Hypertonic Saline Administration via Intraosseous Access During Symptomatic Hyponatremia.

Hyponatremia is a common lab finding. Symptomatology varies greatly and can depend on the degree of hyponatremia and its chronicity. Causes of hyponatremia are also vast and include heart failure, renal injury, liver disease, and gastrointestinal losses, or it can be induced by medication. Treatment depends on the suspected etiology. However, in life-threatening conditions such as seizures or coma, urgent 3% saline is required. Administration of 3% saline is usually through peripheral and central IV access. This case report highlights an alternative route in administering 3% saline, intraosseous vascular access, when other options have been exhausted.

Congenital Atrial Septal Defect Presenting With Tamponade Physiology and an Associated Viral Illness.

Cardiac tamponade is a serious clinical syndrome that often presents with the classic triad of hypotension, jugular vein distention and diminished or muffled heart sounds on auscultation (Beck's Triad). This phenomenon occurs due to fluid accumulation in the pericardial space which compresses the heart, reduces cardiac output and may cause cardiogenic shock. In this report, we present a case of a 22-year-old female with a congenital atrial septal defect (ASD) and right ventricular failure with tamponade physiology with an associated viral illness.

The Importance of Excisional Biopsy in Nodular Lymphocyte-Predominant Hodgkin's Lymphoma.

Hodgkin's lymphoma (HL) is a malignancy that is typically B-cell in origin. HL can be further classified into classical HL and nodular lymphocyte-predominant HL (NLPHL). NLPHL is a rare lymphoma. It commonly presents locally with palpable firm lymphadenopathy or mediastinal mass seen on chest imaging. Some patients may have B symptoms (fever, night sweats, and unintentional weight loss), splenomegaly, and hepatomegaly. We describe a case of NLPHL in a 32-year-old male with classical findings of this rare class of HL.

Preoperative parathyroid localization. Relevance of MIBI SPECT-CT in adverse scenarios.

PURPOSE: Selective parathyroidectomy, the treatment of choice for primary hyperparathyroidism, requires precise preoperative localization. Our purpose was to compare the accuracy and concordance of pre-surgical MIBI parathyroid scintigraphy and ultrasonography, as well as to assess the relevance of hybrid acquisition (SPECT/CT) in compromised circumstances: low-weight or ectopic adenomas, coexisting thyroid disease and re-interventions. METHODS: The study included 223 patients with primary hyperparathyroidism operated in a single Surgical Unit from August 2016 to March 2021. Preoperative ultrasonography and double-phase MIBI were performed with early SPECT/CT acquisition. A minimally invasive surgical approach was initially attempted, except in patients with concomitant thyroid surgery or multiglandular parathyroid disease. RESULTS: Selective parathyroidectomy was accomplished in 179 patients (80.2%); cervicotomy and/or thoracoscopy in 44. Removal of the parathyroid lesion was achieved in 211 patients (94.6%), corresponding 204 (96.7%) to adenomas (37 ectopic). The cure rate was 94.2%. Preoperative MIBI SPECT/CT showed higher sensitivity and accuracy (84%; 80%) compared to ultrasound (72%; 71%), being more precise in defining the exact anatomical location (75.8% vs 68.7%). These differences reached statistical significance in ectopic glands. The existence of concomitant thyroid pathology did not decrease the sensitivity of SPECT/CT (84.2%). Mean parathyroid weight was 692.2mg (95%CI: 443.5-941) in MIBI-negative cases and 1145.9mg (95%CI: 983.6-1308.3) in MIBI-positive (p=0.001). Re-intervention was successful in the 8 patients with previous surgery. CONCLUSION: MIBI SPECT/CT presents greater sensitivity, accuracy and anatomical precision than ultrasound for preoperative parathyroid localization, even in the case of ectopic glands or coexisting thyroid pathology. The weight of the pathological gland is a significantly limiting factor.

Diffuse Neurofibroma in a Micronesian Male.

