The confusional picture is determined by the dementia that the patient already suffers, so no matter how much we delay surgery, we are not going to achieve anything. The elevation of blood pressure is due, in principle, to pain (so the first option is an analgesic) and then to the stressful situation that leads an already hypertensive patient to increase her blood pressure, so labetalol could help us. The last answer is not correct because it depends on the type of fracture, which is not specified in the statement: a pertrochanteric fracture would require closed osteosynthesis and a subcapital fracture would require a prosthesis.

The confusional picture is determined by the dementia that the patient already suffers, so no matter how much we delay surgery, we are not going to achieve anything. The elevation of blood pressure is due, in principle, to pain (so the first option is an analgesic) and then to the stressful situation that leads an already hypertensive patient to increase her blood pressure, so labetalol could help us. [HIDDEN] because it depends on the type of fracture, which is not specified in the statement: a pertrochanteric fracture would require closed osteosynthesis and a subcapital fracture would require a prosthesis.

We are consulted to assess an 83-year-old woman admitted to the Trauma service for a hip fracture 6 hours ago. She has AP of hypertension, LBP, moderate dementia and lives in a nursing home. Her usual treatment is thiazide, atorvastatin, donepezil, Calcium and vitamin D. EF: Confused patient, pulse 90 bpm, respiratory rate 20 rpm, T art 170/88, jugular venous pressure normal. The CBC and chest X-ray are normal and the ECG shows sinus rhythm without ischemic alterations. Which of the following is the most correct therapeutic approach?

Delay surgery until the confusional picture has disappeared.

Delay surgery and perform an echocardiogram.

Delay surgery until good blood pressure control.

Start a beta-blocker and initiate surgery.

Perform closed osteosynthesis, avoiding in any case the implantation of prosthesis.

Surgery_Schwartz

an injection of 1% lidocaine solution around this structure should attenuate this reflexive response.The most common delayed complication following carotid endarterectomy remains myocardial infarction. The possibility of a postoperative myocardial infarction should be considered as a cause of labile blood pressure and arrhythmias in high-risk patients.Thyroid and Parathyroid Glands. Surgery of the thyroid and parathyroid glands can result in hypocalcemia in the immedi-ate postoperative period. Manifestations include ECG changes (shortened P-R interval), muscle spasm (tetany, Chvostek’s sign, and Trousseau’s sign), paresthesias, and laryngospasm. Treatment includes calcium gluconate infusion and, if tetany ensues, chemical paralysis with intubation. Maintenance treat-ment is thyroid hormone replacement (after thyroidectomy) in addition to calcium carbonate and vitamin D.Recurrent laryngeal nerve (RLN) injury occurs in less than 5% of patients. Of those with injury, approximately 10%

[Anesthesia and intensive therapy for a patient with mitochondrial myopathy].

Since 1983 we have been involved in the diagnostic work-up and emergency treatment of a female patient now 48 years old who has a mitochondrial myopathy resembling Luft's disease. The syndrome was first described in 1959, and in more detail in 1962, by Luft and et al., who reported a picture of hypermetabolism with high temperature, extreme sweating, tachycardia, dyspnoea at rest, polydipsia, polyphagia and irritability but normal thyroid function. In 1971 and 1976 Haydar and Di Mauro presented a second case and proposed treatment with chloramphenicol. Our patient has the third case of the syndrome reported so far: her case was initially published in 1987. CASE REPORT. Since her 17th year of life the patient had suffered from episodes of fever, tachycardia and sweating. At the age of 32 these attacks worsened, leading to unconsciousness and apnoea. The patient then had to be intubated, ventilated and sometimes resuscitated. The diagnosis of MH susceptibility and Luft's disease was made on biochemical grounds after the first muscle biopsy in 1983. Therapy with chloramphenicol failed. Therapy with beta blockers, vitamin C and K or E, coenzyme Q10 and a high-caloric diet was started in 1985. The patient was registered with an emergency service, which flew her to our ICU whenever she had a severe crisis. For milder episodes she was supplied with an oxygen breathing mask at home. Myalgia increased with the episodes starting in 1988, and the patient needed dantrolene infusions and analgesics at home. To facilitate venepuncture a Port-A-Cath system was implanted in 1987, which had to be removed four times due to infection and sepsis. A muscle biopsy was taken in Rotterdam, which revealed differences in mitochondrial function from the biochemical findings recorded in 1983 and not in keeping with Luft's disease. Unfortunately, the patient was not able to undergo further metabolic investigations or therapeutic trials. ANAESTHESIA. The patient received three local and six general anaesthetics in our clinic. The muscle biopsies, two in 1983 and one in 1985, were performed under local infiltration with procaine and were uneventful. The general anaesthetics were carried out without MH trigger substances following pretreatment with dantrolene for the following surgical procedures: the repair of an extensive arterio-venous fistula between the brachiocephalicus trunk and the right jugular and subclavian vein, revision of the sternum cerclage, implantations and explanations of infectious Port-A-Cath systems. We used etomidate, propofol and fentanyl or alfentanil with nitrous oxide and oxygen for induction and maintenance of anaesthesia. Muscle relaxation was induced with vecuronium or atracurium. All cardiovascular, respiratory, metabolic and temperature measurements stayed in normal ranges. After the extensive vascular repair (av fistula) the patient had to be mechanically ventilated for some hours until normal body temperature was restored. At the end of all other periods of anaesthesia she was extubated in the operating theatre. In five cases the postoperative period was uneventful. Only once she developed a crisis with hyperthermia, tachycardia, sweating and dyspnoea. INTENSIVE CARE. From 1985 to 1992 the patient was treated in our ICU 21 times. On 11 occasions she was already intubated and being ventilated by the emergency service on arrival. Extubation was usually possible within 2-20 h. During the crisis, heart rate was about 160-190 per minute and temperature above 40 degrees C. Serum values of CK, glucose, BUN, electrolytes, lactate and thyroid hormones were always in the normal ranges. Blood gas controls showed a constant respiratory alkalosis, arterial pCO2 values decreasing to 20 mm Hg or less. In addition to mechanical ventilation, treatment consisted in dantrolene infusions and droperidol injections, supplemented from 1989 onward with piritramide injections because of the increased severity of myalgia. In 1991 we gave propofol by

[What's new in geriatric medicine].

