Heart's Dangerous Symphony: Torsade De Pointes Unleashed by Gitelman Syndrome-Induced Hypomagnesemia.

Gitelman syndrome (GS) is a rare autosomal recessive salt-losing renal tubular disorder associated with a mutation of SLC12A3 or CLCNKB genes which encodes the thiazide-sensitive sodium-chloride co-transporter (NCCT) in the distal renal tubule. It is inherited as an autosomal recessive disorder. Hypokalemia, metabolic alkalosis, hypomagnesemia, hypocalciuria, and renin-angiotensin-aldosterone system (RAAS) activation are characteristics of GS. GS is often misdiagnosed or underdiagnosed owing to its low incidence and lack of awareness. Its prevalence is estimated to be around 1-10 per 40,000 people. We report a case of cardiac arrest secondary to torsade de pointes (TdP) because of GS-induced hypomagnesemia. Our case highlights the importance of clinicians being aware of the potential electrolyte abnormalities and complications associated with GS, as it can lead to catastrophic consequences if not identified and corrected earlier.

Alcohol Abuse as a Silent Risk Factor for Purpura Fulminans and the Importance of Pneumococcal Vaccination.

Purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) and a life-threatening complication of septic shock. DIC can present with bleeding and thrombosis in acute settings, making its management exceptionally challenging. Common causative organisms include Neisseria meningitidis, Streptococcus pneumoniae, andHaemophilus influenzae. We report a case of a 47-year-old patient with a history of alcohol abuse and marijuana use with a bizarre presentation of copious diarrhea and altered mental status. The patient was subsequently admitted to the intensive care unit (ICU) for acute respiratory failure and septic shock secondary to Streptococcus pneumoniae bacteremia complicated by DIC. Unfortunately, the patient's condition worsened with multiorgan failure and purpura fulminans, leading to extensive necrosis of all his extremities, with the involvement of his lips, nose, and genitals. Unfortunately, despite aggressive interventions, he continued to deteriorate and ultimately was transitioned to comfort care before he expired. In the literature, there is only one reported case of PF in an individual with alcohol abuse. However, the frequency and severity of pneumococcal infections in individuals with a history of alcohol abuse are much higher than in the general population. PF is a devastating complication of Streptococcus pneumoniae, with a mortality of 43%. We hope that this case will continue highlighting the importance of vaccinating patients with a history of alcohol abuse with the pneumococcal vaccine.

A Rare Presentation of Duplicate Superior Vena Cava Precipitating Premature Atrial Contractions: A Case Report and a Review of the Literature.

Millions of central lines are placed each year worldwide for life-saving measures. We present a case of left internal jugular (IJ) triple lumen catheter (TLC) placement for life-saving vasopressors, which appeared to be in the left mediastinum after a confirmed chest X-ray. After correlation with a previous MRI of the heart with and without contrast, duplication of the superior vena cava (SVC), also known as persistent left SVC (PLSVC), was discovered. PLSVC often causes no symptoms to affected individuals and is usually first found as an incidental finding discovered during thoracic surgeries, cardiovascular interventional procedures, and central line insertions. Placement of TLC or central venous catheter (CVC) can be challenging in such patients and may lead to life-threatening complications such as severe arrhythmias, cardiogenic shock, pneumothorax, and tamponade. Knowing such anomalies can prevent unnecessary catheter removal and help determine the origin of some arrhythmias and dilated heart chambers in these patients.

Papilledema Secondary to Barotrauma in a Young Adult With Severe Status Asthmaticus With Ventilatory Failure, Pneumothorax, and a Complex Clinical Course.

Intubation and mechanical ventilation are common therapeutic interventions in intensive care unit settings. Barotrauma is a known complication of using positive pressures in a tissue defined by extra alveolar air in locations where it is not generally found in patients receiving mechanical ventilation. Several clinical manifestations of barotrauma include pneumothorax, subcutaneous emphysema, pneumoperitoneum, pneumomediastinum or pneumopericardium, air embolization, and hyperinflated left lower lobe. However, papilledema is an unreported and uncommon complication we observed in one of our patients, making it a unique presentation. We present the case of a young male patient intubated for asthma exacerbation requiring mechanical ventilation with subsequent development of papilledema. Our case report highlights the importance of knowing this rare complication of barotrauma as early commencement of lung-protective strategies will help prevent it.

Five-year results after total knee arthroplasty in lymphoedema and lipoedema: encouraging functional and clinical outcomes and low rates of infection.

