Superior mesenteric arteriovenous fistula embolization with a vascular plug for upper gastrointestinal hemorrhage: a case report.

BACKGROUND: Superior mesenteric arteriovenous fistula is a rare vascular anomaly often presenting with sequelae of portal hypertension, heart failure, or mesenteric ischemia. This report describes a patient with a previously unidentified superior mesenteric arteriovenous fistula who presented with variceal bleeding, thought to be the leading cause of mortality associated with this condition. Although this patient was initially referred for a transjugular intrahepatic portosystemic shunt procedure, following a thorough review of her clinical history and imaging, she instead underwent embolization of the arteriovenous fistula likely responsible for her symptoms. CASE PRESENTATION: A 75-year-old woman with a past surgical history of extensive small bowel resection presented with active variceal bleeding requiring transfusions. She was referred to vascular and interventional radiology for transjugular intrahepatic portosystemic shunt procedure; however, her clinical presentation was inconsistent with cirrhosis. This prompted a further review of her imaging, which identified a superior mesenteric arteriovenous fistula as the probable etiology of her varices. This fistula was subsequently embolized with a vascular plug and follow-up upper endoscopy at 1-month demonstrated complete resolution of her varices. CONCLUSIONS: This report highlights a potential etiology of variceal bleeding in the acutely ill patient. Through a thorough consultation, the patient described here was able to avoid a procedure with the potential to cause catastrophic consequences, and instead receive the appropriate treatment for an uncommon condition. LEVEL OF EVIDENCE: Level 4, Case Report.

COVID-19 Drive-Through Point of Screening and Testing (POST) System: A Safe, Efficient, and Adaptable Model for Nasopharyngeal Swab Collection.

OBJECTIVE: The authors aim to demonstrate that the current drive-through testing model at a health district was improved in certain parameters compared with a previous testing protocol, and to provide the methodology of the current model for other coronavirus disease (COVID-19) testing sites to potentially emulate. METHODS: Initially, a small drive-through site was constructed at a converted tuberculosis clinic, but due to an increase in testing needs, an expanded point of screening and testing (POST) system was developed in an event center parking lot to administer tests to a higher volume of patients. RESULTS: An average of 51.1 patients was tested each day (2.0 tests per personnel in personal protective equipment [PPE] per hour) at the initial tuberculosis clinic drive-through site, which increased to 217.8 patients tested each day (5.9 tests per personnel in PPE per hour) with the new drive-through POST system (P < 0.001). Mean testing time was 3.4 minutes and the total time on-site averaged 14.4 minutes. CONCLUSIONS: This POST drive-through system serves as an efficient, safe, and adaptable model for high volume COVID-19 nasopharyngeal swabbing that the authors recommend other COVID-19 testing sites nationwide consider adopting for their own use.

Missed Testing Opportunities Among HIV-Positive Adults in a Community Emergency Department.

Northern Nevada's most utilized emergency department (ED) could represent a locale of missed opportunity for human immunodeficiency virus (HIV) detection, as the ED serves as a source of primary care for many patients at risk for HIV infection. The authors conducted a retrospective chart review, through the electronic health record, evaluating new diagnoses of HIV between 2012 and 2017 within a single hospital system. An opportunity for prior detection of HIV in the hospital's adult ED, within the past 5 years, was recorded as a missed testing opportunity (MTO). Out of 46 new HIV diagnoses at this hospital for a 5-year period, 19 patients with at least one MTO were identified. Eight of these patients with an MTO were diagnosed with acquired immunodeficiency syndrome (AIDS) concomitant with detection of their HIV status. Encouraging earlier HIV detection in the ED could reduce transmission, mortality, and health care expenditures.

The Association Between Adverse Childhood Experiences (ACEs) and Postoperative Bariatric Surgery Weight Loss Outcomes.