Several studies clarified the role of different interventions such as vitamine D replacement, denosumab treatment, and vertebroplasty in the prevention and management of falls and fractures. A trial tested the effectiveness of pharmaceutical assistance at the time of discharge, emphasizing the potential benefits for the patients and the health care system. Syncopal episodes frequently lead to hospital admission. A retrospective study evaluated the diagnostic yield of different tests and emphasized the importance to actively seek orthostatic hypotension in older patients. Finally, advances remain modest in the field of dementias.

Extracorporeal membrane oxygenation system as a bridge to reparative surgery in ventricular septal defect complicating acute inferoposterior myocardial infarction.

Post-infarction ventricular septal defect (VSD) is a rare but potentially lethal complication of acute myocardial infarction. Medical management is usually futile, so definitive surgery remains the treatment of choice but the risk surgery is very high and the optimal timing for surgery is still under debate. A 55-year-old man with no previous medical history attended the emergency-room for 12 h evolution of oppressive chest pain and strong anginal pain 7 days ago. On physical examination, blood pressure was 96/70 mmHg, pansystolic murmur over left sternal border without pulmonary crackles. An electrocardiogram revealed sinus rhythm 110 bpm, elevation ST and Q in inferior-posterior leads. Transthoracic echocardiogram showed inferoposterior akinesia, posterior-basal septal rupture (2 cm × 2 cm) with left-right shunt. Suspecting VSD in inferior-posterior acute myocardial infarction evolved, we performed emergency coronarography with 3-vessels disease and complete subacute occlusion of the mid segment of the right coronary artery. Left ventriculography demonstrated shunting of contrast from the left ventricule to the right ventricule. He was rejected for heart transplantation because of his age. Considering the high surgical risk to early surgery and his hemodynamic and clinical stability, delayed surgical treatment is decided, and 4 days after admission the patient suffered hemodynamic instability so venoarterial extracorporeal membrane oxygenation system (ECMO) is implanted as a bridge to reparative surgery. The 9th day after admission double bypass, interventricular defect repair with pericardial two-patch exclusion technique, and ECMO decannulation were performed. The patient's postoperative course was free of complications and was discharged 10 days post VSD repair surgery. Follow-up 3-month later revealed the patient to be in good functional status and good image outcome with intact interventricular septal patch without shunt. ECMO as a bridge to reparative surgery in postinfarction VSD is an adequate option to stabilize patients until surgery.

[Patient whose surgery was postponed due to complete atrioventricular block on arrival at operating theater].

An 86-year-old woman with low cardiac function was scheduled to undergo hip fracture surgery. Preoperative electrocardiogram showed complete left bundle brunch block, first degree atrioventricular block, left axis deviation and bigeminy. However, her electrocardiogram had changed to complete atrioventricular block on arrival at operating theater. ACC/AHA guideline on perioperative cardiovascular evaluation and care for non cardiac surgery indicates the assessment of both the urgency of the surgery and cardiac complications. Because complete atrioventricular block is classified to "active cardiac conditions", we decided to postpone the surgery for more detailed evaluation and treatment of cardiac conditions. In spite of the discontinuation of digoxin and carvegilol, complete atrioventricular block continued for a week, and the permanent pacemaker was inserted. The surgery was performed 2 weeks following the insertion of the pacemaker without any problems under combined general and lumbar epidural anesthesia.

Aneurysm of sinus of Valsalva

Treatment Medical therapy of aneurysm of the aortic sinus includes blood pressure control through the use of drugs, such as beta blockers. Another approach is surgical repair. The determination to perform surgery is usually based upon the diameter of the aortic root (with 5 centimeters being a rule of thumb - a normal size is 2-3 centimeters) and the rate of increase in its size (as determined through repeated echocardiography). An alternative to surgical repair or a ruptured aneurysm is percutaneous closure. In this technique, a wire is introduced via a small incision in the groin and advanced through the vascular system to the aneurysm. A closure device is advanced along the wire before being expanded to straddle the site of rupture.

[Severe hypercalcemia of unusual cause, looking for the culprit: Case report and review of the literature].

Hypercalcemia is not a rare event and can lead to severe consequences. Its main etiologies are primary hyperparathyroidism and neoplasic conditions. The iatrogenic etiology by vitamin D intoxication is more rarely found. A 76-year-old finish woman comes to the emergency room for chest pain. Her medical history is impossible to specify due to the language barrier and initial confusion. She has severe hypercalcaemia (4.14mmol/L), renal insufficiency, cardiac arrhythmia later complicated by an ischemic cardiac episode. Clinic and biologic examinations initially guided the research towards a hematological and neoplasic pathology. The iatrogenic etiology will be permitted by the contribution of details on its medical history and treatment learnt secondly. She was treated for post-surgical hypoparathyroidism by dihydrotachysterol, a vitamin D derivative. The cessation of substitution, treatment with hydration and biphosphonates allowed the rapid correction of hypercalcemia. Dihydrotachysterol intoxication is a rare etiology of hypercalcemia. Because of the longer half-life of this molecule, the risk of hypercalcemia seems to be greater than with other vitamin D derivatives. This molecule, withdrawn from the French market in 1982, is not detected by the dosage of 25 and 1.25 OH vitamin D. We report an original case of intoxication by dihydrotachysterol. The risk of hypercalcemia encountered with this molecule must be known. The close medical follow-up recommended in case of hypoparathyroidism seems to be particularly necessary in case of supplementation by this molecule.

Cardiotoxicity after massive amantadine overdose.

Amantadine hydrochloride is an antiviral medication used as therapy for parkinsonism and as a cognitive enhancer. We report 2 cases of massive, acute ingestion of amantadine hydrochloride confirmed with serial serum levels. A 47-year-old woman presented to the emergency department (ED) 30 minutes after ingesting 10 g of amantadine (150 mg/kg) by her report. Initial ECG revealed a sinus rhythm with rate of 93 bpm, and a QRS of 84 msec. While in the ED, the patient sustained a pulseless cardiac arrest and the monitor revealed ventricular tachycardia. She was successfully defibrillated. Postdefibrillation ECG showed a sinus rhythm (rate = 82 bpm), QRS of 236 msec, and QTc of 567 msec. The serum potassium was 1.0 mEq/L (1.0 mmol/L). The patient was given 300 ml (300 cc) 3% sodium chloride IV over 10 minutes. Ten minutes after completion of the hypertonic saline infusion, the patient's ECG abnormalities resolved and the QRS was 88 msec. Her potassium was repleted over the next 11 hours postpresentation, and she also received an IV bolus of 4 g of magnesium sulfate immediately after the cardiac arrest. No further hypotension, dysrhythmia, conduction delay, or ectopy was noted during the patient's hospital stay. The second case involved a 33-year-old female patient who presented 1 hour after ingesting 100 tablets of amantadine hydrochloride (100 mg/tab). Initial ECG revealed sinus tachycardia with a QRS of 113 msec, an R wave in lead aVR of 4-5 mm and a QTc of 526 msec. Her serum potassium was 3.0 mEq/L (3.0 mmol/L), her serum calcium was 9.4 mg/dl (2.35 mmol/L), and serum magnesium was 2.1 mg/dl (0.86 mmol/L) on labs drawn at initial presentation. The patient was intubated for airway protection, and her potassium was repleted and corrected over the next 9 hours. Her ECG abnormalities improved 8 hours after initial presentation and normalized at approximately 14 hours postingestion. The patient was discharged home 11 days after her ingestion. Acute amantadine toxicity manifests with life-threatening cardiotoxicity. Concurrent, often profound, hypokalemia may complicate the administration of sodium bicarbonate in the management of cardiac dysrhythmias.

[Interaction of calcium drug and vitamin D3 with some medicines used in coronary heart disease therapy].

130 young and middle age patients of both sexes with chronic form of coronary heart disease: functional class II-III stable exertional angina pectoris including functional class I-III chronic cardiac insufficiency were studied. In protocol 1 cured 70 patients (48 (68.6%) males and 22 (31.4%) females) 32-59 years of age (medium age was 48.4 +/- 3.25 years) with coronary heart disease. In protocol 2 (with prescription of calcium-D3) cured 60 patients (40 (66.7%) males and 20 (33.3%) females) 34-58 years of age (medium age was 47.8 +/- 3.12 years) with coronary heart disease. The groups were comparable on key parameters of disease. All patients had alimentary calcium deficit and (or) risk factors of osteoporosis, instrumental signs (X-ray filming and densitometry) of initial or evident osteoporosis. Correction of alimentary calcium deficit was realized by prescription of 1-3 tablets of calcium- Ds in different food intakes. Positive dynamics in decrease of functional class of angina pectoris and nitroglycerin requirement in both groups was noticed. Negative influence of calcium- D3 on studied indices of coronary heart disease severity was absent. The thirst and dry mouth in patients, who took furosemide, in group 1 were noticed against the background of body weight decrease (p < 0.05) and increase of diuresis. Decrease of the therapy antiarrhythmic action (p < 0.05) in patients, who took hydrochlorothiazide, was noticed too. It leaded to needs of furosemide and hydrochlorothiatide dose correction in protocol 1. In whole use of calcium- D3 together with anti-ischemic drugs in patients with chronic forms of coronary heart disease did not impair clinical course of angina pectoris and did not decrease efficiency of coronary heart disease therapy.

Hip fracture

Most hip fractures are treated surgically by implanting a prosthesis. Surgical treatment outweighs the risks of nonsurgical treatment which requires extensive bedrest. Prolonged immobilization increases risk of thromboembolism, pneumonia, deconditioning, and decubitus ulcers. Regardless, the surgery is a major stress, particularly in the elderly. Pain is also significant, and can also result in immobilization, so patients are encouraged to become mobile as soon as possible, often with the assistance of physical therapy. Skeletal traction pending surgery is not supported by the evidence. Regional nerve blocks are useful for pain management in hip fractures. Peripheral nerve blocks may reduce pain on movement and acute confusional state, may improve time to first mobilisation, and may reduce the risk of postoperative lower respiratory tract infection. Surgery can be performed under general anaesthesia or with neuraxial techniques – choice is based on surgical and patient factors, as

[Hypo and hypercalcemia as an emergency].

1. Hypo- and hypercalcemia can be explained as derangements of the calcium homeostasis. Hypocalcemic tetany usually alarming the patient tremendously is, at least in adults, rarely life-threatening. Hypercalcemia leads in 30% of the cases to clinical symptoms which may inadvertedly pass into a state of hypercalcemic crisis. This latter requires an often difficult emergency treatment. 2. Hypocalcemic tetany may be reversed by administering calcium i.v. or, in severe cases, by a calcium infusion. Only rarely are magnesium supplements necessary to let the tetany disappear. Vitamin D or dihydrotachysterol (DHT) do not correct hypocalcemia immediately, since their effects may be delayed up to 15-25 days. In order to normalize the serum calcium permanently, vitamin D or DHT treatment should be instituted as rarely as possible. 3. Initially, hypercalcemic crisis is best treated by forced intravenous fluid administration with normal saline (and furosemide) in combination with high doses of prednisone. Fluid-, sodium- and potassium balances ought to be checked during this type of treatment. A first evaluation of the effectiveness of these measures is recommended after 24 hours: treatment is continued in patients who respond favorably, while subjects who do not show a significant decrease of the serum calcium may either be given a phosphate infusion or mithramycine as a bolus. Calcitonin appears to be useful only to start treatment before institution of a phosphate infusion.

[Case of ischemic heart disease resulting from persistent diuresis after giant ovarian tumor resection].

A patient with a giant ovarian tumor weighing about 7 kg was successfully removed by operation. However, her ECG demonstrated ischemic changes after the operation. We report a case of ischemic heart disease due to persistent diuresis after giant ovarian tumor resection. A 75-year-old, 56.5 kg, 143.5 cm woman was admitted to our hospital for ovarian tumor resection. The preoperative ECG showed normal sinus rhythm and no ischemic changes. Both general anesthesia and epidural anesthesia were planed. An epidural catheter was inserted at T12-L1. Anesthesia was induced with propofol 100 mg, fentanyl 100 microg and vecuronium 8 mg under 100% oxygen inhalation. General anesthesia was maintained with sevoflurane while epidural anesthesia was achieved using 0.375% ropivacaine 6 ml. During the operation, blood pressure was 90-110/70-80 mmHg, with SaO2, 100% and heart rate, 70-80 beats x min(-1). The content of tumor was suctioned for 30 minutes. Surgery was successfully finished without any other incidence. After extubation, her ECG changed to atrial fibrillation from normal sinus rhythm and showed ST-T depression. And then her systolic blood pressure became 80 mmHg or below, but we found continued diuresis at about 10 ml x kg(-1) x hr(-1) for over 2 hr. The total of 7 unit vasopressin was intermittently given for vasoconstriction and antidiuresis. Her hemodynamic was immediately restored, and ECG turned to normal ST-T. The patient had uneventful postoperative recovery.

[Geriatric medicine].

2017 highlights benefits of prevention. Better control of cardiovascular risk reduces the incidence of dementia and monthly high-dose vitamin D the incidence of respiratory infections in nursing home. Pre-operative geriatric assessment lowers by 20% the rate of delirium after hip-fracture surgery and complications in vascular surgery. Deleterious effects are also reported. High-dose vitamin D triples the rate of falls in supplemented residents and doesn't improve gait speed in sedentary men. Widely used in cardiovascular prevention, antithrombotic therapy is associated with an astonishing risk of subdural bleeding that further increases with the number of drugs combined together. Finally, the non-pharmacological management of behavioral and psychotic symptoms in advanced dementia, although effective, doesn't reduce the associated burden for proxies.

The Young Heart Tears Easily Apart: A Case Report of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS), seen mostly in young females. The rarity and limited knowledge of the disease make its management challenging. Prompt diagnosis of the condition is extremely important to decrease both long- and short-term complications. Treatment options depend on hemodynamic stability and the location of the dissection- with more distal lesions treated more conservatively as opposed to proximal lesions which are treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The following are the two cases with different presentation, management and outcomes. Our first patient was a 35-year-old woman with no medical history who presented with acute, anginal pain, diaphoresis and palpitations. She was hemodynamically stable on presentation, with work-up significant for electrocardiogram (ECG) with sinus bradycardia, ST elevation in leads V1-V6, and elevated troponin level of 4 ng/ml. There was no evidence of a pulmonary embolism on computed tomography (CT) of the chest. A coronary angiogram showed 100% dissection of the proximal to mid-left anterior descending (LAD) artery. Attempts to place a stent in the proximal to mid LAD were unsuccessful as the true lumen of the LAD was not accessible. The patient became hemodynamically unstable, and an emergent CABG was done, restoring blood flow. The patient recovered during her hospital stay and was discharged with dual antiplatelet therapy (DAPT), beta-blockers, and atorvastatin. The second patient was a 28-year-old woman, with a history of hypertension who presented with anginal chest pain. Workup showed ECG with minimal ST elevations in anteroseptal leads, with elevated troponin level to 0.71 ng/ml. Coronary angiogram showed 40-50% stenosis of the mid LAD with an aneurysmal segment. An echocardiogram showed no evidence of wall motion abnormalities, and she had a normal left ventricular ejection fraction (LVEF). She was discharged home the next day, on medical management. After two days, she returned to the hospital with similar complaints, with work-up significant for ECG with non-specific ST-T abnormality, and troponin level which peaked at 2.22 ng/ml. She was started on a heparin drip, and a repeat left heart catheterization revealed type 2 dissection of the mid to distal LAD, with intravascular ultrasound showing a fractional flow reserve of 0.76. She was discharged home on DAPT, beta-blocker, calcium channel blocker (CCB), and atorvastatin, with close cardiology follow up. These two cases highlight the importance of keeping in mind the possibility of SCAD, especially when relatively healthy young women present with anginal symptoms. Early diagnosis of the condition and prompt management are extremely important to ensure favourable outcomes. The two cases also describe the coronary angiogram findings in SCAD, and the different strategies employed in the management of this condition.

[The parathyroid risk in thyroid surgery. Argument against the early postoperative prescription of vitamin D. Experience with 729 thyroidectomies in 1988].

729 consecutive patients underwent thyroidectomy in 1988 in the same institution, including 477 (68%) bilateral resections and 242 (33%) total thyroidectomies. An effort was made to see and save all 4 parathyroids and their blood supply. Early post-operative hypoparathyroidism was defined at day 5, by serum calcium less than 8 mg/dl. and serum phosphate less than 4 mg/dl or by serum calcium only if greater than 7.5 mg/dl. Patients afflicted with early hypoparathyroidism were given calcium tablets without any vit D for 1 year at most. Follow-up, checking serum Ca, P and i PIH was done on a 3 months basis during 1 year. Permanent hypoparathyroidism was defined by persistence of the above-mentioned criteria after 1 year, and eventually vit D was started. 27 patients (5.6% our of 477 bilateral thyroid resections) experienced early post-op hypoparathyroidism. Inciting factors were previous thyroid surgery (4), radioiodine treatment (2), modified neck dissection (2), sternal split with mediastinal node clearance (1), visualization of 1 parathyroid gland only (3 redo cases) and autotransplantation of more than 1 parathyroid (1 case). 1 patient was lost for follow-up. 25 others recovered a normal parathyroid function. 1 is permanently hypoparathyroid (1 redo case with other risk factors). Painstaking parathyroid dissection allows a 0% rate of permanent hypoparathyroidism after primary surgery, if vit D is not given in the early post-operative period. We suggest that avoidance of early vit D prescription in cases of early post-operative hypoparathyroidism, leading to mild sustained hypocalcemia, stimulates the spared parathyroid glands (including a possible 5th) and therefore allows full recovery of the parathyroid function.

Breathlessness with pulmonary metastases: a multimodal approach.

Case Study  Sarah is a 58-year-old breast cancer survivor, social worker, and health-care administrator at a long-term care facility. She lives with her husband and enjoys gardening and reading. She has two grown children and three grandchildren who live approximately 180 miles away. SECOND CANCER DIAGNOSIS  One morning while showering, Sarah detected a painless quarter-sized lump on her inner thigh. While she thought it was unusual, she felt it would probably go away. One month later, she felt the lump again; she thought that it had grown, so she scheduled a visit with her primary care physician. A CT scan revealed a 6.2-cm soft-tissue mass in the left groin. She was referred to an oncologic surgeon and underwent an excision of the groin mass. Pathology revealed a grade 3 malignant melanoma. She was later tested and found to have BRAF-negative status. Following her recovery from surgery, Sarah was further evaluated with an MRI scan of the brain, which was negative, and a PET scan, which revealed two nodules in the left lung. As Sarah had attended a cancer support group during her breast cancer treatment in the past, she decided to go back to the group when she learned of her melanoma diagnosis. While the treatment options for her lung lesions included interleukin-2, ipilimumab (Yervoy), temozolomide, dacarbazine, a clinical trial, or radiosurgery, Sarah's oncologist felt that ipilimumab or radiosurgery would be the best course of action. She shared with her support group that she was ambivalent about this decision, as she had experienced profound fatigue and nausea with chemotherapy during her past treatment for breast cancer. She eventually opted to undergo stereotactic radiosurgery. DISEASE RECURRENCE  After the radiosurgery, Sarah was followed every 2 months. She complained of shortness of breath about 2 weeks prior to each follow-up visit. Each time her chest x-ray was normal, and she eventually believed that her breathlessness was anxiety-related. Unfortunately, Sarah's 1-year follow-up exam revealed a 2 cm × 3 cm mass in her left lung, for which she had a surgical wedge resection. Her complaints of shortness of breath increased following the surgery and occurred most often with anxiety, heat, and gardening activities, especially when she needed to bend over. Sarah also complained of a burning "pins and needles" sensation at the surgical chest wall site that was bothersome and would wake her up at night. Sarah met with the nurse practitioner in the symptom management clinic to discuss her concerns. Upon physical examination, observable signs of breathlessness were lacking, and oxygen saturation remained stable at 94%, but Sarah rated her breathlessness as 7 on the 0 to 10 Borg scale. The nurse practitioner prescribed duloxetine to help manage the surgical site neuropathic pain and to assist with anxiety, which in turn could possibly improve Sarah's breathlessness. Several nonpharmacologic modalities for breathlessness were also recommended: using a fan directed toward her face, working in the garden in the early morning when the weather is cooler, gardening in containers that are at eye level to avoid the need to bend down, and performing relaxation exercises with pursed lip breathing to relieve anxiety-provoked breathlessness. One month later, Sarah reported relief of her anxiety; she stated that the fan directed toward her face helped most when she started to feel "air hungry." She rated her breathlessness at 4/10 on the Borg scale. SECOND RECURRENCE: MULTIPLE PULMONARY NODULES  Sarah's chest x-rays remained clear for 6 months, but she developed a chronic cough shortly before the 9-month exam. An x-ray revealed several bilateral lung lesions and growth in the area of the previously resected lung nodule. Systemic therapy was recommended, and she underwent two cycles of ipilimumab. Sarah's cough and breathlessness worsened, she developed colitis, and she decided to stop therapy after the third cycle. In addition, her coughing spells triggered bronchospasms that resulted in severe anxiety, panic attacks, and air hunger. She rated her breathlessness at 10/10 on the Borg scale during these episodes. She found communication difficult due to the cough and began to isolate herself. She continued to attend the support group weekly but had difficulty participating in conversation due to her cough. Sarah was seen in the symptom management clinic every 2 weeks or more often as needed. No acute distress was present at the beginning of each visit, but when Sarah began to talk about her symptoms and fear of dying, her shortness of breath and anxiety increased. The symptom management nurse practitioner treated the suspected underlying cause of the breathlessness and prescribed oral lorazepam (0.5 to 1 mg every 6 hours) for anxiety and codeine cough syrup for the cough. Opioids were initiated for chest wall pain and to control the breathlessness. Controlled-release oxycodone was started at 10 mg every 12 hours with a breakthrough pain (BTP) dose of 5 mg every 2 hours as needed for breathlessness or pain. Sarah noted improvement in her symptoms and reported a Borg scale rating of 5/10. Oxygen therapy was attempted, but subjective improvement in Sarah's breathlessness was lacking. END OF LIFE  Sarah's disease progressed to the liver, and she began experiencing more notable signs of breathlessness: nasal flaring, tachycardia, and restlessness. Opioid doses were titrated over the course of 3 months to oxycodone (40 mg every 12 hours) with a BTP dose of 10 to 15 mg every 2 hours as needed, but her breathlessness caused significant distress, which she rated 8/10. The oxycodone was rotated to IV morphine continuous infusion with patient-controlled analgesia (PCA) that was delivered through her implantable port. This combination allowed Sarah to depress the PCA as needed and achieve immediate control of her dyspneic episodes. Oral lorazepam was also continued as needed. Sarah's daughter moved home to take care of her mother, and hospice became involved for end-of-life care. As Sarah became less responsive, nurses maintained doses of morphine for control of pain and breathlessness and used a respiratory distress observation scale to assess for breathlessness since Sarah could no longer self-report. A bolus PCA dose of morphine was administered by Sarah's daughter if her mother appeared to be in distress. Sarah died peacefully in her home without signs of distress.

InternalMed_Harrison

use calcitriol (doses of 0.5–1 μg/d) because of the rapidity of onset of effect and prompt cessation of action when stopped, in comparison to other forms of vitamin D. A rise in blood calcium after several months of vitamin D replacement may indicate restoration of parathyroid function to normal. It is also appropriate to monitor serum PTH serially to estimate gland function in such patients.

Atypical Presentation of Interval Colorectal Cancer/Post-Colonoscopy Colorectal Cancer in a Nursing Home Patient.

The Centers for Disease Control and Prevention estimates that there are around 1.7 million beds in certified nursing homes across the United States and approximately 1.3 million residents in long-term and end-of-life care. There could be several factors causing a delayed recovery in such patients, such as decreased ambulation, multiple comorbidities, and polypharmacy. An 83-year-old Caucasian woman sustained a fall resulting in compression fractures of the thoracic and lumbar spine. She had multiple comorbidities, including anemia of chronic disease, malnutrition, and a significant weight loss of 30 lbs over the four months prior to hospitalization. She was on antihypertensives, antidepressants, vitamin D, and calcium supplementation. Her medical history was significant for constipation with the passage of stools once in three days. Her family history was significant for colorectal cancer (CRC) and her screening colonoscopy three years ago was normal. Physical examination revealed no abdominal tenderness or distention. Subsequently, she developed edema in the left lower extremity. She underwent a venous Doppler/ultrasound study, which showed an occlusive thrombus from the common femoral vein to the popliteal vein. She was started on anticoagulants and supportive therapy. Four months later, while at the nursing home, she developed bloating and flatulence, in addition to pre-existing constipation. Examination revealed a 6 x 7 cm mass in the right lower quadrant without peritoneal signs. Bowel sounds were significantly decreased. CT imaging showed a 6-cm diameter cecal mass. The tumor was a low-grade 4 x 9 cm T4N0M0 cecal cancer, and she underwent placement of a Greenfield filter and subsequent hemicolectomy. She had methicillin-resistant <iStaphylococcus aureus</i infection and right upper extremity deep vein thrombosis (DVT), urinary tract infection, <iClostridium difficile</i colitis, and depression, all managed successfully and without sequelae in the post-operative period. Treatment on discharge comprised Coumadin maintenance for nine months with an international normalized ratio goal of 2-3, a back brace, antidepressants, and antihypertensive medications. She received follow-up care at home. Maintaining a high degree of suspicion for new and persistent symptoms in the elderly is essential to identify the underlying cause. One of the leading causes of post-colonoscopy CRC is a missed lesion. Careful attention to all cases of anemia as well as DVT in the elderly is also imperative to diagnose such missed cases. Future research should focus on the methods of CRC diagnosis in elderly patients with comorbidities apart from using colonoscopy alone.

[Dual mobility total hip arthroplasty for the treatment of femoral neck fracture with hemiplegia].

To investigate the clinical effects of dual mobility total hip prosthesis in treating femoral neck fracture patients with hemiplegia. A retrospective analysis was performed on 18 patients with femoral neck fracture combined with hemiplegia who underwent dual mobility total hip prosthesis replacement from March 2014 to December 2016. The follow up data of these patients was complete. There were 5 males and 13 females, aged 65 to 70 years old with an average of (66.50±1.38) years. The left side was involved in 12 cases, while the right side in 6 cases. There were 4 cases with Garden Ⅲ type and 14 cases with type Ⅳ. Limb muscle strength of hemiplegia were in grade Ⅳ. The posterior-lateral approach of hip joint was used in surgery for all patients. The implant position, dislocation and loosening of the prosthesis were evaluated by X-ray examination. Harris hip score and the Merle D'aubigne score were used to assess the hip function in the follow up. The operation duration was for 70-90 (81.56±7.48) min and the blood loss during the operation was for 160-200 (170.32± 12.56) ml. No blood was transfused during the operation. Postoperative incisions were healed at the first stage. The follow-up time was for 28-60(36.0±3.5) months. Harris hip score increased from 16.94±0.73 preoperatively to 96.19±1.27 at the final follow-up(<iP</i<0.05). Merle D 'Aubigne score increased from 3.96±0.06 preoperatively to 16.81±0.63 at the final follow-up(<iP</i< 0.05). No fracture or nerve or vascular injury were found during the operation. The postoperative X-ray showed that the prosthesis was in good position. No complications such as joint dislocation, dislocation of prosthesis, loosening of prosthesis, fracture around the prosthesis, pain in the front of thethigh, fracture of the self tapping screw in the ilium, and delayed infection occurred in the patients after operation. Dual mobility total hip prosthesis has the advantages of both good initial stability and low dislocation rate of the prosthesis, and the clinical application of total hip replacement in hemiplegic femoral neck fracture is satisfactory.

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FIgURE 11-17 Algorithm depicting assessment and management of falls in older patients. HR, heart rate. (From American Geriatrics Society and British Geriatrics Society: Clinical Practice Guideline for the Prevention of Falls in Older Persons. New York, American Geriatric Society, 2010.) sensory, nervous system, brain, cardiovascular, and musculoskeletal contributors. Interventions depend on the factors identified but often include medication adjustment, physical therapy, and home modifications. Meta-analyses of strategies to reduce the risk of falls have found that multifactorial risk assessment and management as well as individually targeted therapeutic exercise are effective. Supplementation with vitamin D at 800 IU daily may also help reduce falls, especially in older persons with low vitamin D levels.

Management of aneurysmal subarachnoid hemorrhage.

Treatment of ischemic deficits caused by vasospasm relies on enhancing cardiac output, inducing arterial hypertension, and expanding the intravascular volume in an attempt to improve CBF. Different treatment protocols exist from institution to institution to achieve these goals. The role of calcium-channel blockers now is well established. The newest focus on prevention of vasospasm includes tPA and a variety of anti-inflammatory drugs and potential neuroprotective drugs under research. Endovascular therapy for vasospasm has an increasing role in treating patients who are unable to tolerate induced hypertension or aggressive volume augmentation. We will return to our index case of the 63-year-old woman with SAH caused by an ACoA aneurysm to review some major management issues. After placing a ventriculostomy and slowly lowering ICP, the patient became alert and was fully oriented. She had aneurysm surgery on hospital day 2, with an uncomplicated immediate postoperative course. A Swan-Ganz catheter, placed for intraoperative monitoring, was kept in place and she was hydrated with 125 mL/hour of normal saline, achieving a PAWP of 10 to 16 mm Hg. Her mean arterial blood pressure without pharmacologic intervention was 95 to 110 mm Hg. She had continued clinical improvement with resolution of her left hemiparesis. On hospital day 5, her ventriculostomy was clamped because cerebrospinal fluid drainage was minimal. The following morning, the patient was arousable only to deep pain and her left side was flaccid. An emergent CT scan demonstrated no new hemorrhage, no increase in ventricular size, and no infarct. Vasospasm was considered the most likely cause. Hypertensive therapy was about to be initiated with a phenylephrine drip, but within an hour she was fully alert and moving all extremities equally. A search for other potential causes of neurologic decline was undertaken and revealed a phenytoin level of 5.5. It was thought that the patient most likely had had a seizure and that her clinical deterioration represented a postictal state. She received a bolus infusion of phenytoin. On hospital day 7, the patient became confused, insisting that her nurse was her son and ordering him out of her "apartment." Lower extremity weakness was detected. CT scan was unchanged. Phenylephrine was started but she developed precordial lead ST elevation and elevated cardiac enzymes. Topical nitrate therapy was initiated and phenylephrine was discontinued. The patient underwent emergent cerebral angiography, which demonstrated moderate to severe bilateral ACA spasm and moderate right MCA spasm.(ABSTRACT TRUNCATED AT 400 WORDS)

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Signs of hypocalcemia include symptoms such as muscle twitching, a general sense of anxiety, and positive Chvostek’s and Trousseau’s signs coupled with serum calcium consistently <2 mmol/L (8 mg/dL). Parenteral calcium replacement at a low level should be instituted when hypocalcemia is symptomatic. The rate and duration of IV therapy are determined by the severity of the symptoms and the response of the serum calcium to treatment. An infusion of 0.5–2 mg/kg per hour or 30–100 mL/h of a 1-mg/mL solution usually suffices to relieve symptoms. Usually, parenteral therapy is required for only a few days. If symptoms worsen or if parenteral calcium is needed for >2–3 days, therapy with a vitamin D analogue and/or oral calcium (2–4 g/d) should be started (see below). It is cost-effective to use calcitriol (doses of 0.5–1 μg/d) because of the rapidity of onset of effect and prompt cessation of action when stopped, in comparison to other forms of vitamin D. A rise in blood calcium after

Iatrogenic aortic insufficiency following mitral valve replacement: case report and review of the literature.

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.

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TREATMEnT ManageMent of aV conduction Block

Delayed vascular injury and severe respiratory distress as a rare complication of a central venous catheter and total parenteral nutrition.

Complications related to central venous catheters (CVCs) in the postoperative period can be fatal. We recently had a case of bilateral pleural effusion and respiratory distress caused by delayed vascular injury. A 79-y-old Japanese woman was admitted to our hospital because of advanced gastric carcinoma. A multiple-lumen CVC was placed through the left subclavian vein 1 d before surgery for postoperative nutritional management. The patient suddenly complained of dyspnea, and the chest X-ray film revealed right massive pleural effusion. Although the patient's symptoms soon disappeared after the thoracentesis, she again developed severe respiratory distress, and an endotracheal intubation was performed and her respiration was managed by mechanical ventilation. Computed tomographic scan of the chest revealed a displacement of the tip of the CVC out of the wall of the superior vena cava, mediastinitis, and leakage of intravenous fluid, which may have been caused by delayed vascular injury due to the CVC. The CVC was removed immediately after the diagnosis of delayed vascular injury at 10 d after surgery. The patient soon recovered with conservative treatment and was discharged from the hospital 43 d after surgery. This case highlights an extremely rare presenting complication of CVC placement and total parenteral nutrition.

Differential diagnosis of hypercalcaemia and indications for treatment.

Primary HPT is a common medical problem of the middle-aged and elderly. The diagnosis is generally simple and seldom requires elaborate studies. The precise consequences of mild-to-moderate virtually asymptomatic disease are not clarified and provided there is regular follow-up attendance expectancy may be justified. In most patients, however, the experienced surgeon will have a more than 90% chance of success at the first exploration, which for the patient is a fairly safe procedure.

Indications and results for the Exogen™ ultrasound system in the management of non-union: a 59-case pilot study.

This pilot series sought to assess the use of external ultrasound stimulation (Exogen™) in the treatment of femoral or tibial non-union. A continuous retrospective study was conducted from 2004 to 2009. It included patients with a non-united fracture or osteotomy at 6 months or more post-surgery, with less than 10mm inter-fragment gap. Daily 20-min ultrasound sessions were continued until bone healing was achieved or for a maximum 6-month duration. Radio-clinical control was performed at months 3 and 6; treatment compliance and transmitter positioning were checked at each follow-up visit. Sixty non-unions were included in the series. One patient was excluded for early material breakage. Mean fracture-to-surgery interval was 271 days. The 6-month consolidation rate was 88%. There was no loss to follow-up. Mean ultrasound treatment duration was 151 days (range, 90-240 days). Bone healing correlated significantly with stability of the internal fixation assembly (P=0.01). The seven cases of failure included four fixations,considered unstable at inclusion, one femoral non-union associated with BMI 45 and one inadequate subchondral roughening (at the time of arthrodesis). There was a significant difference in delay to non-union treatment start between the groups with (251 days) and without (420 days) bone healing. The present results are in line with the literature. The main prognostic factors were fracture fixation stability, short time to treatment, and inter-fragment gap less than 10mm. Bone healing rates in the literature are around 80% for non-union treated at around 6 months, versus 60% for more than 12 months' delay. Factors such as gender, bone site, smoking, numbers of previous operations or type of osteosynthesis do not impact consolidation. External treatment offers an alternative to traditional surgery (graft, or bone-marrow concentrate or bone morphogenetic protein injection), provided that the fracture fixation is stable. Bone healing rates are better, and the procedure is non-invasive. External treatment results using ultrasound are similar to those using electromagnetic fields; the main difference lies in treatment session duration, which is 20 min for ultrasound, versus 3 hours for electromagnetic fields. Active patient commitment is vital, as the treatment is delivered at home, although the machine is equipped with a monitor to count treatment cycles. The 88% bone healing rate supports advocating first-line implementation in non-union of less than 10mm with stable osteosynthesis. This rate is higher than in traditional surgery, with a unit cost at least 60% lower: €1772 for external therapy, versus €4480 for decortication with or without fracture fixation exchange (itemized 08c50 under the French healthcare treatment coding system). Level IV. Retrospective therapeutic study.

Reducing cardiovascular mortality in chronic kidney disease: something borrowed, something new.

CLINICAL VIGNETTE: A 48-year-old man with chronic kidney disease stage five due to type II diabetes mellitus and hypertension was referred for hemodialysis initiation. His physical exam showed a blood pressure of 150/80, normal fundi, a positive fourth heart sound (S4), and trace pedal edema. Moderate aortic calcification was present on prior chest X-ray. The ECG showed left ventricle hypertrophy by voltage and slight prolongation of the QT interval. Medications included chlorthalidone, amlodipine, carvedilol, cholecalciferol, erythropoietin, and a phosphate binder. What additional therapy should be initiated to reduce vascular calcifications and cardiovascular mortality?

Meniscus tear

There are three phases that follow meniscal surgery. Each phase consists of rehabilitation goals, exercises, and criteria to move on to the next phase. Phase I starts immediately following surgery to 4–6 weeks or until the patient is able meet progression criteria. The goals are to restore normal knee extension, reduce and eliminate swelling, regain leg control, and protect the knee (Fowler, PJ and D. Pompan, 1993). During the first 5 days following the surgery, a passive continuous motion machine is used to prevent a prolonged period of immobilization which leads to muscular atrophy and delays functional recovery. During the 4–6 weeks post-surgical, active and passive non-weight bearing motions which flex the knee up to 90° are recommended. For patients with meniscal transplantation, further knee flexion can damage the allograft because of the increased shear forces and stresses. If any weight-bearing exercises are applied, a controlled brace should be worn on the knee to keep the

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500–800 mg, followed by continuous infusion at 2–5 mg/min) is now rarely used in this setting but may be tried for persisting, hemodynamically stable arrhythmias. Intravenous calcium gluconate is no longer considered safe or necessary for routine administration. It is used only in patients in whom acute hyperkalemia is known to be the triggering event for resistant VF, in the presence of known hypocalcemia, or in patients who have received toxic doses of calcium channel antagonists. Cardiac arrest due to bradyarrhythmias or asystole (B/A cardiac arrest) is managed differently (Fig. 327-3B). The patient is promptly intubated, CPR is continued, and an attempt is made to control hypoxemia and acidosis and identify other reversible causes. Epinephrine may be given intravenously or by an intraosseous route. Atropine is no longer considered effective for asystole or PEA, but can be used for bradyarrhythmias. External pacing devices are used to attempt to establish a regular rhythm when

[A case of spontaneous rupture of the ascending aorta].

We report a rare case of spontaneous rupture of the ascending aorta without any evidence of aneurysm formation or aortic dissection. A woman aged 64 was admitted to our cardiac care unit as an emergency patient with severe chest pain. Her face was pale and systolic blood pressure was 70 mmHg in spite of intravenous administration of dopamine (10 micrograms/kg/min). She had a history of hypertension for two years under good medical control. No trace of the chest trauma was noted before her admission. Physical examination revealed neck vein engorgement and distant heart sounds. Chest X-ray film showed enlargement of the cardiac silhouette. ECG showed no evidence of acute coronary syndrome. Pericardial effusion with a floating hematoma-like mass was detected by 2-dimensional echocardiogram. Pericardiocentesis revealed bloody pericardial fluid (Ht: 26%). Aortagraphy was performed resulting in a clinical diagnosis of acute aortic dissection, but there were no signs of a false lumen, aneurysm formation or extravasation of the contrast medium. Although continuous pericardial drainage was performed, she suddenly lost consciousness, collapsed and died. A longitudinal intimal laceration 5 cm long was observed in the ascending aorta. Pathological examination revealed cystic medial necrosis and irregularity of the elastic fibers in the media. No atheromatous plaque was noted in the intima. Spontaneous rupture of the aorta is a life-threatening condition that requires urgent surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Vitamin D toxicity presenting as hypercalcemia and complete heart block: An interesting case report.

Vitamin D deficiency is widely prevalent across the globe. This has lead to widespread use of vitamin D supplements in populations. We present our experience of vitamin D toxicity in a subject resulting in hypercalcemia and CHB (Complete Heart Block). A 70-year-old female, known hypertensive for thirty five years and diabetic for seven years underwent total knee replacement (TKR) for osteoarthritis left knee in December 2010. For perioperative glycemic control, multiple subcutaneous injections of insulin were advised. Patient later presented with poor glycemic control, decreased appetite and constipation for last 1 month with history of episodes of transient loss of consciousness for 15 days and recurrent vomiting. Biochemical work-up showed hypercalcemia (Serum calcium 12.4 mg/dL). Sr. albumin, ALP, Sr. phosphorus and PTH levels were normal, thus suggesting PTH independent hypercalcemia. Strong suspicion led us to check vitamin D levels in dilution which were 2016 ng/mL, thus confirming vitamin D toxicity. Retrospective analysis of treatment history revealed patient receiving 4 injections of Architol (6 Lac units im) prior to presentation. Work-up for malignancy was negative, brain imaging and EEG were normal. Holter was suggestive of intermittent CHB. Patient was given hydration, injection calcitonin 100 I.U. subcutaneously, injection pamidronate 60 mg infusion, with serum calcium levels normalizing, with relief in constipation, vomiting and behavioral improvement. However, persistence of rhythm disturbances led to permanent pacemaker placement. The present case highlights the dangers of indiscriminate vitamin D usage, exposing patients to potentially life threatening complications.