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder, with variable clinical features, most commonly including café-au-lait macules and neurofibromas. The incidence of NF1 is approximately one in 3,000 individuals. Diffuse neurofibroma is the rarest subtype of neurofibromas. We present a case of a 39-year-old Micronesian male presenting with a substantially large and heavy overgrowth on his back, found to be consistent with diffuse neurofibroma on histopathologic examination. The patient also met the diagnostic criteria for NF1 based on clinical examination. Imaging showed the dermal and subcutaneous thickening without deep extension into the underlying fascial layer or muscles. A patient-centered, multidisciplinary approach was taken in the workup and management of this case. Our patient expressed disinterest in surgical interventions.

Thrombospondin Type 1 Domain-Containing 7A (THSD7A)-Associated Membranous Nephropathy Leading to Metastatic Neuroendocrine Carcinoma.

Idiopathic membranous nephropathy also known as primary membranous nephropathy (PMN) is a common cause of nephrotic syndrome often seen in nondiabetic adults worldwide, rising as high as 40% in adults over the age of 60. Most PMN is mediated by antibodies to the M-type phospholipase A2 receptor (anti-PLA2R) in nearly 70%-80% of individuals. Thrombospondin type 1 domain-containing 7A (THSD7A) accounts for 1%-5% of individuals with PMN. In these individuals, malignancies have a varying incidence of 6%-25%. We present a case of idiopathic membranous nephropathy with anti-PLA2R negative and THSD7A positive with an underlying metastatic neuroendocrine carcinoma. Our goal is to highlight the importance of cancer screening in individuals with THSD7A-positive PMN. In addition, although nonspecific, a negative anion gap may be an indicator of an underlying malignancy.

Hypertension-Induced Thrombotic Microangiopathy Leading to End-Stage Renal Disease.

Thrombotic microangiopathy (TMA) is a term used for a group of rare and life-threatening hematological conditions. Usually, these disease processes are characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and microthrombi leading to tissue or organ injury. We present a case of a 41-year-old male with TMA induced by uncontrolled hypertension leading to end-stage renal disease requiring hemodialysis. Our goal is to highlight the importance of distinguishing hypertension-induced thrombotic microangiopathy from other etiologies of TMA, particularly thrombotic thrombocytopenic purpura (TTP), and its effect on renal function despite treatment focused on blood pressure control. Thus, it is a challenging diagnosis for clinicians to determine whether to initiate plasmapheresis for prompt treatment of suspected TTP in the setting of severe hypertension with thrombocytopenia.

Late-Onset 22q11.2 Deletion Syndrome With Mild Cardiac Phenotype: A Unique Adult Presentation Diagnosed at 45 Years of Age.

This case report presents a detailed exploration of an adult-onset 22q11 deletion syndrome, a rare genetic disorder typically diagnosed in children. The report highlights the diagnostic challenges posed by this atypical presentation, emphasizing the need for clinicians to consider such conditions in differential diagnoses, especially in adults. This case is remarkable for its late onset and mild symptoms, which significantly deviated from the common pediatric presentation, including hypocalcemia due to hypoparathyroidism and a fenestrated atrial septal defect without significant hemodynamic implications. The importance of recognizing the broad phenotypic variability of the syndrome and the implications for clinical practice are discussed, providing insights into the genetic and phenotypic diversity of the condition. In conclusion, this case illuminates the diverse clinical spectrum of adult-onset 22q11 deletion syndrome, emphasizing its relevance to clinical practice.

Severe Gastroparesis Leading to Hypoglycemia and Subsequent Seizures.

Gastroparesis is a known complication in patients with diabetes mellitus (DM). This disorder has been known to make glycemic control difficult due to diabetic autonomic neuropathy, resulting in an increase in hypoglycemic episodes. On occasion, gastroparesis may be so severe that prokinetic medications and gastric pacemakers are not sufficient to control the symptoms, in which case some patients need to supplement their diet through a jejunal tube (J-tube) to bypass the stomach. Severe or long-lasting hypoglycemia may rarely be associated with epileptic seizures. We present a case of a 47-year-old female with a history significant for type 1 DM complicated by gastroparesis requiring a gastric pacemaker and J-tube placement who presented to the emergency department after having a witnessed seizure. Her glucose at that time was 27 mg/dl (normal 70-110 mg/dl) and she was treated appropriately with dextrose 25% solution and her glucose recovered to 110 mg/dl. Subsequently, seizure activity ceased.