PURPOSE: Previous research demonstrates that exposure to adverse childhood experiences (ACEs) is associated with development of obesity. The same mechanisms mediating this relationship could theoretically affect attempts to lose weight in adulthood. However, it is unclear whether or not exposure to ACEs impacts the effectiveness of bariatric surgery. The present study aimed to examine the association of exposure to ACEs to postoperative weight loss outcomes. MATERIALS AND METHODS: One hundred ninety-eight patients undergoing bariatric surgery were evaluated for their exposure to ACEs, determined by a presurgical questionnaire and recorded as an ACEs score. Percent total weight loss (%TWL) was calculated to evaluate postoperative weight loss at 1-, 3-, and 6-month intervals postoperatively. One hundred forty-two participants were available for follow-up at the 6-month postoperative interval. RESULTS: The sample consisted of 167 women and 31 men with a mean age of 47.7. Twenty-five percent of participants experienced high exposure to ACEs, defined as experiencing ≥ 4 ACEs. The average %TWL at 6 months was 16.52%. Multilevel modeling found no significant relationship between ACEs score and %TWL at any of the postoperative time intervals, both before and after adjusting for age, sex, and race. CONCLUSION: High exposure to ACEs was not associated with poorer weight loss outcomes, and participants with a large number of ACEs generally lost the anticipated amount of weight.

Paraneoplastic encephalitis with leukoencephalopathy in primary fallopian tube carcinoma.

Previous reports of paraneoplastic encephalitis occurring in primary fallopian tube carcinoma have been exclusively classified as paraneoplastic cerebellar degeneration, with MR imaging either unremarkable or demonstrating cerebellar atrophy. We report a case of paraneoplastic encephalitis in a 64-year-old female with primary fallopian tube carcinoma, reminiscent of N-methyl d-aspartate receptor encephalitis, with MR imaging demonstrating bilateral subcortical and deep white matter T2-FLAIR hyperintensities sparing cerebellar and brainstem structures. To our knowledge, this represents the first reported case of noncerebellar paraneoplastic encephalitis related to primary fallopian tube carcinoma.

Progressive cavitating leukoencephalopathy associated with a homozygous POLG mutation of 264C>G (p.F88L).

Progressive cavitating leukoencephalopathy is a childhood neurodegenerative syndrome characterized by brain MR imaging findings of patchy leukoencephalopathy with cavities and vascular permeability, initially affecting the corpus callosum and centrum semiovale, and eventually coalescing into large cystic regions of white matter. We report a case of progressive cavitating leukoencephalopathy in a 2-year-old female patient presenting as intermittent motor deficits which partially resolved over several months. Whole exome sequencing revealed a homozygous c.264C>G (p.F88L) POLG variant of uncertain pathogenicity which was potentially related to this presentation. Further testing and information are needed to prove the pathogenicity of this variant, but considering other studies which report similar genotypes in association with differing phenotypes, the current case report supports a possible pathogenicity. This case could therefore represent the first reported instance of progressive cavitating leukoencephalopathy in the presence of a POLG mutation.

Large Hiatal Hernia Repair with Urinary Bladder Matrix Graft Reinforcement and Concomitant Sleeve Gastrectomy.

BACKGROUND: There is no current consensus on the management of large hiatal hernias concomitant with performance of a sleeve gastrectomy procedure. Proposed solutions have included performing a modified Nissen fundoplication, performing cruroplasty alone, utilizing the Linx device, performing cruroplasty with reinforcement material, and avoiding the sleeve procedure altogether in favor of a bypass procedure in order to minimize gastroesophageal reflux. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials. METHODS: This study reports the results of a retrospective chart review of 32 cases of large hiatal hernia repair utilizing both primary crural repair and UBM reinforcement concomitant with laparoscopic sleeve gastrectomy by a single surgeon. Hernia diameter averaged 6 cm (range 4-9 cm). After an average of 1 year followup, 30 patients were assessed for subjective symptoms of gastroesophageal reflux (GERD) using the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Twenty patients were evaluated with either upper gastrointestinal (GI) series, endoscopy, or both. RESULTS: Each repair was successful and completed laparoscopically concomitant with sleeve gastrectomy. Anterior and posterior cruroplasty was performed using interrupted 0-Ethibond suture using the Endostitch device. The UBM graft exhibited favorable handling characteristics placed as a keyhole geometry sutured to the crura with absorbable suture. A careful chart review was undertaken to assess for complications. There have been no reoperations. After a median of 12 months (range, 4-27 months) of followup, an assessment of recurrences or long-term complications was completed. Median GERD-HRQL score was 6, with a range of 0 to 64 (of possible 75), indicating very low-level reflux symptomatology. Follow-up upper GI radiographs or endoscopy were obtained in 20 cases and show intact repairs. CONCLUSION: In this series of 32 cases, laparoscopic cruroplasty with UBM graft reinforcement has been effective and durable at 12 months of followup. This technique may offer one satisfactory solution for large hiatal hernia repair concomitant with laparoscopic sleeve gastrectomy that may achieve a durable repair with low GERD symptoms.