BACKGROUND: The aim of this study was to define outcomes after total knee arthroplasty (TKA) in lymphoedema and lipoedema patients managed by a multidisciplinary team and daily compression bandaging. METHODS: A retrospective study was performed in a single centre. Between 2007 and 2018, 36 TKA procedures were performed on 28 consecutive patients with a diagnosis of lymphoedema and lipoedema. Oxford Knee Scores (OKS), EuroQol-5D (EQ-5D) scores, satisfaction scores, radiographs, and complications were obtained at the final follow-up. Patients were admitted to the hospital up to two weeks prior to surgery and remained on the ward for daily compression bandaging by the specialist lymphoedema team. RESULTS: Over the study period, 36 TKAs were performed on 28 patients (5 males, 23 females) with a mean age of 71 years (range 54-90). Of these, 30 TKAs were in patients with lymphoedema, five with lipoedema, and one with a dual diagnosis. Overall, 28 TKAs (21 patients) were available at the final follow-up with a mean follow-up time of 61 months (range 9-138). The mean BMI was 38.5 kg/m2. The mean pre-operative and post-operative Oxford Knee Score increased from 18 (range 2-38) to 29 (range 10-54); p < 0.001. EQ-5D score increased from 0.48 (range 0.15-0.80) to 0.74 (0.34-1.00) (p < 0.001). Mean post-operative satisfaction was 7.6/10 (range 2-10), with 89.3% TKAs satisfied. Complications were one (4%, 1/28) deep vein thrombosis, one superficial wound infection, one prosthetic joint infection, one stiff knee requiring manipulation, and one intra-operative femoral fracture. CONCLUSIONS: Lymphoedema and lipoedema should not be seen as barriers to TKA if adopting a multidisciplinary approach.

Outcomes and early revision rate after medial unicompartmental knee arthroplasty: prospective results from a non-designer single surgeon.

BACKGROUND: This prospective study evaluates outcomes and reoperation rates for unicompartmental knee arthroplasty (UKA) from a single non-designer surgeon using relatively extended criteria of degenerative changes of grade 2 or above in either or both non-operated compartments. METHODS: 187 consecutive medial mobile bearing UKA implants were included after history, clinical assessment and radiological evaluation. 91 patients had extended clinical outcomes. Post-operative assessment included functional scoring with the Oxford Knee Score (OKS) and radiographic review. Survivorship curves were constructed using the life-table method, with 95% confidence intervals calculated using Rothman's equation. Separate endpoints were examined: revision for any reason and revision for confirmed loosening. RESULTS: The mean follow-up was 3.5 years. The pre-operative OKS improved from a mean of 21.2 to 38.9 (Mann-Whitney U Test, p = < 0.001). Twelve Patients required further operations including 9 revisions. No patients developed deep infection and no surviving implants were loose radiographically. Survivorship at 7 years with endpoints of re-operation, revision and aseptic loosening at surgery or radiographically was 88.4% (95% CI 79.6-93.7), 93.1% (95% CI 85.5-96.9) and 97.3% (95% CI 91.2-99.2) respectively. The presence of pre-operative mild contralateral tibiofemoral or any extent of patellofemoral joint degeneration was of no consequence. DISCUSSION: The indications for UKA are being expanded to include patients with greater deformity, more advanced disease in the patellofemoral joint and even certain features in the lateral compartment indicative of an anteromedial pattern of osteoarthritis (OA). However, much of the supporting literature remains available only from designer centres. This study represents a group of patients with what we believe to be wider indications, along with decisions to treat made on clinical grounds and radiographs alone. CONCLUSION: This study shows comparable clinical outcomes of UKA for extended indications from a high volume, high-usage non-designer unit.

Laparoscopic-assisted endoscopic retrograde cholangiopancreatography post bariatric surgery: how to overcome the technical challenges.

The prevalence of bariatric surgery is increasing worldwide and as a direct consequence, there shall be an increasing number of patients presenting with the complications of bariatric surgery, often to non-specialist units. The authors report a case of a 42-year-old Caucasian female who had previous laparoscopic Roux-en-Y gastric bypass, open cholecystectomy and abdominoplasty presenting with right upper quadrant pain in keeping with retained common bile duct stones. After the failure of conservative management, a laparoscopic-assisted transgastric endoscopic retrograde changiopancreatography and sphincterotomy was performed. We shall be describing our technique.