calculated according to the percentage of patients who had at least one polyp (method A) and according to the percentage of detected lesions (method B). The primary outcome included the change in the PDR, and the secondary outcome included the change in the characteristics of the detected polyps with increasing experience of the colonoscopist. RESULTS: No proportional correlation was found between the PDR and increasing experience in colonoscopy with method A; however, with method B, the PDR increased after 400 colonoscopies (p=0.0209). With method B, the detection rates of small polyps (<5 mm) (p=0.0015) and polyps in proximal sites (p=0.0050) increased after 300 colonoscopies. CONCLUSIONS: Our study demonstrated that the quality of a colonoscopy, measured by using the PDR, may increase when performed by experienced fellows.

Comparison of the Efficacy and Tolerability between Same-day Picosulfate and Split-dose Polyethylene Glycol Bowel Preparation for Afternoon Colonoscopy: A Prospective, Randomized, Investigator-blinded Trial.

BACKGROUND/AIMS: In the present study, we evaluated the efficacy and tolerability between same-day bowel preparation protocols using 2 sachets of Picosulfate and a 4 L split-dose polyethylene glycol (PEG) bowel preparation for afternoon colonoscopy. METHODS: The study had a single-center, prospective, randomized, and investigator-blinded, non-inferiority design. We evaluated bowel preparation quality according to the Ottawa scale, patient tolerability, compliance, incidence of adverse events, sleep quality, and polyp/adenoma detection rate. RESULTS: Among the 196 patients analyzed (mean age, 55.3 years; 50.3% men), 97 received the same-day regimen of 2 sachets of picosulfate (group A) and 99 received the 4 L split-dose PEG regimen (group B). The Ottawa score of the total colon was 4.05±1.56 in group A and 3.80±1.55 in group B (P=0.255). The proportion of patients having adequate bowel preparation in the same-day picosulfate group (61.5%) was slightly less than the 4 L PEG group (71.3%); however, the difference was not statistically significant (P=0.133). Tolerability of the group A regimen was superior to that of the group B regimen (P<0.000). The same-day picosulfate regimen was associated with fewer adverse events, such as abdominal bloating (P=0.037) and better sleep quality (P<0.000). CONCLUSIONS: The same-day picosulfate regimen and the 4 L split-dose PEG regimen had similar efficacy in bowel preparation for afternoon colonoscopy. However, the same-day picosulfate regimen was easier to administer, produced fewer adverse events, and enabled better sleep quality.

Successful percutaneous coronary intervention for acute coronary syndrome in a patient with severe hemophilia a.

Patients with hemophilia generally have a reduced frequency of coronary artery disease compared to the general population. As advances in the management of hemophilia have increased their life expectancy, the prevalence of coronary artery disease also has increased. However, there are no standard treatment guidelines for coronary artery disease in patients with hemophilia, especially in the field of coronary intervention. We report the case of a patient with severe hemophilia A who presented with acute coronary syndrome and was successfully treated with percutaneous coronary intervention.