Bilateral ligation of the anterior trunk of the internal iliac artery in uterine atony secondary to uterine inversion: case report.

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. Uterine atony is the main cause, representing up to 90% of cases, and is a risk factor for uterine inversion. Morbidity and mortality occur in 41% of uterine inversion cases, including massive obstetric hemorrhage. Massive obstetric hemorrhage is a medical emergency that puts life and reproductive function at risk, and therefore, its treatment must be timely and immediate. If there is no favorable response with the initial measures, surgical intervention proceeds. When choosing the surgical procedure, priority should be given to the technique with the easiest access and which is the least invasive, the safest, and in which the surgeon has more experience. We present a case report with our technique of bilateral ligation of the anterior trunk of the hypogastric artery, after a uterine compression suture failed, with excellent results and preserved fertility in an adolescent patient. We describe the technique and the result. The response time of the uterus with normal tone was 5 minutes, and postligation bleeding was only 50 mL after the patient had bled 1200 mL without complications; thus, it is an adequate and cost-effective technique. The bilateral ligation of the anterior trunk of the hypogastric artery technique in the case of postpartum hemorrhage is an effective, safe, and fertility-preserving surgical procedure that constitutes an alternative to emergency obstetrical hysterectomy when other, less invasive methods have failed.

Pruebas Terapéuticas Con Fines Diagnósticos En Trastornos Del Movimiento / Therapeutic Tests For The Diagnosis Of Movement Disorders

Resumen El diagnóstico en medicina tiene su piedra angular en la obtención de la historia clínica y la exploración física; sin embargo, en algunas de las patologías el uso de pruebas diagnósticas es de gran utilidad como apoyo para confirmar o descartar una enfermedad. Las pruebas diagnósticas incluyen una amplia variedad de procedimientos y dentro de estas se incluyen las pruebas terapéuticas, también llamadas desafíos o retos, en los que se administra una sustancia activa para evaluar la respuesta y apoyar la impresión diagnóstica. En el contexto de los trastornos del movimiento las pruebas terapéuticas más frecuentemente utilizadas son la de levodopa, apomorfina y etanol. En esta revisión se presenta, describe y discute el alcance y utilidad de estas.

Abstract The diagnosis in medicine has its cornerstone in obtaining the clinical history and in the physical examination. However, in some of the pathologies the use of diagnostic tests is very useful as a support to confirm or rule out a disease. Diagnostic tests include a wide variety of procedures and these include therapeutic tests, also called challenges, in which an active substance is administered to evaluate the response and support the presumptive diagnosis. In the context of movement disorders, the most frequently used therapeutic tests are those with levodopa, apomorphine and ethanol. In this review we present, describe and discuss the scope and usefulness of these challenges.

De la compuerta a la neuromatriz y neuromodulación / From gate and neuromodulation to neuromatrix

The following article presents a review of the evolution of the gate and neuromatrix theories as well as their contribution in the development of neuromodulation to the present day. Nowadays the mechanism of action of neuromodulation is better to understand by dividing it according to the level where it acts (local, central or peripheral). Patient selection is crucial to optimize the effectiveness of the device; although the indications for pain that support current guidelines are failed back syndrome, complex regional pain syndrome and lower limb ischemic pain and refractory angina; neuromodulation is already being extended to multiple fields of action that affect the future, such as the improvement of human capacities.

El siguiente artículo consiste en una revisión no sistemática de la evolución de la teoría de la compuerta y la neuromatriz, así como su aporte en el desarrollo de los dispositivos de neuromodulación. Para entender mejor el mecanismo de acción de la neuromodulación se divide según el nivel en que actúe sea local, central o periférico. La selección de pacientes es crucial para optimizar la eficacia del dispositivo; aunque las indicaciones para manejo del dolor que soportan las guías actuales son síndrome de espalda fallida, síndrome doloroso regional complejo y dolor tipo isquémico en miembros inferiores y dolor por angina refractaria; actualmente la neuromodulación se está extendiendo a múltiples campos de acción entre los cuales se encuentra el mejoramiento de las capacidades humanas.

