Atypical haemolytic uraemic syndrome in a postpartum patient.

A postpartum patient presented 1 week following uncomplicated pregnancy and elective repeat caesarean section with acute hypertension, severe anaemia and acute kidney injury. Her workup demonstrated microangiopathic anaemia, thrombocytopenia and liver enzyme elevations. Differential diagnoses included postpartum haemolysis-elevated liver enzyme-low platelet (HELLP) syndrome, haemolytic uraemic syndrome (HUS), and thrombotic thrombocytopenic purpura (TTP). She was treated initially with systemic corticosteroids, haemodialysis and plasmapheresis for presumed TTP while awaiting the results of ADAMSTS13 assay performed at an outside laboratory. When reported back as normal, the diagnosis of atypical HUS was established. Eculizumab was administered with rapid improvement of her condition.

Pharmacokinetics of Ketamine Transfer Into Human Milk.

PURPOSE/BACKGROUND: Ketamine is an N -methyl- d -aspartate-antagonistic dissociative anesthetic infused intermittently for off-label management of treatment-resistant depression, acute suicidality, and postpartum depression. Despite the prevalence of postpartum depression nearing upward of 15% of deliveries, almost no research has been done to evaluate its safety during lactation. METHODS: In this study, human milk samples were released from the InfantRisk Center's Human Milk Biorepository of 4 participants treated with intermittent ketamine infusions (49-378 mg) to determine the levels of the drug and its active norketamine metabolite using liquid chromatography-mass spectrometry. RESULTS: The absolute infant dose of ketamine from human milk was 0.003 to 0.017 mg/kg per day, and norketamine was 0.005 to 0.018 mg/kg per day. The relative infant dose (RID) for ketamine ranged from 0.34% to 0.57%. The RID for norketamine ranged from 0.29% to 0.95%. There were no reported infant adverse effects. CONCLUSION: The findings of this study suggest that the transfer of ketamine, as well as its active metabolite, norketamine, into human milk is minimal, as estimated by RIDs less than 1% in all participants. These relative doses are well below standardly accepted safety thresholds.

Psychiatric Manifestations of Withdrawal Following Domperidone Used as a Galactagogue.

Background: Domperidone is a dopamine-2 antagonist used off-label to increase breast milk production. Dosages commonly promoted for lactation are often far above those of studied on-label indications and might pose additional risks, especially upon discontinuation of the drug. Patients: Three U.S. patients are presented who used domperidone for lactation and experienced varying degrees of psychiatric withdrawal symptoms lasting months during dosage tapering and after cessation. Conclusion: Domperidone as a galactagogue may pose a significant psychiatric risk upon discontinuation. This presentation is commonly confused with, but clinically distinct from, postpartum depression. Lactating mothers who present with psychiatric symptoms should be explicitly probed about domperidone use, even in areas where domperidone is not authorized for use. Maternal hesitancy to disclose domperidone use may lead to suboptimal outcomes for the patient and delay management of withdrawal manifestations. The best course of treatment remains unknown, but a slow hyperbolic taper to gently discontinue domperidone may minimize withdrawal symptoms in these patients. Individuals exploring domperidone use should be informed of potential risks upon withdrawal, including psychiatric manifestations, requisite taper, and potential impacts of using unstudied high doses.

Head Lice Infestation: An Unusual Cause of Iron Deficiency Anemia in a 13-Year-Old Female.

Pediculosis is a parasitic infestation of the human head and body by Pediculus humanus. This is a benign condition commonly seen in children and capable of causing severe pruritus. The parasite thrives on human blood and in some cases, the volume of blood loss over time could be large enough to precipitate anemic symptoms in the patient. We describe the case of a 13-year-old girl who presented with shortness of breath on exertion, palpitations, and easy fatigability. An incidental finding of Pediculus humanus capitis infestation was made during physical examination. Complete laboratory investigations did not reveal other possible causes of anemia, leading to a diagnosis of iron deficiency anemia (IDA) secondary to severe chronic pediculosis. This case highlights a rare and unusual cause of IDA in children caused by pediculosis, and the need for a thorough investigation, close follow-up, and treatment.

