Sodium Polystyrene Sulfonate-Induced Massive Bowel Necrosis With Distant Extraintestinal Crystal Deposition: A Case Report and Review of the Literature

Sodium polystyrene sulfonate (SPS), a cation-exchange resin, has been a mainstay in long-term hyperkalemia management but is associated with significant gastrointestinal complications, particularly when used with sorbitol. The deposition of SPS crystals within the intestinal mucosa has been suggested to precipitate ischemia, necrosis, and ulcerations, ultimately leading to bowel perforation. This case report details a striking instance of massive bowel perforation subsequent to SPS administration, with accompanying findings of disseminated crystals in distant organs and tissues upon autopsy. Additionally, we provide a comprehensive review of the existing literature on this rare yet significant drug-induced side effect.

Blind Nasotracheal Intubation in a Patient With Ankylosing Spondylitis and Severe Cervical Spine Deformities: A Case Report on Challenges and Approaches to Difficult Airway Management

Airway management in patients with advanced ankylosing spondylitis (AS) presents a unique challenge due to possible cervical spine deformities that restrict neck mobility and affect access to the airway. Traditional airway management strategies, such as direct laryngoscopy and even fiberoptic intubation, are often rendered ineffective due to these anatomical limitations. Furthermore, surgical options like tracheostomy can be infeasible in cases with significant neck deformities, necessitating alternative approaches. This case depicts a 48-year-old male with untreated AS who presented to the emergency department following a fall, resulting in unstable vertebral fractures and paraplegia. The patient's severe cervical deformities posed significant challenges to airway management, and conventional airway management strategies, including fiberoptic intubation, were unsuccessful. Given the impracticality of tracheostomy due to the anatomical limitations, blind nasal intubation was successfully performed in a semi-recumbent position. This case underscores the complexities of airway management in AS patients with severe deformities. It highlights the importance of alternative intubation strategies, even blind nasotracheal intubation, when conventional methods fail due to anatomical constraints.

Assessing suicide risk in chronic pain management: a narrative review across drug classes

INTRODUCTION

Chronic pain presents a multifaceted challenge in clinical practice, necessitating a nuanced understanding of pharmacological interventions to optimize treatment outcomes. This review provides an outline of various pharmacological agents commonly used in chronic pain management and highlights their safety considerations, particularly regarding suicide risk.

AREAS COVERED

This review discusses the role of antidepressants, anticonvulsants, GABA receptor agonists, NMDA receptor antagonists, corticosteroids, cannabis and cannabinoids, bisphosphonates, calcitonin, and alpha-2 adrenergic receptor agonists in chronic pain management. It assesses their therapeutic benefits, potential for misuse, and psychiatric adverse effects, including the risk of suicide. Each pharmacological class is evaluated in terms of its efficacy, safety profile, and considerations for clinical practice. We searched peer-reviewed English literature on the topic using the MEDLINE database without time restrictions.

EXPERT OPINION

While pharmacological interventions offer promise in alleviating chronic pain, healthcare providers must carefully weigh their benefits against potential risks, including the risk of exacerbating psychiatric symptoms and increasing suicide risk. Individualized treatment approaches, close monitoring, and multidisciplinary collaboration are essential for optimizing pain management strategies while mitigating adverse effects. Ongoing research efforts are crucial for advancing our understanding of these pharmacological interventions and refining pain management practices.

Persistent Vegetative State Following a Cardiac Arrest in a Patient With Preeclampsia and Posterior Reversible Encephalopathy Syndrome: A Case Report

We report the case of a 35-year-old female patient who presented to a tertiary referral hospital in a persistent vegetative state (PVS) following a cardiac arrest that occurred approximately one hour after an elective cesarean delivery for a postterm pregnancy complicated by preeclampsia. Magnetic resonance imaging (MRI) of the brain performed seven days after the cardiac arrest showed findings consistent with posterior reversible encephalopathy syndrome (PRES). Following transfer to our hospital, the patient was carefully evaluated, stabilized, and successfully weaned off mechanical ventilation. However, due to the lack of neurological recovery, the decision was made to transfer her to a neurorehabilitation center for further management. This case report explores the potential link between PRES and PVS.

Pulmonary Blastomycosis in Two Immunocompetent Patients: The Role of Obesity and Vitamin D Deficiency

This case report depicts two patients with morbid obesity who presented to the ED with signs and symptoms of community-acquired pneumonia and were treated accordingly. Despite empiric antibiotic therapy, their symptoms did not subside, prompting further evaluation, which revealed pulmonary blastomycosis. Both patients were also found to have severe vitamin D deficiency. Treatment with amphotericin B followed by itraconazole, along with aggressive vitamin D supplementation, led to clinical improvement and resolution of lung lesions in both cases. Although blastomycosis is not rare in immunocompetent individuals, its severe forms are usually associated with underlying immunosuppression or significantly high inoculum. Blastomycosis presents a diagnostic challenge due to its nonspecific symptoms and radiographic findings. This case series underscores the importance of considering blastomycosis in the differential diagnosis of persistent pneumonia in obese individuals, particularly in endemic areas. It also suggests that vitamin D deficiency may play a role in disease susceptibility and severity. This report contributes to existing medical literature by emphasizing the potential link between obesity, vitamin D deficiency, and the risk of blastomycosis, highlighting the need for further research into this association.

Chronic Stress and Headaches: The Role of the HPA Axis and Autonomic Nervous System

Chronic stress significantly influences the pathogenesis of headache disorders, affecting millions worldwide. This review explores the intricate relationship between stress and headaches, focusing on the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS). Persistent stress could lead to neuroinflammation, increased pain sensitivity, and vascular changes that could contribute to headache development and progression. The bidirectional nature of this relationship creates a vicious cycle, with recurrent headaches becoming a source of additional stress. Dysregulation of the HPA axis and ANS imbalance could amplify susceptibility to headaches, intensifying their frequency and severity. While pharmacological interventions remain common, non-pharmacological approaches targeting stress reduction, such as cognitive-behavioral therapy, biofeedback, and relaxation techniques, offer promising avenues for comprehensive headache management. By addressing the underlying stress-related mechanisms, these approaches provide a sustainable strategy to reduce headache frequency and improve patients' quality of life.