Uso y aplicación de la tecnología de impresión y bioimpresión 3D en medicina / Use and application of 3D printing and bioimpression technology in medicine

RESUMEN En el mundo actual, las llamadas "tecnologías de fabricación por adición" o impresión 3D también llamado prototipado rápido, han trascendido las fronteras de casi todos los campos de la ciencia, y su incursión en la medicina es cada vez mayor. Es justamente en el campo médico que esta tecnología de impresión por adición ha evolucionado a la bioimpresión, que incluye un proceso de cultivo celular en laboratorio haciendo posible la formación de órganos y/o tejidos personalizados. Para la impresión tridimensional de órganos en humanos se toman muestras de un tejido o células madre del paciente, para ser cultivadas y expandidas en laboratorio para su posterior diferenciación a una línea celular específica. Para este proceso se utiliza un material sólido como andamio a temperatura ambiente con un punto de fusión conocido. En la creación de un modelo para la fabricación de un órgano o tejido en impresión 3D, se utilizan los estudios de imágenes médicas de los pacientes intentando preservar al máximo la anatomía de las estructuras que se desean reproducir. En este artículo se abordan las bases y el potencial uso de esta tecnología en el área médica.

ABSTRACT In today's world, so-called "addition manufacturing technologies" or 3D printing also called rapid prototyping have transcended the borders of almost every field of science and medicine is no exception. It is not surprising that its exploration for practical uses is increasing. In medicine, this technology of printing by addition has evolved to bioprinting, which occurs by a special process, from cells grown in a laboratory, which makes possible its transformation into a type of organs tailored to the patient. The three-dimensional impression of human organs requires take samples of tissues or stem cells from the patient, which are grown in the laboratory waiting to multiply or differentiate to other cell lines; then, to create said object, a solid material at room temperature and with a known melting point is applied layer by layer. Currently the use of this technology uses the medical images of patients trying to preserve the anatomy of the structures that they want to reproduce. In this article the bases and the potential use of this technology in the medical area will be addressed.

Biological survey of a cloud forest in southwestern Mexico: plants, amphibians, reptiles, birds, and mammals / Estudio biológico del bosque mesófilo de montaña en el suroeste de México: plantas, anfibios, reptiles, aves y mamíferos

Abstract: Cloud forest ecosystems contain unique flora and fauna characterized by high levels of richness and endemism. However, this ecosystem is one of the most threatened because of land-use changes stemming from anthropogenic activities. Therefore, biological inventories are necessary to adequately assess the effects of land-use changes on species now and in the future. In this study, we conducted an inventory of plants and terrestrial vertebrates (amphibians, reptiles, birds, and mammals) in three fragments of cloud forest in southwestern Mexico. Field work was carried out for 15 days per biological group during distinct time periods (2005-2008). Conventional methods of species capture and observation were employed to record species. Recorded species were then categorized based on their endemism and risk category. A total of 67 species of plants, 17 species of amphibians, 25 species of reptiles, 93 species of birds, and 46 species of mammals were recorded. The species accumulation curves for most taxa, except for birds and mammals, showed an asymptotic trend. A total of 56 species endemic to Mexico and four quasi-endemic species were recorded. Plants, amphibians, and reptiles presented the greatest number of species exclusive to Mexico (13 species). Six species of herpetofauna endemic to Guerrero were recorded. According to Mexican laws, 24 of the encountered species are under special protection, while 16 are categorized as threatened and seven as endangered. Reptiles and birds presented the greatest number of at-risk species (14 species). Bird and mammal richness in this study is high in comparison to that recorded in the cloud forests of the entire Mexican state of Guerrero (157 and 75 species, respectively). This data highlights the importance of cloud forests in the study area for local and regional biodiversity. Effective conservation strategies should be prioritized in cloud forests, as this ecosystem is poorly represented in natural protected areas.