Increased in-hospital mortality and emergent cases in patients with stage IV cancer.

BACKGROUND: Cancer patients in the USA are still being treated with aggressive, life-prolonging interventions. Palliative care services remain vastly underutilized despite surges in both quality and quantity of programs. We evaluated surgical outcomes of metastatic cancer patients to question whether palliative care may be a better option. STUDY DESIGN: We queried the 2014 National Surgical Quality Improvement Program database (NSQIP) for patients with a diagnosis of malignancy (ICD 9 Codes 145.00 to 200.00). Cases were divided into metastatic and non-metastatic cancer. Demographic data including preoperative, intraoperative, and postoperative factors, as well as complications and comorbidities were compared between these two groups. Independent t testing was used to compare continuous variables. Chi-square testing was used to compare categorical variables. Multiple logistic regression was used to assess for predictors of mortality in metastatic cancer. RESULTS: A total of 80,275 cancer patients were analyzed, 11.8% (9423) of whom had metastatic disease. In-hospital mortality rate was found to be 4 times higher among patients with metastatic cancer (2.1% vs. 0.5%; P = < 0.0001). Of those metastatic cancer patients that died while in hospital, 18.5% had an emergency surgery performed. After adjusting for confounders, dyspnea at rest/moderate exertion (OR 5.7/2.4; 95% CI 2.7/1.6 to 11.9/3.7; P < 0.0001) was found to be the most significant predictor of in hospital mortality in stage IV cancer patients. CONCLUSION: Aggressive treatment in advanced cancer patients contributes to alarmingly high in-hospital mortality. Improved, deliberate communication of palliative care options with patients is exceedingly conducive to enhancing end-of-life cancer care.

Polymer-Encased Nanodiscs and Polymer Nanodiscs: New Platforms for Membrane Protein Research and Applications.

Membrane proteins (MPs) are essential to many organisms' major functions. They are notorious for being difficult to isolate and study, and mimicking native conditions for studies in vitro has proved to be a challenge. Lipid nanodiscs are among the most promising platforms for MP reconstitution, but they contain a relatively labile lipid bilayer and their use requires previous protein solubilization in detergent. These limitations have led to the testing of copolymers in new types of nanodisc platforms. Polymer-encased nanodiscs and polymer nanodiscs support functional MPs and address some of the limitations present in other MP reconstitution platforms. In this review, we provide a summary of recent developments in the use of polymers in nanodiscs.

Dyspnoea at rest predictor of increased in-hospital mortality in metastatic cancer patients undergoing emergent surgery in United States.

BACKGROUND: Dyspnoea is an extremely common finding in patients presenting with metastatic cancer and can be caused by cancer progression, treatment toxicity or pathology secondary to deteriorating overall health. In this study, we decided to analyse post-operative outcomes to understand if dyspnoea is a significant prognostic predictor of in-hospital mortality in patients with stage IV cancer who underwent emergent surgery in the United States. METHODS: We performed a search of the 2014 National Surgical Quality Improvement Program database (NSQIP) for patients with a diagnosis of malignancy (ICD-9 Codes 145.00-200.00). Cases were divided into two groups: metastatic cancer and non-metastatic cancer. Demographical data including preoperative, intraoperative and postoperative factors, as well as data regarding complications and comorbidities were compared between these two groups. Independent t-testing was used to compare continuous variables. Chi-square testing was used to compare categorical variables. Multiple logistic regression was used to assess for predictors of mortality in metastatic cancer. Mortality was adjusted for demographics, comorbid conditions and perioperative factors. RESULTS: Referring to the NSQIP database, a total of 80,275 cancer patients were analysed, 11.8% (9,423) of whom had metastatic cancer. Dyspnoea at rest/moderate exertion (OR 5.7/2.4; 95% CI 2.7/1.6-11.9/3.7; p < 0.0001) were found to be the biggest predictors of in-hospital mortality in stage IV cancer patients who underwent emergent surgery. CONCLUSION: Dyspnoea at rest and with moderate exertion may be used as predictors of in-hospital mortality for metastatic cancer patients undergoing emergent surgery.