Ketoacidosis can Be alcohol in origin: A case report.

Background: Alcoholic ketoacidosis (AKA) is a common reversible biochemical pathology arising from hyperketonaemia in patients with a history of chronic alcohol consumption. It is typically fatal when there is a delay in early recognition and management. A further complicating factor is that this condition is frequently confused with diabetic ketoacidosis (DKA). Case presentation: This report presents the case study of an elderly Chinese man with a 40-year history of alcohol consumption. The patient presented with acute shortness of breath, generalised abdominal pain, and vomiting. Blood gas analysis indicated severe high anion gap metabolic acidosis (HAGMA) with elevated serum ketones and modest hyperglycaemia which was initially treated as diabetic ketoacidosis (DKA). A diagnosis of AKA was later made after obtaining a thorough history of his binge drinking. The patient subsequently responded well to thiamine and aggressive fluid resuscitation. This case highlights the importance of a well-documented patient history and in-depth knowledge of ketoacidosis. Discussion: AKA must be suspected in patients with a history of chronic alcohol consumption and dependence. The symptoms are non-specific such as abdominal pain, nausea, vomiting and diarrhoea. The latter two result in malnutrition and starvation subsequently leading to hyperketonaemia, hypovolaemia and HAGMA. AKA should be clearly differentiated from DKA to prevent mismanagement. The mainstay of management of AKA is thiamine, fluid resuscitation and good sugar control to prevent Wernicke's encephalopathy. Conclusion: A precise patient's medical history is crucial to prevent misdiagnosis. A non-diabetic patient with a history of chronic alcohol consumption who presents with severe HAGMA, hyperketonaemia and dysglycaemia should raise a clinical suspicion of AKA. Thiamine and judicious fluid resuscitation as well as electrolytes and malnutrition correction should be promptly initiated in patients with AKA. Good family, social support and rehabilitation programs are crucial to help patients with alcohol abuse.

A rare occurrence of a metastatic urothelial carcinoma to the thoracic vertebra: A case report.

BACKGROUND: Urothelial carcinoma (UC) is a common urinary tract malignancy that predominantly affect the urinary bladder with a low recurrence rate after surgical removal. It usually metastasizes to the lungs, regional lymph nodes, and liver. However, it rarely spread to the thoracic spine and bones, especially in the Asian populations. CASE PRESENTATION: A 50-years-old Asian man, with a one-year history of surgically resected UC, presented to us with a complaint of worsening upper back pain for three months. Magnetic resonance imaging (MRI) showed a destructed second thoracic (T2) vertebra with lytic lesion. A thoracic vertebrectomy was performed and histopathological examination (HPE) showed high-grade infiltrating metastatic malignant UC. Postoperatively, he was well and did not have any back pain. He was followed up under combined spine and oncology clinic regularly and was planned for chemoradiotherapy. DISCUSSION: UC commonly metastasizes to the lungs, liver, and lymph nodes. In young Asians, thoracic spinal metastases are rare. Urgent palliative spinal surgery is indicated to prevent further deterioration of function. Intraoperative usage of targeted controlled infusion (TCI) of remifentanil and propofol as maintenance of anaesthesia are gold standard in assisting spine surgeons who are guided by neuromuscular monitoring. CONCLUSION: Spinal metastasis to the thoracic vertebra is rare among young Asian men. Patients presented with acute neurological deficits and back pain are indicated for spinal surgery. Multidisciplinary approach is needed for management of patients with spinal metastasis. Targeted controlled infusion (TCI) of remifentanil and propofol are gold standard for maintenance of anaesthesia for spine surgeries which are guided by somatosensory, and motor evoked potential monitoring.

Can First-trimester AST to Platelet Ratio Index Scores Predict HELLP Syndrome?

Null.

Obstetric challenges during COVID-19 pandemic: A narrative review.

The severe acute respiratory coronavirus 2 (COVID-19) pandemic impacts the health of women at reproductive age in different ways, starting from pregnancy planning to post-delivery. This narrative review summarises the challenges to obstetric practice posed by the severe acute respiratory coronavirus 2 (COVID-19) pandemic. In this paper, we highlight the impacts of COVID-19 to obstetric practice globally and the efforts taken to address these challenges. Further study is critical to investigate the effects of COVID-19 on pregnancy, the outcome of COVID-19 positive pregnant women, and the safety of vaccination during pregnancy and breastfeeding.

Anaesthetic challenges in a child with perforated appendicitis and COVID-19 Co-Infection: A case report.

BACKGROUND: The deadly coronavirus disease 2019 (COVID-19) wreaked havoc globally in early 2020 and caused lives to a standstill. Healthcare workers (HCW) handling patients infected with COVID-19 wore protective equipment to defend themselves from cross infection and curbing further spread. Nevertheless, these do hamper their dexterity, especially during surgical procedures. CASE PRESENTATION: A child presented to our centre needing an emergency open appendicectomy during the coronavirus disease 2019 (COVID-19) pandemic in June 2021. Prior to the surgery, her initial test for COVID-19 was negative but subsequently became positive on the second test. Fortunately, all HCW during the care for the patient, donned full personal protective equipment (PPE), and avoided cross-infection. DISCUSSION: HCW handling patients with COVID-19 should wear adequate PPE to. However, these pose detrimental effects to their dexterity during routine care of such patients. Good teamwork and communication among HCW and parents are important during the safe management of a young child with COVID-19. CONCLUSION: HCW should have low index of suspicion of COVID-19 in children with upper respiratory tract infection. Prompt and pro-active measures should be rapidly taken to prevent exposure and co-infection. Wearing multi layers of PPE do negatively affect the mood and agility of HCW handling young children with COVID-19. Thus, they should practice good team work, receive regular simulation and scenario-based training to be better prepared for pressurised situations.

