1/29. infant pulmonary hemorrhage in a suburban home with water damage and mold (stachybotrys atra).The American Academy of pediatrics recently issued guidelines regarding the potential toxic effect of indoor molds. We now report another case of an infant with pulmonary hemorrhage whose residential environmental assessment revealed the presence of the toxigenic mold stachybotrys atra. We used a questionnaire to identify environmental factors that could predispose the home to fungal contamination. We collected air samples from multiple locations in the home that we felt would reflect areas of relevant exposure. Surface samples were collected with a piece of transparent tape for semiquantitative measurement of spores present. We classified spores into their respective genera based on shape, size, and color. We also measured mycotoxin levels. air sampling revealed significantly elevated total spore counts in the patient's bedroom and in the attic. aspergillus/penicillium species were predominant. stachybotrys spores were found in the air sampled in the patient's bedroom, as well as from surfaces sampled in the patient's closet and the attic ceiling. Additionally, a small patch of stachybotrys-contaminated area in the closet ceiling was sent for mycotoxin analysis. This material proved to be highly toxigenic. As the link between the presence of stachybotrys in the home and pulmonary hemorrhage in infants increases, further efforts should be made to educate physicians, health care providers, and new parents about the potential toxic effects of this mold.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/29. Orbital hemorrhage following face-mask barotrauma.A 41-yr-old female recreational diver suffered an orbital hemorrhage following face-mask barotrauma This case illustrates the potential for significant orbital injury to occur as a result of face-mask barotrauma Barotraumatic orbital hemorrhage is an unusual disorder, but recognition of this entity is important for diving physicians. The signs and symptoms should not be mistaken for decompression sickness or arterial gas embolism. patients with barotraumatic orbital hemorrhage require emergency referral to an ophthalmologist so that potentially vision-threatening ocular complications may be identified and treated. barotrauma may result in several different types of cranial neuropathies and should be recognized as another possible cause for neurologic deficits following a dive.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/29. Intraperitoneal blood missed on a FAST examination using portable ultrasound.Bedside ultrasonography is rapidly gaining popularity in the evaluation of emergency patients. Several manufacturers have developed hand-held ultrasound machines that make the technology easy to transport and available in settings where such diagnostic tests were previously unobtainable. The miniaturization of equipment often means compromises and no studies exist comparing the high quality imaging capabilities of larger conventional ultrasound units to hand-held machines on actual patients. We present 3 cases in which intra-abdominal fluid stripes, important markers of intraperitoneal bleeding, were not visible with a popular hand-held unit, but were identified with a larger mobile ultrasound machine. These findings should caution emergency physicians to be aware of this limitation along with the many advantages of these new and popular hand-held ultrasound units.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/29. Hemorrhagic cystitis as an unexpected adverse reaction to temozolomide: case report.A case is reported in which temozolomide, a promising new dna alkylating agent, was successfully used to treat radiation refractory metastatic brain tumors arising from primary breast cancer. However, the treatment had to be terminated after the second round of treatment due to the development of hemorrhagic cystitis. This side effect was totally unexpected. Another class of alkylating agents (cyclophosphamide and related compounds) exhibits this side effect caused by a prevalent acrolein metabolite. Temozolomide and its sister compounds, dacarbazine and 5-(3-methyltriazen-1-yl)imidazole-4-caroxamide, have never been reported to have this adverse reaction. This case serves to alert physicians to the existence of a possible subpopulation of patients who may experience hemorrhagic cystitis on treatment with imidazotetrazines by a mechanism that is yet to be established.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/29. Tailored therapy of adult acute leukaemia in jehovah's witnesses: unjustified reluctance to treat.Treatment of acute leukaemia in adult jehovah's witnesses (JW) is challenging because of 'a priori' refusal of most physicians to apply diagnostic and therapeutic procedures to haematological abnormalities resembling acute leukaemia. Rejection of blood transfusions by individuals of this faith is usually blamed to justify this attitude, thus leading to severe personal, medical and psychological distress related to the lack of care. We therefore intended to verify whether a standard (tailored) chemotherapy, without the use of prophylactic blood product transfusions, could be applied during treatment of acute leukaemia under such circumstances. Eleven consecutive JW adult patients with acute leukaemia, all of whom had been denied care in other institutions, were treated at the European Institute of Oncology (EIO) in Milan, italy. Five had acute lymphoblastic leukaemia (ALL) (one bcr/abl positive), six had acute myeloid leukaemia (AML) with immunophenotype and/or cytogenetic intermediate-high risk features, except one patient with acute promyelocytic leukaemia (APML). Standard induction chemotherapy [cytosine arabinoside (ARA-C) and daunorubicin (DNR) for AML, vincristine (VCR), DNR and prednisone (PDN) for ALL, all-trans retinoic acid (ATRA) and DNR for APML] with the antracycline dose of at least 30 mg/sqm were used. All patients experienced severe anaemia after induction chemotherapy despite erythropoietin. Median haemoglobin nadir for patients with ALL and AML was 4.5 g/dL (range 1.3-6.9) and 5.1 g/dL (range 2.6-6.8), respectively. Median platelet nadir counts for all patients was 14.5 x 10(9))/L (range 1-24). One patient died during induction probably due to haemorrhage. Four of five patients with ALL achieved a complete remission (CR) (including the bcr/abl case) while among patients with AML only the one with APML achieved CR. Three patients (APML = 1 and ALL = 2) are still alive and disease-free. This small series of adult patients with leukaemia illustrates difficulties in treating patients who are practising JW, yet nevertheless provides a significant argument against the prejudicial decision leading to evasion of treatment in these patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/29. Successful reversal of deleterious coagulopathy by recombinant factor viia.Effective treatment of severe or uncontrolled bleeding is a challenge for physicians in the operating room and intensive care unit. However, even aggressive conventional therapy may ultimately fail in some patients. Administration of recombinant activated factor VII (rFVIIa) may be the only remaining therapeutic option to stop life-threatening coagulopathic bleeding. We here describe the clinical course of 5 patients exhibiting severe continuous bleeding that could not be stopped by surgical intervention and appropriate hemostatic management but resolved after a mean dose of 90 microg/kg of rFVIIa (range, 90-120 microg/kg). Four of the five patients recovered completely, and one patient died after developing sepsis in multiorgan failure. In all patients, bleeding from wound surfaces stopped within minutes of the administration of rFVIIa. Coagulation measurements improved, and transfusion requirements declined considerably. No adverse effects associated with rFVIIa were observed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/29. Dysphagia aortica: a neglected symptom of aortoesophageal fistula.Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. Typical symptoms are midthoracic pain and/or dysphagia followed by a usually short, albeit unpredictable, symptom-free interval and by a 'herald' haemorrhage, which is observed in 80% of patients before fatal exsanguinations. Dysphagia is present in 45% of patients, sometimes for several weeks, before the first bleeding occurs. However, dysphagia aortica is rarely considered in the differential diagnosis of dysphagia and lack of awareness, as well as symptom's underevaluation, both contribute to a significant diagnostic and therapeutic delay. We present a case of a 77-year-old woman who died for a bleeding AEF consequent to a thoracic aortic aneurysm and whose main symptom during the past 2 months was dysphagia, which was not taken seriously into consideration by her general practitioner. This case report emphasises that primary care physicians should be alerted to evaluate carefully the alarming symptoms like dysphagia -- especially in elderly patients -- before life threatening complications occur, as they are the ones who could suspect early the diagnosis and make a proper referral.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/29. Drug interaction between capecitabine and warfarin: a case report and review of the literature.OBJECTIVE: To report on possible adverse interaction between capecitabine and warfarin in a patient with cancer, who developed subconjunctival and nose bleeding during treatment with these drugs and review of the previously reported five cases in the literature. CASE SUMMARY: In the second week of capecitabine treatment the patient was hospitalized owing to subconjunctival hemorrhage and nose bleeding. Her international normalized ratio (INR) level was found to have increased, and both drugs were discontinued. Fresh frozen plasma replacement was administered. warfarin and capecitabine treatment were restarted again but the warfarin dose was decreased. The patients INR was kept between 2.5-3 with the reduced dose of warfarin. DISCUSSION: Capecitabine is an orally active prodrug of fluorouracil (FU) and is extensively used as an antineoplastic agent. It is converted to 5-FU in the liver and tumor tissues. warfarin is an antithrombolytic agent and is metabolized by liver cytochorom P450 (CYP) isoenzymes in liver. Preclinical in vitro studies using human liver microsomes report no inhibitory effects between capecitabine and substrates of CYP. However, the concomitant administration of capecitabine and warfarin resulted in gastrointestinal, retroperitoneal bleeding and hemorrhagic blisters in the five cases previously reported. The exact mechanism of this interaction is unknown; however, a significant pharmacokinetic interaction between capecitabine and S-warfarin resulting in exaggerated anticoagulant activity has recently been demonstrated. Here, we describe another case and use of the Naranjo adverse drug reaction (ADR) probability scale, which indicated a probable relationship between subconjunctival bleeding and epistaxis in this patient after concomitant warfarin and capecitabine use. CONCLUSION: Capecitabine is extensively used in outpatient clinics, and physicians should be aware of ADRs arising from combined used of capecitabine and warfarin. In the light of the current data, INR levels should be closely monitored in patients using this medication regimen.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/29. hemorrhage into a thyroid nodule as a cause of thyrotoxicosis.OBJECTIVE: To describe a case of thyrotoxicosis after nontraumatic hemorrhage into the thyroid gland during anticoagulant therapy. methods: We report the details of the initial presentation, subsequent course, and outcome in a patient with a nontraumatic thyroid hematoma and thyrotoxicosis. RESULTS: In a 63-year-old woman, an acute painful neck mass developed during follow-up while she was receiving low-molecular-weight heparin therapy for deep vein thrombosis. Ultrasound study and magnetic resonance imaging revealed a massive intrathyroidal hematoma. This finding was followed by an increase in serum free thyroxine and free triiodothyronine levels and a decrease in the level of serum thyroid-stimulating hormone (thyrotropin). Anticoagulant therapy was discontinued. The clinical course of the thyrotoxicosis was self-limited, and no antithyroid therapy was necessary. The serum thyroid hormone levels decreased into normal ranges as the hematoma underwent subtotal shrinkage. CONCLUSION: endocrine glands are highly vascularized tissues, but nontraumatic hematomas into these organs are extremely rare conditions. Nevertheless, physicians should be aware of the potential occurrence of such a situation, as emphasized in the current case report.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/29. How to manage splenic rupture during major liver resection?Spontaneous splenic rupture is a rare but life threatening complication of major liver resection with only five reported cases during major liver resection under hepatic vascular occlusion. We report two cases of splenic rupture during liver resection including the first case during portal triad clamping. In both patients, the hemorrhage was stopped by removing the vascular clamp. A splenectomy was performed in both patients and liver resection was completed under vascular clamping without complications. Although very rare, physicians should be aware of the possibility of splenic rupture during liver resection because instead of increasing vascular occlusion, clamp removal usually stops the hemorrhage.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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