Successful Non-Operative Management of Extensive Pneumatosis Cystoides Intestinalis Due to Graft Versus Host Disease.

Graft versus host disease is a serious complication of allogenic stem cell transplants and can manifest with gastrointestinal complications including pneumatosis cystoides intestinali (PCI). A 43-year-old male with a history of acute myeloid leukemia presented to the hospital with abdominal pain and sepsis. The patient was intubated and admitted to the ICU. His CT scan demonstrated extensive colonic pneumatosis. He was high risk for laparotomy so was treated non-operatively. He improved and his abdominal exam remained benign. With aggressive resuscitation, close monitoring, and antibiotics, the patient was able to avoid major abdominal surgery. pneumatosis cystoides intestinali is a concerning finding that often leads to surgical interventions. Concurrent sepsis, gut ischemia, and frank perforation often lead to surgical intervention. In patients with high surgical risk and lack of critical bowel findings, non-operative management can be successful.

Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies.

OBJECTIVE: To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies. DATA SOURCE: Published randomized controlled trials in humans, observational human studies, animal studies, review articles, ventilator textbooks, and editorials. DATA SUMMARY: Airway pressure release ventilation optimizes alveolar recruitment, reduces airway pressures, allows for spontaneous breathing, and offers many hemodynamic benefits. Despite these physiologic advantages, there are inconsistent data to support the use of APRV over other modes of ventilation. There is considerable heterogeneity in the application of APRV among providers and a shortage of information describing initiation and titration strategies. To date, no direct comparison studies of APRV strategies have been performed. This review describes 2 common management approaches that bedside providers can use to optimally tailor APRV to their patients. CONCLUSION: Airway pressure release ventilation remains a form of mechanical ventilation primarily used for refractory hypoxemia. It offers unique physiological advantages over other ventilatory modes, and providers must be familiar with different titration methods. Given its inconsistent outcome data and heterogeneous use in practice, future trials should directly compare APRV strategies to determine the optimal management approach.

Thyroid storm and warm autoimmune hemolytic anemia.

Graves' disease is often associated with other autoimmune disorders, including rare associations with autoimmune hemolytic anemia (AIHA). We describe a unique presentation of thyroid storm and warm AIHA diagnosed concurrently in a young female with hyperthyroidism. The patient presented with nausea, vomiting, diarrhea and altered mental status. Laboratory studies revealed hemoglobin 3.9g/dL, platelets 171×109L-1, haptoglobin <5mg/dL, reticulocytosis, and positive direct antiglobulin test (IgG, C3d, warm). Additional workup revealed serum thyroid stimulating hormone (TSH) <0.01µIU/mL and serum free-T4 (FT4) level 7.8ng/dL. Our patient was diagnosed with concurrent thyroid storm and warm AIHA. She was started on glucocorticoids to treat both warm AIHA and thyroid storm, as well as antithyroid medications, propranolol and folic acid. Due to profound anemia and hemodynamic instability, the patient was transfused two units of uncrossmatched packed red blood cells slowly and tolerated this well. She was discharged on methimazole as well as a prolonged prednisone taper, and achieved complete resolution of the thyrotoxicosis and anemia at one month. Hyperthyroidism can affect all three blood cell lineages of the hematopoietic system. Anemia can be seen in 10-20% of patients with thyrotoxicosis. Several autoimmune processes can lead to anemia in Graves' disease, including pernicious anemia, celiac disease, and warm AIHA. This case illustrates a rarely described presentation of a patient with Graves' disease presenting with concurrent thyroid storm and warm AIHA.

Urodynamics findings in transverse myelitis patients with lower urinary tract symptoms: Results from a tertiary referral urodynamic center.

AIMS: To characterize urodynamic findings in patients referred with transverse myelitis (TM) and lower urinary tract symptoms (LUTS), as well as to identify any characteristics predictive of urodynamics findings. METHODS: This is a retrospective review of an IRB-approved neurogenic bladder database of patients followed by a single surgeon between 2001 and 2013. Patient characteristics, questionnaire data, radiologic studies, and urodynamic parameters were analyzed. RESULTS: Of the 836 patients in the neurogenic bladder database, 28 patients (17 females, 11 males) were referred with a principle diagnosis of TM (3%). Twenty-one of twenty-eight patients (75%) underwent urodynamics testing. Bladder management at initial urologic evaluation was CIC or urethral catheter for 16/28 patients (57.1%). Median MCC was 303 ml (85-840 ml), detrusor overactivity (DO) was present in 16/21 (76%), detrusor sphincter dyssynergia (DSD) in 10/21 (48%), and decreased compliance in 7/21 (33%). For those voiding, mean Qmax was 12 ± 10 ml/sec and pdet at Qmax was 41 ± 17 cmH2 O. Longitudinally extensive TM (LETM) was the only patient characteristic associated with DO (P = 0.0276). No other patient characteristics were associated with urodynamics parameters. CONCLUSIONS: Significant urodynamic testing abnormalities are noted in the majority of TM patients undergoing urodynamics, with 95% having DO, DSD, altered compliance, or detrusor underactivity. Other than the association between LETM and DO, there were no patient characteristics predictive of urodynamics findings. Based on the severity of urodynamics findings in our series, patients with TM and LUTS should have thorough baseline urological evaluations including urodynamics and be offered ongoing surveillance. Neurourol. Urodynam. 36:360-363, 2017. © 2015 Wiley Periodicals, Inc.

Quality of life after suprapubic catheter placement in patients with neurogenic bladder conditions.

AIMS: To evaluate quality of life in patients with neurogenic bladder (NGB) conditions who have elected to undergo suprapubic catheterization (SPC), as well as assess adverse events (AEs) related to the procedure. METHODS: This is a retrospective review from a database of NGB patients from 1/1/2003 to 6/30/2013. Patients who underwent SPC placement were invited to complete a validated, single item Patient Global Impression of Improvement (PGI-I) questionnaire. Success or positive response was defined as 1 or 2 on a scale of 1-7. All patients were included in the assessment of AEs. RESULTS: Of the 128 patients who underwent SPC, 89 patients (54 female, 35 male) met inclusion criteria. Response rate to the PGI-I questionnaire was 65.2% (58/89). Mean age at the time of SPC placement was 54.4 years (± 14.4). The mean time from SPC placement to PGI-I questionnaire was 48.3 months (Range 4.4-128.4). Overall, success was seen in 49/58 patients (84.5%). Only 5.2% (3/58) patients reported a negative PGI-I (score 5/7). There was an 18.8% rate of short term complications, with the majority of these being classified as Clavien I. There was one Clavien IIIb complication (0.8%), which consisted of a small bowel perforation. CONCLUSIONS: SPC is an effective bladder management in carefully selected NGB patients who have failed other options. Over 80% considered the SPC to have improved their urological quality of life with a mean time to questionnaire of 4 years. Severe AEs are rare, though can be particularly serious in this group of neurologically impaired patients. Neurourol. Urodynam. 35:831-835, 2016. © 2015 Wiley Periodicals, Inc.

Intraoperative Decision-making for Precise Penile Straightening During Inflatable Penile Prosthesis Surgery.

OBJECTIVE: To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures. METHODS: Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction. RESULTS: Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36°, and all patients were corrected to < 10°. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P <.05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction. CONCLUSION: Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively.