Adequacy of thyroid hormone replacement for people with hypothyroidism in real-world settings: A systematic review and meta-analysis of observational studies

OBJECTIVE

Thyroid hormone under-replacement and over-replacement are associated with adverse health outcomes. This systematic review aimed to evaluate the extent of thyroid hormone replacement adequacy for patients with known hypothyroidism in real-word settings, excluding those receiving thyroid hormone suppressive therapy as thyroid cancer treatment.

DESIGN

Four electronic databases (Embase [Ovid], Medline [Ovid], PubMed and SCOPUS) were searched for published and unpublished observational studies until 12 December 2022. The results of the studies were meta-analysed to calculate pooled prevalence estimates for thyroid hormone supplementation adequacy, over-replacement and under-replacement. Quality assessment of studies was performed using the Joanna-Briggs appraisal tool for prevalence studies.

RESULTS

Seven studies with a total of 4230 patients were eligible for quantitative synthesis. The pooled prevalence estimates of adequate thyroid replacement, over-replacement and under-replacement were 0.55 (95% confidence interval [CI]: 0.49-0.60, p = .001), 0.20 (95% CI: 0.14-0.27, p = .001) and 0.24 (95% CI: 0.13-0.36, p = .001), respectively. Four studies subclassified hypothyroidism and hyperthyroidism into overt and subclinical. The pooled prevalence of overt and subclinical hyperthyroidism was 0.04 (95% CI: 0.00-0.11, p = .01) and 0.17 (95% CI: 0.09-0.27 p = .001), respectively. For overt and subclinical hypothyroidism, the pooled prevalence was 0.02 (95% CI: 0.01-0.03, p = .001) and 0.20 (95% CI: 0.12-0.29, p = .001), respectively.

CONCLUSIONS

On average, approximately half of patients with hypothyroidism are only treated to target euthyroidism. In real-world practice, a significant number of patients are over-treated or under-treated, leading to adverse healthcare outcomes. It is imperative that more effective thyroid monitoring strategies be implemented, with an emphasis on primary care thyroid function monitoring, to minimise inappropriate thyroid replacement treatments and optimise healthcare outcomes at a population level.

Iatrogenic Vascular Injuries in Resource-Limited Setting: A 4-Year Experience Monocentric Retrospective Study

Background

Iatrogenic vascular injuries (IVIs) due to diagnostic and therapeutic interventions are known but rare or probably under-reported. We present our four-year findings on patients with IVIs after catheterization or surgery who underwent vascular surgical repairs in a resource-limited setting.

Methods

A retrospective case series study between Jun 2018 and Sep 2022 of 35 patients diagnosed with IVIs and treated surgically at our hospital was included. The data on IVIs including patient characteristics, causes and type of injury, treatment, and outcomes were collected and analyzed.

Results

The mean age was 37.12± 17.0 years, and most patients (65.7%) were male. Of the 35 IVIs, 21 were caused by percutaneous procedures, while 14 occurred intraoperatively and affected various arteries and veins. The main injured vessels were the femoral artery (20%) and direct blood vessel puncture made by non-qualified specialists (42.9%) during dialysis cannulation was the main cause. The intraoperative IVI affected the inferior vena cava in three patients, the aorta in two patients, the external iliac artery in four, the tibial and popliteal arteries in four, and the internal carotid artery in one. The following types of repairs were recorded: direct suture of the vessel with or without endarterectomy (71.4%), synthetic patch placement (25.7%), ligation (8.6%), bypass or interposition graft (14.3%), and thromboembolectomy (5.7%). Vascular repair was successful in 32 (91.4%) patients while three patients (8.6%) were expired. Complications occurred in 7 (20%) patients, of which superficial wound infections were the common complication (11.6%) and were treated with proper antibiotic therapy.

Conclusion

Prompt identification of IVIs, as well as proper triage for future treatment, can enhance patient outcomes. Our data showed that non-qualified specialists seem to be responsible for the majority of IVIs. For that, we emphasize the importance of performing vascular procedures by a qualified specialist with adequate training.

Hypoglossal Nerve Neuropathies-Analysis of Causes and Anatomical Background

The hypoglossal nerve is the last, and often neglected, cranial nerve. It is mainly responsible for motor innervation of the tongue and therefore the process of chewing and articulation. However, tumors, aneurysms, dissections, trauma, and various iatrogenic factors such as complications after surgeries, radiotherapy, or airway management can result in dysfunction. Correct differential diagnosis and suitable treatment require a thorough knowledge of the anatomical background of the region. This review presents the broad spectrum of hypoglossal neuropathies, paying particular attention to these with a compressive background. As many of these etiologies are not common and can be easily overlooked without prior preparation, it is important to have a comprehensive understanding of the special relations and characteristic traits of these medical conditions, as well as the most common concomitant disorders and morphological traits, influencing the clinical image. Due to the diverse etiology of hypoglossal neuropathies, specialists from many different medical branches might expect to encounter patients presenting such symptoms.

Systemic and iatrogenic factors contribute to the development of severe hypernatraemia in vulnerable inpatients

OBJECTIVES

To determine all-cause in-hospital mortality associated with severe hypernatraemia and the causes, comorbidities, time to treatment, discharge destination and postdischarge mortality.

DESIGN

Retrospective observational cohort study.

PATIENTS

Severe hypernatraemia, (sodium concentration ≥ 155 mmol/L), at any time during a tertiary hospital admission in Melbourne, Australia, 1 January 2019 to 31 December 2019 (pre-COVID19).

MEASUREMENTS

Deaths, Charlson Comorbidity Index (CCI), hypernatraemia causes, time to treatment, discharge destination.

RESULTS

One hundred and one inpatients: 64 community-acquired, 37 hospital-acquired. In-hospital mortality was 38%, but cumulative mortality was 65% by 1 month after discharge, with only a minor further increase at 6 and 12 months. After adjusting for peak sodium concentration, the community acquired group had significantly reduced odds of in-hospital mortality (odds ratio 0.15, 95% confidence interval [0.04-0.54], p = .003). Iatrogenic factors were present in 57% (21/37) of the hospital-acquired group. Only 55% of all cases received active sodium directed treatment. Time to start treatment did not affect outcomes. High levels of comorbidity were present, median CCI (IQR) was 6 (5-8) in the community and 5 (4-7) in the hospital group. Dementia prevalence was higher in the community group, 66% (42/64) versus 19% (7/37) (p = .001). Infection was the most common precipitant with 52% (33/64) in the community and 32% (12/37) in the hospital group. Of the survivors, 32% who had been living independently required residential care after discharge.

CONCLUSIONS

Mortality was high and loss of independence in survivors common. To potentially improve outcomes, hypernatraemia-specific guidelines should be formulated and efforts made to reduce system and iatrogenic factors.

A case of celiac plexus block causing iatrogenic Cushing's syndrome

Treatment with corticosteroids can lead to iatrogenic Cushing's syndrome when used for longer intervals and in high doses. Less common administration routes may conceal the exposure, raising the possibility of misdiagnosis and mismanagement.

Iatrogenic botulism cases after gastric and axillary application of botulinum toxin and review of literature

INTRODUCTION

Iatrogenic botulism is a rare, serious disease that progresses with descending paralysis and develops after cosmetic or therapeutic botulinum toxin-A (BoNT-A) application.

CASE PRESENTATIONS

In this case series; six cases of iatrogenic botulism followed up in our center are presented. Four of these developed after gastric BoNT-A and two after axillary BoNT-A application.

RESULTS

The most important cause for the disease was the use of unlicensed products and high-dose toxin applications. The first symptoms were blurred vision, double vision, difficulty in swallowing, and hoarseness. Symptoms appeared within 4-10 days after the application of BoNT-A. Symptoms progressed in the course of descending paralysis in the following days with fatigue, weakness in extremities and respiratory distress. Diagnosis was based on patient history and clinical findings. The main principles of foodborne botulism therapy were applied in the treatment of iatrogenic botulism. If clinical worsening continued, regardless of the time elapsed after BoNT-A application, the use of botulinum antitoxin made a significant contribution to clinical improvement and was recommended.

CONCLUSIONS

Routine and new indications for BoNT-A usage are increasing and, as a result, cases of iatrogenic botulism will be encountered more frequently. Physicians should be alert for iatrogenic botulism in the follow-up after BoNT-A applications and in the differential diagnosis of neurological diseases that are presented with similar findings.

Rare Presentation of Papillary Carcinoma Within a Sentinel Lymph Node in a Patient With Ductal Carcinoma in Situ of the Breast: A Challenging but Useful Case Report Discussion Regarding Displacement or True Metastasis?

Papillary carcinoma of the breast is a rare histologic subtype of invasive breast cancer. In contrast, ductal carcinoma in situ (DCIS) is a noninvasive, nonobligate precursor to invasive mammary carcinoma, confined within the terminal duct lobular unit of the breast and surrounded by an intact myoepithelial cell layer at the stromal/epithelial interface. We present an unusual case in which a patient with only DCIS of the breast exhibited papillary carcinoma within a sentinel lymph node, leading to questions about the origin of the lymph node lesion-whether it represents a true metastasis or iatrogenic displacement during diagnostic procedures. This case underscores the diagnostic challenges and clinical implications associated with such rare presentations.

Pericardioesophageal fistulae after left atrial ablation: a case series

Pericardioesophageal fistula is an uncommon, yet serious complication that can occur after left atrial ablation for cardiac arrhythmias. Timing of this complication is variable; however, it has been reported to occur from a week to over a month post-ablation. The incidence of this complication after ablation is <0.05%; however with increasing rates of left atrial ablations, early recognition is imperative. Nonspecific symptoms, including chest pain, dysphagia, and fever, can indicate the presence of a fistula within the first month after ablation. Early drainage with subsequent definitive treatment is key to limiting morbidity. Here we report four cases of pericardioesophageal fistula all occurring ~1 month post-ablation, with two patients surviving after prompt diagnosis and surgical treatment. Successful treatment in these two cases was achieved with fistula takedown and intercostal muscle flap interposition and esophageal stenting.

Trends in preterm birth in the Netherlands in 2011-2019: A population-based study among singletons and multiples

INTRODUCTION

Preterm birth (PTB) is the leading cause of infant mortality and morbidity worldwide. Rates of PTB in the Netherlands are declining, possibly due to the implementation of preventive strategies. In this study we assessed the overall trend in PTB rates in the Netherlands in recent years, and in more detail in specific subgroups to investigate potential groups that require scrutiny in the near future.

MATERIAL AND METHODS

Based on the national perinatal registry, we included all pregnancies without severe congenital abnormalities resulting in a birth from 24 to 42 completed weeks of gestation between 2011 and 2019 in the Netherlands. We assessed PTB rates in two different clinical subtypes (spontaneous vs. iatrogenic) and in five gestational age subgroups: 24-27+6 weeks (extreme), 28-31+6 weeks (very), 32-33+6 weeks (moderate, 34-36+6 weeks [late] and, in general, 24-36+6 weeks [overall PTB]). Trend analysis was performed using the Cochran Armitage test. We also compared PTB rates in different subgroups in the first 2 years compared to the last 2 years. Singleton and multiple gestations were analyzed separately.

RESULTS

We included 1 447 689 singleton and 23 250 multiple pregnancies in our study. In singletons, we observed a significant decline in PTB from 5.5% to 5.0% (p < 0.0001), mainly due to a decrease in iatrogenic PTBs. When focusing on different gestational age subgroups, there was a decrease in all iatrogenic PTB and in moderate to late spontaneous PTB. However, in spontaneous extreme and very PTB there was an significant increase. When assessing overall PTB risk in different subgroups, the decline was only visible in women with age ≥25 years, nulliparous and primiparous women, women with a medium or high socioeconomic status and hypertensive women. In multiples, the rate of PTB remained fairly stable, from 52.3% in 2011 to 54.1% in 2019 (p = 0.57).

CONCLUSIONS

In the Netherlands, between 2011 and 2019, PTB decreased, mainly due to a reduction in late PTB, and more in iatrogenic than in spontaneous PTB. Focus for the near future should be on specific subgroups in which the decline was not visible, such as women with a low socioeconomic status or a young age.

Intradental Displacement of a Deciduous Tooth Root in a Dog

This case study describes the diagnosis and treatment of a deciduous left maxillary canine tooth root that had been displaced into the pulp of the developing permanent left maxillary canine tooth in a 23-month-old female neutered Cavalier King Charles Spaniel. The patient was initially presented for bilateral persistent deciduous maxillary canine teeth extraction. Seventeen months later the permanent left maxillary canine tooth was found to be non-vital and tooth development had ceased prior to apical closure. Radiographs revealed a radio-opaque dentine-like structure and straight line centrally within the pulp of the permanent tooth. The displacement of the deciduous tooth into the developing permanent tooth was confirmed. This unusual potential complication should be considered when performing deciduous teeth extraction.

From Beauty to Botulism: A Case Report Highlighting the Rare Risk of Botox Administration

Botox (onabotulinumtoxinA) is a pharmaceutical approved by the Food and Drug Administration (FDA) for use in both cosmetic and therapeutic applications. Despite its increasing use worldwide, Botox carries a rare but potentially life-threatening risk of iatrogenic botulism. This condition, although treatable with antitoxin if promptly recognized, presents a diagnostic challenge to healthcare providers due to its rarity, lack of awareness, and diverse clinical presentations. Here, we present a case of iatrogenic botulism from Botox injections administered in Istanbul, Turkey, in a healthy 47-year-old female. Prompt administration of antitoxin led to remarkable clinical improvement. This case underscores the importance of vigilance among healthcare providers in recognizing and promptly treating iatrogenic botulism, particularly in patients with recent Botox use. Given that the majority of reported cases of iatrogenic botulism occur outside the United States, this case raises concerns about the need for stricter regulations and oversight of Botox administration worldwide.

Nodular fasciitis of the orbit: rapid growth phase post iatrogenic incisional trauma

Nodular fasciitis (NF) is a benign, reactive, myofibroblastic proliferative solitary lesion that commonly develops in the subcutaneous or superficial fascia. We present a case of a 35-year-old male with a rapidly enlarging upper eyelid mass postiatrogenic incisional trauma. Subsequent en toto excisional biopsy demonstrated NF. Given the rapid clinical course of this patient and the reactive nature of NF, we hypothesize that the initial incisional trauma likely incited an inflammatory response resulting in rapid proliferation and growth of the lesion. NF accounts for <1% of all orbital lesions, and is often a clinically and pathologically difficult diagnosis to make given its propensity to mimic other benign and malignant conditions. Therefore, we recommend that en toto biopsies of orbital lesions in this anatomical area be performed rather than incisional biopsies.

A case of exaggerated exuberance: Iatrogenic atrioventricular block/intra-Hisian Wenckebach during conduction system pacing

Isolated sinus node dysfunction with its pursuant long-term risk for atrioventricular (AV) conduction disease poses a unique dilemma for proponents of CSP due to paucity of imprimatur guidelines. In such scenarios, the risk and prognosis of iatrogenic AV block is not well elucidated but is a valid concern. We report a case where CSP was complicated by iatrogenic AV block and peculiarly the rare phenomenon of intra-Hisian Wenckebach.

Moderate Splenic Injury Caused by Colonoscopy

Little is known about iatrogenic splenic injury (SI) as an adverse event after colonoscopy. SI is sometimes fatal because of hemorrhaging. We herein report a man who developed SI after colonoscopy. He recovered conservatively. His history of left hydronephrosis and insertion with a maximally stiffened scope were suspected as possible risk factors. Endoscopists should consider the possibility of SI when they encounter patients suffering from left-sided abdominal pain after colonoscopy. Careful interview concerning the medical history and gentle maneuvering around the splenic flexure can help avoid SI.

A pediatric HIV outbreak in Pakistan

Background

Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019.

Aims

To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person.

Methods

Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices.

Results

Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services.

Conclusions

Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

Pharmacological Triggers of Takotsubo Cardiomyopathy: An Updated Review of Evidence and Recommendations

BACKGROUND

Previous publications in 2011, 2016, and 2022 have presented lists of drugs associated with takotsubo cardiomyopathy (TCM). This review aims to provide updated drug lists that have been reported as potential causes of TCM.

METHODS

Following the same methodology employed in previous reviews, a detailed investigation was carried out in the PubMed/Medline database from June 2022 to July 2023 to identify drug-induced TCM (DITC) case reports. Various search terms related to the drug-induced transient left ventricular ballooning syndrome, ampulla cardiomyopathy, apical ballooning syndrome, drug-induced broken heart syndrome, drug triggered takotsubo cardiomyopathy, takotsubo cardiomyopathy, and iatrogenic takotsubo cardiomyopathy were utilized. Filters for fulltext availability, case reports, human studies, and English language were applied. Articles reporting drugs associated with TCM development were included in the analysis.

RESULTS

Foremost 192 case reports were initially identified, with 75 drugs meeting the inclusion criteria after a thorough review. The latest revision identified seven drugs that might lead to TCM, with four drugs (57.14%) already reported in previous reviews and three drugs (42.86%) newly identified. Consequently, the updated drug list potentially triggering TCM in 2023 comprises a sum of 75 drugs.

CONCLUSION

The recent 75 drugs provided additional evidence linking to TCM development. The updated list predominantly includes drugs that induce sympathetic overstimulation, although some drugs on the list have unclear associations with sympathetic nervous system activation.

Vitamin B12 insufficiency and deficiency: a review of nondisease risk factors

Vitamin B12 deficiency and insufficiency can lead to both hematological and neurological impairments. This review examines nondisease causes and risk factors associated with dietary availability, such as eating habits, food processing, cooking techniques, and bioavailability, as well as increased physiological needs and iatrogenic factors linked to medication use or surgical procedures. As a result of these nondisease influences, groups at higher risk include vegans, vegetarians, older adults, individuals with limited diets, breastfed and preterm infants, and those who primarily consume foods prepared or cooked in ways that reduce vitamin B12 content, as well as individuals on certain medications or who have undergone specific surgeries. Recognizing these diverse risk factors helps develop strategies for prevention and intervention to minimize the adverse health effects related to B12 deficiency and insufficiency.

Non-operative management of iatrogenic esophageal perforation in a 6-year-old child

BACKGROUND

Esophageal perforations are rare, the most common encountered esophageal perforation is iatrogenic in origin. It can be life-threatening if not diagnosed and treated early. Medical treatment has been recommended primarily in hemodynamically stable children. Drainage of intrathoracic or periesophageal fluid formation should be reserved to patients with hemodynamic instability. Surgical intervention may seldomly be required, depending on the localization and size of the defect.

CASE REPORT

A 6-year-old male patient was referred to our clinic due to an esophageal perforation whilst removing the foreign body from upper esophagus under direct vision of a rigid esophagoscope. A radiologic appearance similar to esophageal duplication was detected along the esophagus in the esophagogram. A secondary esophagoscopy was carried out by our clinic, laceration at the esophagopharyngeal junction and dissection along the esophagus were observed and the foreign body was propelled into the stomach. The patient, whose clinical condition was stable, was managed medically without the need for a surgical intervention.

CONCLUSIONS

Esophageal perforation is rare, yet perilous if not handled properly. We do not encounter this clinical entity frequently. Despite its rarity it can arise either iatrogenically or while managing a previous complication such as a simple nasogastric tube insertion in an infant or during an endoscopy for an esophageal foreign body. Its management is challenging, and we believe that non-operative treatment is still an important option in childhood esophageal perforations.

Iatrogenic bladder injury following gynecologic and obstetric surgery: A systematic review and meta-analysis

INTRODUCTION

Iatrogenic bladder injury is a rare complication following obstetric and gynecologic surgery and only sparse information is available regarding length of transurethral catheterization following injuries, suturing techniques including choice of suture, and complications. The primary aim of this systematic review was to evaluate length of transurethral catheterization in relation to complications following iatrogenic bladder injury. Second, we aimed to evaluate the number of complications following repair of iatrogenic bladder injuries and to describe suture technique and best choice of suture.

MATERIAL AND METHODS

A systematic review and meta-analysis was conducted, and the results were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, and Medline electronic databases were searched, and followed by screening from two independent reviewers. Studies published between January 2000 and March 2023 describing methods of bladder injury repair following obstetric or gynecologic benign surgery were included. Data extraction was done using Covidence. We performed a meta-analysis on complications after repair and explored this with a meta-regression analysis (Metafor package R) on length of catheterization to determine if length of catheterization influenced the risk of complication. A risk of bias tool from Cochrane was used to assess risk of bias and the study was registered in PROSPERO (CRD42021290586).

RESULTS

Out of 2175 articles, we included 21 retrospective studies, four prospective studies, and one case-control study. In total, 595 bladder injuries were included. Cesarean section was the most prominent surgery type, followed by laparoscopically assisted vaginal hysterectomy. We found no statistically significant association between length of transurethral catheterization and numbers of complications following repair of iatrogenic bladder injuries. More than 90% of injuries were recognized intraoperatively. Approximately 1% had complications following iatrogenic bladder injury repair (0.010, 95% confidence interval 0.0015-0.0189, 26 studies, 595 participants, I2  = 4%).

CONCLUSIONS

Our review did not identify conclusive evidence on the length of postoperative catheterization following bladder injury warranting further research. However, the rate of complications was low following iatrogenic bladder injury with a wide range of repair approaches.

Assessment of Risk Factors for Iatrogenic Genitourinary Injuries During a Proctectomy

BACKGROUND

It is critical to avoid iatrogenic injuries affecting genitourinary organs in order to prevent postoperative urinary or sexual dysfunction, which lead to lengthier recovery and possibly reoperation.

METHODS

Using the 2016-2019 American College of Surgeons National Quality Improvement Program (ACS NSQIP) Targeted Proctectomy Database, we collated 2577 patients with non-metastatic rectal cancer who underwent a laparoscopic or open proctectomy. Univariate analysis was used to identify differences in perioperative factors and genitourinary injuries (GUIs) between operative approaches, and multivariate logistic regression was used to identify independent risk factors for sustaining an intraoperative GUI.

RESULTS

The rates of preoperative comorbidities were significantly higher among patients who received an open operation. The proportion of GUIs was also significantly higher in this patient population. Multivariate logistic regression demonstrated that patients who underwent a laparoscopic proctectomy were associated with a 51.4% lower risk of sustaining a GUI. Furthermore, >10% body weight loss in the past 6 months and ASA class 3 status were independently associated with a higher risk of GUI regardless of operation type.

CONCLUSION

Patients who undergo a laparoscopic proctectomy are associated with a lower risk of GUI. On the other hand, patients with >10% body weight loss and ASA class 3: Severe Systemic Disease were associated with a higher risk of GUI.

Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases

BACKGROUND

Classic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified.

CASE REPORTS

We describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.

Bradyphrenia and Tachyphrenia in Idiopathic Parkinsonism Appear, in Part, Iatrogenic: An Observational Study with Systematic Review Background

We question whether bradyphrenia, slowing of cognitive processing not explained by depression or a global cognitive assessment, is a nosological entity in idiopathic parkinsonism (IP). The time taken to break contact of an index finger with a touch-sensitive plate was measured, with and without a warning in the alerting signal as to which side the imperative would indicate, in 77 people diagnosed with IP and in 124 people without an IP diagnosis. The ability to utilise a warning, measured by the difference between loge-transformed reaction times (unwarned minus warned), was termed 'cognitive efficiency'. It was approximately normally distributed. A questionnaire on self- and partner perception of proband's bradyphrenia was applied. A multivariable model showed that those prescribed levodopa were less cognitively efficient (mean -5.2 (CI -9.5, -1.0)% per 300 mg/day, p = 0.02), but those prescribed the anti-muscarinic trihexyphenidyl were more efficient (14.7 (0.2, 31.3)% per 4 mg/day, p < 0.05) and those prescribed monoamine oxidase-B inhibitor (MAOBI) tended to be more efficient (8.3 (0.0, 17.4)%, p = 0.07). The variance in efficiency was greater within IP (F-test, p = 0.01 adjusted for any demographic covariates: coefficient of variation, with and without IP, 0.68 and 0.46, respectively), but not so after adjustment for anti-parkinsonian medication (p = 0.13: coefficient of variation 0.62). The within-participant follow-up time, a median of 4.8 (interquartile range 3.1, 5.5) years (101 participants), did not influence efficiency, irrespective of IP status. Perception of bradyphrenia did not usefully predict efficiency. We conclude that both bradyphrenia and 'tachyphrenia' in IP appear to have iatrogenic components, of clinically important size, related to the dose of antiparkinsonian medication. Levodopa is the most commonly prescribed first-line medication: co-prescribing a MAOBI may circumvent its associated bradyphrenia. The previously reported greater efficiency associated with (low-dose) anti-muscarinic was confirmed.

Iatrogenic Vertebral Arteriovenous Fistula Involving Brachiocephalic Vein Due to Central Venous Catheterization: A Case Report

PURPOSE

To report a case of vertebral arteriovenous fistula (VAVF) caused by iatrogenic trauma of central venous catheterization (CVC) involving brachiocephalic vein (BCV).

CASE REPORT

A 79-year-old female was referred for assessment of a vertebral artery (VA) aneurysm at the V1 segment. The patient had no signs other than a vascular murmur on the right neck and was diagnosed 20 years after undergoing CVC. Right vertebral angiography revealed a high-flow shunt from the V1 segment of the right VA and draining into the right BCV. The fistula had a single communication between a pseudoaneurysm and large varix. We diagnosed the patient with CVCinduced VAVF (CIVAVF) involving BCV and obliterated the shunt by selective transarterial and transvenous embolization of the pseudoaneurysm under flow control using a balloon catheter with no complications.

CONCLUSION

This case highlights the point that CIVAVF involving BCV is rare but possible. In addition, there is a possibility that CIVAVF involving BCV does not demonstrate the findings of arterial steal or retrograde venous drainage and is undiagnosed for a long term due to lack of neurological manifestation and other subjective symptoms. We also showed that endovascular treatment can be feasible and useful for CIVAVF involving BCV.

Iatrogenic Abdominal Aortic Rupture During Transpedicular Bone Grafting for Thoracolumbar Burst Fractures Successfully Treated by Endovascular Stent Implantation

PURPOSE

Vascular injury resulting from transpedicular bone grafting in the treatment of thoracolumbar burst fractures has not been reported but can be lethal. The management of patients with iatrogenic aortic injury remains a difficult clinical problem. This study describes a case of iatrogenic abdominal aortic rupture at the level of L2 during transpedicular bone grafting for the first time.

CASE REPORT

A 55 year-old male patient suffered from a T12 vertebral body mild compression fracture and an L2 vertebral body burst fracture due to falling. This patient was treated with posterior open reduction and pedicle screw fixation combined with transpedicular bone grafting in the L2 vertebrae using a paravertebral approach. Unfortunately, during transpedicular bone grafting, the abdominal aorta was punctured by the tip of the graft funnel. The use of endovascular stent implantation successfully averted a clinical catastrophe. The patient had a good clinical outcome, and no complications associated with vascular trauma were apparent at a 1-year follow-up examination.

CONCLUSION

For the repair of vascular injury caused by transpedicular bone grafting, endovascular techniques can provide a safe, minimally invasive, and effective treatment option.

CLINICAL IMPACT

Surgeons should carefully evaluate the specificity of the patient's anatomical structures preoperatively and be more cautious during transpedicular bone grafting in the treatment of thoracolumbar burst fractures.

Efficacy and outcomes of systemic chemotherapy in posttransplant and immunosuppression associated Kaposi sarcoma: Twenty years experience of a tertiary cancer center

Kaposi sarcoma is a malignant angioproliferative disease, and human herpesvirus-8 plays a major role in its etiology. Iatrogenic Kaposi sarcoma (IKS) can occur in patients undergoing immunosuppressive therapy. The treatment strategy for patients with IKS is immunosuppressive therapy modification. However, it is unclear which chemotherapy drug is the most effective and safe in the treatment of IKS. Therefore, we investigated the efficacy and safety of systemic treatment in patients with IKS at our tertiary cancer center. This cross-sectional retrospective study analyzed the clinical data of 22 patients diagnosed with IKS between January 2000 and January 2020. The patients were divided into the following 2 groups according to the transplantation status: organ transplant recipient (OTR) group and non-organ transplant recipient (non-OTR) group. Of the 22 patients, 12 were included in the OTR group and 10 were included in the non-OTR group. The median patient age at diagnosis was 52.1 years in the OTR group and 68.1 years in the non-OTR group. The median overall survival (OS) was 65.4 months in the OTR group, while the median OS was not reached in the non-OTR group. There was no statistically significant difference in OS between the 2 groups (P = .45). The 5-year OS rate among all patients was 54%. In the OTR group, the objective response rate and disease control rate were 50% and 83%, respectively, and in the non-OTR group, the objective response rate and disease control rate were 60% and 90%, respectively. Chemotherapy was well tolerated in both groups. Hematological toxicities were the main dose-limiting adverse events. Grade III/IV leucopenia and neutropenia were observed in 5 and 4 patients, respectively; however, no patient experienced febrile neutropenia. No chemotherapy-related death occurred. Systemic chemotherapy is an effective treatment and can be considered for disease control in patients with an aggressive disease course, who do not experience regression with immunosuppressive therapy modification.

Brachial plexus deficits in patients undergoing shoulder arthroplasty

Background

Nerve deficit following shoulder arthroplasty can cause significant morbidity. We examined the incidence and pattern of nerve injury following shoulder arthroplasty in a University Hospital.

Methods

Retrospective review of all patients undergoing shoulder arthroplasty over a five-year period (September 2014 to August 2019). Patients were identified using clinical codes and relevant data extracted by review of patient records. We excluded patients with preoperative nerve injuries.

Results

220 arthroplasties were performed in 210 patients. The overall nerve deficit rate was 2.3% (5/220). Five nerve deficits occurred following reverse total shoulder arthroplasty (rTSA). In two patients, nerve recovery occurred within 12 months. Two patients had persistent deficits at 12 months. One patient had a deficit at seven months, but incomplete follow up. There was no clear documentation of discussions with clinicians specialising in nerve injury.

Conclusion

Nerve injury rates in our series for rTSA are low and comparable to systematic review data. We purport that for rTSA, adequate soft tissue releases, careful arm positioning and retraction alongside limiting over-lowering the centre of rotation may prevent nerve injuries. A postoperative nerve deficit should warrant an opinion from a specialist in nerve surgery with clear referral pathways to allow efficient access to services.

A 10-Year Retrospective Analysis of Medication Errors among Adult Patients: Characteristics and Outcomes

Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011-2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E-I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15-65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.

Amantadine-Induced Craniofacial Myoclonus: Distinctive Iatrogenic Dysarthria in Parkinson's Disease

Background

Amantadine is a widely prescribed medication in Parkinson's disease (PD). A distinctive craniofacial distribution of myoclonus with speech impairment is an underrecognized iatrogenic complication in amantadine-treated patients with PD.

Cases

We report 7 patients with idiopathic PD (disease duration, 6-21 years) who developed speech-induced craniofacial-predominant myoclonus with "stuttering-like" dysarthria and speech arrests days to months after amantadine initiation or dose increase. Renal insufficiency was identified as a risk factor in 4 cases. In all cases, reduction or discontinuation of amantadine markedly attenuated the myoclonus and restored speech intelligibility.

Literature Review

Amantadine can induce subcortical segmental or generalized myoclonus. A report in 1996 of "vocal myoclonus" in an amantadine-treated patient with PD was the first observation of a focal distribution of myoclonus, particularly affecting speech. Since then, few cases of craniofacial myoclonus with speech impairment have been reported, none with accompanying video. With 1 exception, the craniofacial distribution was part of a generalized pattern of amantadine-induced myoclonus. Comorbid renal insufficiency is a recognized risk factor.

Conclusions

Speech-induced craniofacial myoclonus, with marked "stuttering-like" dysarthria and speech arrests, is a disabling iatrogenic complication in PD that resolves upon amantadine discontinuation.

Aetiology, clinical profile and management outcome of pneumothorax patients: A prospective study from Central India

Background

Pneumothorax (PT) is defined as the presence of air in the pleural cavity. Primary spontaneous pneumothorax (PSP) arises in an otherwise healthy person without any underlying lung disease. PSP occurs in people aged 20 to 30 years, with a peak incidence in the early twenties. The recurrence rate in spontaneous PT patients is approximately 10%-20%. In the present study, 50 cases of spontaneous PT were undertaken with an aim to analyse aetiology, clinical profile and management outcome of PT patients.

Materials and Methods

The present study was conducted for a period of 12 months, among 50 patients presenting with unilateral PT. The therapeutic interventions were indicated when there was a loss of volume of lungs of 32% or more, and this loss of volume was calculated using Collins method. The association between the side of PT, smoking status and size of PT were found using the Chi-square test, and the association between variables were considered significant if the P value was <0.05.

Results

In the present study, the male patients were 92.0% and only 8.0% of patients were females. The further history-taking of patients had shown that the mode of onset of PT was sudden in 72.0% of patients. Although the success rate of Intracth procedure was lower in comparison with the intercoastal drainage (ICD) procedure, the complication rate of Intracath was lower when compared with extensive subcutaneous.

Conclusion

PSP is less common than secondary spontaneous PT. Smoking is an independent risk factor for PT, and it delays its resorbtion.

Levothyroxine Prescription Error: A Case Report

Levothyroxine (LT) is the synthetic form of thyroxine (T4), a thyroid hormone analog used to treat hypothyroidism. LT overdose rarely results in severely poor outcomes. General guidelines for treating exogenous thyrotoxicosis depend on the severity of symptoms. There is no standardized protocol; however, drug discontinuation, beta-blockers (specifically propranolol), and cholestyramine effectively manage overdose when needed, with most cases resolving independently without medical intervention.  Here, we present the case of a 26-year-old female with a history of supraventricular tachycardia, anxiety, depression, and Hashimoto thyroiditis who was accidentally overprescribed LT (300 mcg for one and a half months) that resulted in symptoms of lethargy, tremors, body temperature dysregulation, orthostatic hypotension, and diarrhea. This case, with limited evidence, suggests that excessive LT exacerbated the patient's underlying psychiatric symptoms, encouraging suicidal ideation.

Gossypiboma, the Hidden Enemy of an Emergency Cesarean Hysterectomy-Case Report and Review of the Literature

Gossypiboma or textiloma is a rare medical situation that can complicate the favorable evolution of a surgical case, with repercussions for the patient's prognosis. The diagnosis can be difficult due to various clinical symptoms, the time elapsed since the surgical intervention, and the imaging often not being precise in detecting textilomas. Due to the medicolegal implications, the reporting of this event is inconsistent. We present a rare case of a 28-year-old woman who presented with vague pain in the left iliac fossa 11 months after an emergency cesarean hysterectomy was performed. The preoperative imaging examination identified the presence of a subhepatic mass with dimensions of 10 × 8 cm2 and another formation in the right iliac fossa with dimensions of 11 × 9 cm2. Exploratory laparotomy found the presence of a large subhepatic gossypiboma, intimately adherent to the hepatic angle of the colon and omentum and a second one adherent to the sigmoid colon, small intestine, and parietal peritoneum. The particularity of this case is given by the simultaneous presence of two textilomas with inconclusive evolution, which can make the differential diagnosis difficult to achieve. For a better assessment of the risk of occurrence of this pathology and the identification of a correct prevention strategy, we performed an extensive search and a review of all the articles published in the PubMed database, identifying 57 articles. In conclusion, emergency surgery increases the risk of this complication, and, as a result, prevention can be achieved by following existing protocols in the operating room.

Endoscopic Management of Jejunal Perforation During Endoscopic Ultrasonography: A Case Report and Literature Review

Endoscopic ultrasound is a useful diagnostic and interventional device for gastroenterologists. Although extremely useful, endoscopic ultrasound is not a benign tool. Possible complications of endoscopic ultrasound include hemorrhage, infection, and perforation. Although rare, iatrogenic small bowel perforations have been reported largely on the duodenum and rarely on the jejunum or ileum. Traditionally, these iatrogenic small bowel perforations have been managed with open surgery. However, recent emerging clinical data has revealed that immediate endoscopic treatment may be a feasible and safe alternative to surgery in select cases. Here, we describe the endoscopic management of an iatrogenic jejunal perforation during a linear endoscopic ultrasound examination managed successfully using an endoscopic clip.

Type A aortic dissection during diagnostic coronary angiography in normal coronary arteries: A case report

KEY CLINICAL MESSAGE

Aortic dissection is one of the rare complication of coronary angiography. The main treatment underlies surgical intervention however; management should be done with patient's decision.

ABSTRACT

Coronary angiography (CA) is a widely utilized diagnostic procedure used to evaluate blood flow through the coronary arteries and detect coronary artery disease (CAD). Despite its widespread use, it has complications including non-life-threatening, while there are some rare complications that can occur. We present a case of an elderly woman who presented with ST elevation myocardial infarction (STEMI) and underwent CA without evidence of CAD. However, the patient later developed type A aortic dissection (AD) as a complication of the procedure. Surgery is considered emergent treatment for type A-AD, but the patient was asymptomatic without any complaint, shared decision making was conducted and the patient decided to pursue conservative treatment without surgical intervention. Therefore, managing AD should be tailored to each patient individually through shared-decision making.

Case report: Laryngospasm following ethanol ablation of a parathyroid nodule in a dog with primary hyperparathyroidism

A 12-year-old female spayed dachshund was presented for emergency assessment of respiratory distress, characterized by inspiratory dyspnea with stridor. Percutaneous ultrasound-guided ethanol ablation of a functional parathyroid tumor was performed 72-h earlier for management of primary hyperparathyroidism. The dog was hypocalcemic (ionized calcium 0.7 mmol/L, reference interval: 0.9-1.3 mmol/L) at the time of presentation and had evidence of laryngospasm on a sedated oral exam. The dog was managed conservatively with supplemental oxygen, anxiolysis, and parenteral calcium administration. These interventions were associated with rapid and sustained improvement in clinical signs. The dog did not demonstrate any recurrence of signs afterwards. To the authors' knowledge, this is the first description of laryngospasm following ethanol ablation of a parathyroid nodule in a dog that developed hypocalcemia.

Single-Center Retrospective Subgroup Analysis of "Primary Aortic" (Aneurysm, Aortic Dissection, PAU) and "Secondary Aortic" (Iatrogenic, Trauma, Aortoesophageal Fistula) Indications for Emergency TEVAR

BACKGROUND

The aim of this study was to analyze the outcome of emergency thoracic endovascular aortic repair (TEVAR) in the treatment of "primary aortic" (aneurysm, aortic dissection, penetrating aortic ulcer (PAU)) and "secondary aortic" (iatrogenic, trauma, and aortoesophageal fistula) pathologies.

METHODS

Retrospective review of a cohort of patients treated at a single tertiary referral center from 2015 to 2021. The primary end point was postoperative in-hospital mortality. Secondary end points were the duration of the procedure, duration of postoperative intensive care treatment, length of hospital stay, and the nature and severity of postoperative complications according to the Dindo-Clavien classification.

RESULTS

A total of 34 patients underwent TEVAR for emergency indications. Twenty-two patients were treated for primary and twelve patients for secondary aortic pathologies. Concerning in-hospital mortality, no statistically significant difference could be observed between the primary and secondary aortic groups (27.3% vs. 33.3%, p = 0.711). Patients with an aortoesophageal fistula had a mortality rate of 66.7%. Postoperative morbidity (Dindo-Clavien > 3) was also not statistically significantly different between the primary and secondary aortic groups (36.4% vs. 33.3%, p = 0.86). Preoperative hemoglobin level (p < 0.001 for mortality, p = 0.002 for morbidity), hemoglobin level difference (p = 0.022, p = 0.032), postoperative creatinine level (p = 0.009, p = 0.035), and pre- and postoperative lactate levels (p < 0.001 for both mortality and morbidity) were found to be independent factors associated with postoperative mortality and morbidity (Dindo-Clavien > 3), respectively. The preoperative creatinine level was found to be associated with mortality (p = 0.024) but not morbidity.

CONCLUSIONS

Morbidity and in-hospital mortality are still considerable after emergency TEVAR for both primary and secondary aortic indications. Pre- and postoperative levels of hemoglobin, creatinine, and lactate may be valuable to predict patient outcomes.

Other iatrogenic immunodeficiency-associated lymphoproliferative disorders in a patient with anti-melanoma differentiation-associated gene 5-positive dermatomyositis: A case report and systematic literature review

A 58-year-old man with anti-melanoma differentiation-associated gene 5-positive dermatomyositis (MDA5-DM) developed Epstein-Barr virus (EBV)-associated malignant lymphoma as other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD) during the combined immunosuppressive therapy of high-dose prednisolone, tacrolimus, and intravenous cyclophosphamide for MDA5-DM. Serum EBV DNA was detected, and EBV-encoded small RNA was positive in the tissue sample of LPD, indicating that EBV reactivation contributed to the pathogenesis of LPD in our case. The patient underwent chemotherapy, including rituximab, promptly after discontinuation of tacrolimus and cyclophosphamide, resulting in complete remission of the malignant lymphoma, and MDA5-DM has not recurred with 3.5 mg/d of prednisolone monotherapy. We reviewed 19 cases of OIIA-LPD in patients with idiopathic inflammatory myopathies and herein report the first case of MDA5-DM complicated with OIIA-LPD. Among the 19 patients, 7 showed regression of LPD only following withdrawal of immunosuppressants, 9 took chemotherapy for LPD, and 5 died. It should be noted that patients with MDA5-DM-associated rapidly progressive interstitial lung disease could develop OIIA-LPD because they receive aggressive immunosuppressive therapy.

A large travel-associated outbreak of iatrogenic botulism in four European countries following intragastric botulinum neurotoxin injections for weight reduction, Türkiye, February to March 2023

In March 2023, 34 associated cases of iatrogenic botulism were detected in Germany (30 cases), Switzerland (two cases), Austria (one case), and France (one case). An alert was rapidly disseminated via European Union networks and communication platforms (Food- and Waterborne Diseases and Zoonoses Network, EpiPulse, Early Warning and Response System) and the International Health Regulation mechanism; the outbreak was investigated in a European collaboration. We traced sources of the botulism outbreak to treatment of weight loss in Türkiye, involving intragastric injections of botulinum neurotoxin. Cases were traced using a list of patients who had received this treatment. Laboratory investigations of the first 12 German cases confirmed nine cases. The application of innovative and highly sensitive endopeptidase assays was necessary to detect minute traces of botulinum neurotoxin in patient sera. The botulism notification requirement for physicians was essential to detect this outbreak in Germany. The surveillance case definition of botulism should be revisited and inclusion of cases of iatrogenic botulism should be considered as these cases might lack standard laboratory confirmation yet warrant public health action. Any potential risks associated with the use of botulinum neurotoxins in medical procedures need to be carefully balanced with the expected benefits of the procedure.

Iatrogenic Arteriovenous Fistula Following Routine Venipuncture in an Adult Without Coagulopathy: An Uncommon Consequence of a Common Procedure

Background

According to Tonnessen BH (2011),¹ iatrogenic arteriovenous (AV) fistulas in adults most commonly occur due to endovascular access and procedures. Rarely, AV fistulas have been reported in low birth weight neonates following repeating venipuncture. This complication is extremely uncommon in adults, but has been reported after routine venipuncture for blood transfusion.

Case presentation

We report the case of an elderly female patient who presented to the office for evaluation of left upper extremity swelling, ecchymosis, and dilated vessels after routine venipuncture at an outpatient laboratory. She was subsequently found to have an acquired AV fistula from her left cephalic vein to a small branch artery.

Conclusion

This case demonstrates the rare but relevant risk in routine venipuncture and may underscore the benefit of using ultrasound guidance in high-risk populations, such as patients with coagulopathies, or thin, fragile veins, like the elderly or neonates.

Endovascular Repair of Iatrogenic Inferior Vena Cava and Iliac Vein Injury: A Case Series and Review of the Literature

OBJECTIVE

Iatrogenic injury to the large abdominopelvic veins can he highly morbid, and open surgical repair is technically challenging. Endovascular repair with covered stenting across the injured segment offers an alternative to open surgical management. We present a series of patients with operative injury to the inferior vena cava (IVC) and iliac veins who were treated utilizing an endovascular approach and review the available literature on this technique.

METHODS

A PubMed keyword and MeSH term search was performed, and titles were reviewed for relevance by the first author. Studies related to endovascular repair of iatrogenic injury to the IVC and iliac veins were then read in detail for possible inclusion in the review. Those deemed appropriate were further analyzed for interventional approach, stent type and size, technical success, post-procedural pharmacologic management, complications and surveillance strategy.

RESULTS

The initial search resulted in 6221 publications. A total of 17 met criteria for inclusion, all of which were case reports or series. Twenty-six patients were described as suffering iatrogenic injury to the IVC or iliac veins, treated with various types and sizes of stents. All cases achieved technical success with hemorrhage control. Procedural complications occurred in 15.4% of cases, including 3 cases of acute thrombus formation and 1 case of stenosis caudal to the initial stent edge requiring additional stenting. Two additional patients experienced stent occlusion in the surveillance period.

CONCLUSIONS

Endovascular repair of iatrogenic injury to the IVC and iliac veins can be an effective management option. However, due to limited data regarding this approach, many technical questions remain, including ideal size and type of stent graft, necessity and duration of post-procedural anticoagulant or antiplatelet therapy and appropriate surveillance. Additionally, long term outcomes in this population have not yet been described.

Possible Use of a Safety-Valve with a Foley Catheter During Catheterisation of Male Spinal Cord Injury Patients for Prevention of Urethral Trauma Caused by Inflation of the Catheter Balloon in the Urethra

We used a safety-valve (Trans-Urethral Catheterisation Safety Valve, Class Medical, Limerick, Ireland) to prevent urethral trauma due to inflation of the anchoring balloon in the urethra during catheterisation of male spinal cord injury patients in a spinal unit. The safety-valve is attached to the balloon channel of a Foley catheter. If the balloon is inflated when it is in the urethra, the pressure valve is activated. Any fluid pushed into the balloon channel leaks out and balloon inflation stops, indicating that the balloon is not inside the bladder. The safety-valve was used in 44 catheterisations. There was leakage of water during three catheterisations. In the first case, the health professional did not inflate and deflate the balloon prior to its use. This "pre-valve inflation" step overcomes the baseline resistance pressure of the balloon and prevents fluid leaking from the valve when the catheter is in the correct position. In the second instance, the valve was found to be defective. In the third case, the catheter had been misplaced; it was removed and repositioned; there was no leakage of water during inflation of the balloon. In one out of 44 catheterisations, the catheter had been misplaced; leakage of water from the safety-valve stopped inflation of the balloon and prevented iatrogenic urethral trauma. The safety-valve may be used during catheterisation of male patients in the spinal unit to prevent urethral trauma caused by inflation of the balloon of Foley catheter in the urethra. However, health professionals should remember the few shortcomings of the catheter safety-valve.

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence

AIMS

To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data.

METHODS

Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value.

RESULTS

The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery.

CONCLUSION

Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

Acute limb ischemia due to diclofenac sodium iatrogenic intra-arterial injection: a case report

Diclofenac sodium is a nonsteroidal anti-inflammatory, the injection of which by the intra-arterial route can lead to serious vascular complications, including limb ischemia.

Case presentation

We report the case of accidental intra-arterial injection of diclofenac sodium in the brachial artery leading to acute limb ischemia.

Clinical discussion

Iatrogenic intra-arterial injection is rarely reported in the literature; however, it is toxic and can lead to limb amputation. Only two cases of intra-arterial injection of diclofenac have been reported in the literature. The proposed pathophysiological mechanism is vasospasm, intravascular thrombosis, and chemical endoarteritis. The most common anatomical location in accidental intra-arterial injection is the antecubital fossa, where branches of the ulnar and brachial arteries are more superficial.

Conclusion

The injection of medication must be as careful as possible, since the intra-arterial injection can affect the functional prognosis of the organ.

Post-Inflammatory Hypopigmentation: Review of the Etiology, Clinical Manifestations, and Treatment Options

Post-inflammatory hypopigmentation is a common acquired pigmentary disorder that is more prominent in skin of color, leading to great cosmetic and psychosocial implications. Often, a diagnosis with a pigmentary disorder can negatively impact an individual's health-related quality of life and may result in stigma. Although most cases of post-inflammatory hypopigmentation resolve spontaneously over time, a systematic diagnostic approach can help with identifying the underlying etiology and informing treatment strategies. It can be due to cutaneous inflammation, sequelae of inflammatory or infectious dermatoses, or dermatologic procedures. Therefore, a thorough understanding of the epidemiology, patient history, physical exam findings, and clinical features of post-inflammatory hypopigmentation phenomenon can explain the primary cause to providers and allow for patient education. It is also important to understand the various therapeutic approaches available and the efficacy of these options, which will inform providers to choose the appropriate therapy for patients. Although algorithms exist for classifying acquired disorders of hypopigmentation, there are no established algorithms for the diagnosis and treatment of post-inflammatory hypopigmentation, which warrants further exploration and discourse.

Armodafinil to reduce the sleepiness related side-effects of sleep restriction therapy being used to treat insomnia disorder: An open label clinical trial pilot study compared with historical controls

Sleep restriction therapy (SRT) is an effective stand-alone behavioural intervention for insomnia disorder. However, its daytime side effects, particularly sleepiness, may be troubling for patients and/or may be a necessary part of the patient's treatment journey. This pilot trial aims to explore the potential benefit of armodafinil, a wakefulness promoter. Patients were treated with SRT with open label adjunctive armodafinil (150 mg/day). Thirty-three patients from previous studies that have undergone exactly the same SRT intervention acted as controls. The primary outcome measure was the insomnia severity index (ISI), and secondary outcomes were the Epworth sleepiness scale, sleep restriction adherence scale (SRAS), and safety from baseline through to 12 weeks. We recruited 25 patients into the trial. Data for the primary end point (ISI at 12 weeks) was available for 20 of the participants. The baseline insomnia severity index was 20.2 (SD 3.3) and decreased to 9.1 (SE 1.1), with no change, to 10.2 and 11.2 at weeks 6 and 12 respectively (all p > 0.05 compared with baseline). The insomnia severity index values for armodafinil patients were statistically inferior to historical controls at the primary time point of 12 weeks (11.2 vs. 6.7, p < 0.01). Sleep restriction therapy plus armodafinil treatment was associated with frequent minor side effects but was generally safe and acceptable to patients. Sleep restriction therapy was associated with a robust clinical response in the insomnia severity index values for insomnia patients. Based upon historical control data, armodafinil does not appear to have beneficial adjunctive effects in addition to sleep restriction therapy alone.

The Changing Epidemiology of Adrenal Insufficiency: Iatrogenic Factors Predominate

Context

Adrenal insufficiency (AI)-related morbidity persists despite efforts to minimize its effect. Reasons for this are unknown and warrant examination.

Objective

This work aimed to investigate trends in AI hospitalizations and glucocorticoid (GC) replacement therapy use.

Methods

Data on hospitalizations for a principal diagnosis of AI and prescriptions for short-acting GCs between 2000 and 2019 were extracted from national repositories. Age-standardized admission and prescription rates were calculated using census data. Rates were compared over time overall and according to age, sex, and disease subtype.

Results

AI admissions increased by 62.0%, from 36.78/million to 59.59/million (trend P < .0001). Adrenal crisis (AC) admissions also increased, by 90.1% (from 10.73/million to 20.40/million; trend, P < .00001). These increases were more pronounced in the second decade. Prescriptions for short-acting GCs also increased (by 67.2%, from 2198.36/million in 2000/2001 to 3676.00/million in 2017/2018). Females had higher average admission rates and a greater increase in admission rates than males. Increased AI admissions were found in all age groups among females but only in men aged 70+ yrs. Secondary AI (SAI) admission rates increased by 91.7%, whereas admission rates for primary AI (PAI) remained unchanged.

Conclusion

The prevalence of AI and hospitalizations for this disorder (including ACs) have increased since 2000, with a greater increase occurring after 2010. Admission rates for SAI increased but PAI admissions remained stable. Possible causes include immunotherapies for malignancy, increased cranial imaging detecting pituitary tumors and their subsequent treatment, and increased use of low-dose, short-acting GC-replacement therapy.