Case report: A rare occurrence of a huge mediastinal mass from disseminated prostate carcinoma.

BACKGROUND: Prostatic carcinoma is the commonest malignancy among men. It usually metastasizes to the spine and regional lymph nodes. However, it is extremely rare for it to metastasize to the mediastinum. CASE PRESENTATION: An elderly man presented to us with progressive onset of bilateral lower limb weakness which was associated with thoracic radiculopathy and urinary incontinence. An urgent magnetic resonance imaging (MRI) of the spine showed severe cord compression with enlarged prostate and superior mediastinal mass. A computed tomography (CT) guided biopsy of the mediastinal mass was suggestive of prostatic malignancy. An emergency posterior instrumentation and fusion (PSIF) in prone position was successfully done. Histopathological examination of the spine showed malignant glandular tissues, suggestive of prostate. DISCUSSION: A huge mediastinal mass can compromise the cardiorespiratory system and is very challenging for the anaesthetist to safely secure the airway for surgical procedures. Androgen deprivation therapy (ADT) for patients with metastatic prostatic carcinoma can be achieved either by medical castration or with bilateral orchidectomy. CONCLUSION: It is extremely uncommon for a prostatic carcinoma to metastasize to the mediastinum. Patients with a huge mediastinal mass possess risks of cardiorespiratory collapse perioperatively. Chemoradiotherapy and androgen deprivation therapy (ADT) can be utilized for metastatic prostatic carcinoma with good outcomes.

Immediate compared with delayed oxytocin after amniotomy labor induction in parous women: a randomized controlled trial.

OBJECTIVE: To compare immediate with delayed (4 hours) oxytocin infusion after amniotomy on vaginal delivery within 12 hours and patient satisfaction with the birth process. METHODS: Parous women with favorable cervixes after amniotomy for labor induction were randomized to immediate titrated oxytocin or placebo intravenous infusion in a double-blind noninferiority trial. After 4 hours, study infusions were stopped, the women were assessed, and open-label oxytocin was started if required. Maternal satisfaction with the birth process was assessed with a 10-point visual numerical rating scale (lower score, greater satisfaction). RESULTS: Vaginal delivery rates at 12 hours were 91 of 96 (94.8%) compared with 91 of 94 (96.8%) (relative risk 0.98, 95% confidence interval [CI] 0.92-1.04, P=.72), and maternal satisfaction on a visual numerical rating scale (median [interquartile range]) was 3 [3-4] compared with 3 [3-5], P=.36 for immediate compared with delayed arm, respectively). Cesarean delivery, maternal fever, postpartum hemorrhage, uterine hyperactivity, and adverse neonatal outcome rates were similar between arms. The immediate oxytocin arm had a shorter amniotomy-to-delivery interval of 5.3±3.1 compared with 6.9±2.9 hours (P<.001) and lower epidural analgesia rate of 2.9% compared with 9.9% (relative risk 0.3, 95% CI 0.1-1.0, P=.046), but fetal heart rate abnormalities on cardiotocogram were higher, 28.6% compared with 16.8% (relative risk 1.7 95% CI 1.0-2.9, P=.048). In the delayed arm, oxytocin infusion was avoided by 35.6%. CONCLUSIONS: Immediate or delayed oxytocin infusions are reasonable options after amniotomy for labor induction in parous women with favorable cervixes. The choice should take into account local resources and the woman's wish. CLINICAL TRIAL REGISTRATION: ISRCTN Register, http://isrctn.org, ISRCTN51476259. LEVEL OF EVIDENCE: I.

Dengue infection and miscarriage: a prospective case control study.

BACKGROUND: Dengue is the most prevalent mosquito borne infection worldwide. Vertical transmissions after maternal dengue infection to the fetus and pregnancy losses in relation to dengue illness have been reported. The relationship of dengue to miscarriage is not known. METHOD: We aimed to establish the relationship of recent dengue infection and miscarriage. Women who presented with miscarriage (up to 22 weeks gestation) to our hospital were approached to participate in the study. For each case of miscarriage, we recruited 3 controls with viable pregnancies at a similar gestation. A brief questionnaire on recent febrile illness and prior dengue infection was answered. Blood was drawn from participants, processed and the frozen serum was stored. Stored sera were thawed and then tested in batches with dengue specific IgM capture ELISA, dengue non-structural protein 1 (NS1) antigen and dengue specific IgG ELISA tests. Controls remained in the analysis if their pregnancies continued beyond 22 weeks gestation. Tests were run on 116 case and 341 control sera. One case (a misdiagnosed viable early pregnancy) plus 45 controls (39 lost to follow up and six subsequent late miscarriages) were excluded from analysis. FINDINGS: Dengue specific IgM or dengue NS1 antigen (indicating recent dengue infection) was positive in 6/115 (5·2%) cases and 5/296 (1·7%) controls RR 3·1 (95% CI 1·0-10) P = 0·047. Maternal age, gestational age, parity and ethnicity were dissimilar between cases and controls. After adjustments for these factors, recent dengue infection remained significantly more frequently detected in cases than controls (AOR 4·2 95% CI 1·2-14 P = 0·023). INTERPRETATION: Recent dengue infections were more frequently detected in women presenting with miscarriage than in controls whose pregnancies were viable. After adjustments for confounders, the positive association remained.