Resumen: Los bosques mesófilos de montaña son ecosistemas que contienen flora y fauna única, y son caracterizados por sus altos niveles de riqueza y endemismo. Este ecosistema es uno de los más amenazados debido a los cambios en el uso del suelo por actividades antropogénicas. Por tanto, los inventarios bióticos en este ecosistema son necesarios para evaluar adecuadamente los cambios en el uso del suelo sobre las especies en la actualidad y en el futuro. En este estudio se desarrollaron inventarios de plantas y vertebrados terrestres (anfibios, reptiles, aves y mamíferos) en tres fragmentos de bosque mesófilo de montaña en el suroeste de México. El trabajo de campo se realizó durante 15 días por cada grupo biológico durante distintos períodos de tiempo (2005 al 2008). Los registros de las especies se obtuvieron mediante métodos convencionales de captura y observación. Se categorizaron a las especies por su endemismo y categoría de riesgo. Se registró un total de 67 especies de plantas, 17 especies de anfibios, 25 especies de reptiles, 93 especies de aves y 46 especies de mamíferos. Las curvas de acumulación mostraron un comportamiento asintótico para la mayoría de los taxa, excepto aves y mamíferos. Se obtuvo un total de 56 especies endémicas a México y cuatro cuasiendémicas. Los grupos de plantas, anfibios y reptiles presentaron el mayor número de especies exclusivas al país (13 especies), y se obtuvo un total de seis especies de herpetofauna endémicas a Guerrero. De acuerdo con las leyes mexicanas, se registró un total 24 especies en protección especial, 16 amenazadas y siete en peligro de extinción, de los cuales los grupos de los reptiles y aves presentaron el mayor número de especies en categoría de riesgo (14 especies). La riqueza de especies de aves y mamíferos en este estudio representa un número importante comparado con el total de especies registradas en los bosques mesófilos del estado de Guerrero (157 y 75 especies, respectivamente). Estos datos resaltan la importancia de los bosques mesófilos de montaña del área de estudio para la biodiversidad local y regional, por lo que deben priorizarse estrategias de conservación efectivas para este ecosistema poco representado en áreas naturales protegidas.

Isolated AA Amyloidosis of the Radial Nerve.

BACKGROUND: Amyloidosis affecting peripheral nerve is usually seen in primary amyloidosis. METHODS: We are reporting on the case of a 74-year-old man with a 16-month history of progressive left radial nerve paralysis. Perioperative imaging detected an enlarged radial nerve in the middle-distal part of the arm. The patient had an antecedent of amyloid deposits in the lung. RESULTS: A radial nerve amyloidosis was suspected and confirmed with a biopsy assisted by ultrasonography, resulting in a secondary amyloidosis form. CONCLUSIONS: Isolated radial nerve palsy due to nerve damage by amyloidosis has been reported before, but not in AA or secondary amyloidosis.

Sentinel node biopsy in patients with primary cutaneous melanoma of any thickness: A cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of the sentinel node biopsy with lymphadenectomy for nodal metastases (SNB) in patients with primary cutaneous melanoma (CM) of different Breslow thickness (intermediate, thick, thin). METHODS: Decision tree models were constructed to compare two different strategies of management of patients with CM, wide excision of the primary lesion and SNB and wide excision only (WE). Tree models were created for every Breslow thickness over 1-, 5- and 10-year time horizons. Mean and total direct healthcare costs, life years saved (LYSs), quality-adjusted life years (QALYs), cost effectiveness ratio (CER), and incremental cost effectiveness ratio (ICER) were estimated. Every model was considered as a base case, and its results tested with sensitivity analyses. RESULTS: Base case analyses showed that the best results were obtained for intermediate CM over 10-year time horizon. In this case, ICER for SNB was 130,508€/QALY, well over the threshold of acceptance (30,000€/QALY). In patients with intermediate CM over 1 and 5 years, and for those with thick and thin CM at any time horizon, negative ICER values were estimated since SNB was proved to be more expensive and less effective than WE. Sensitivity analyses confirmed the robustness of our results. CONCLUSIONS: SNB caused no improvement in health outcomes in terms of LYSs and QALYs in patients with thick and thin CM, and only a slight benefit in those with intermediate CM. WE was more cost-effective compared with SNB for any CM thickness over any time horizon up to 10 years.