Asploro Journal of Biomedical and Clinical Case Reports | Volume-6 | Issue-2 | Year-2023

Compared to ordinary gastroscopy, painless gastroscopy has more advantages due to the application of anesthesia techniques such as sedation and analgesia, providing patients with comfort and a quick recovery. However, patients undergoing painless gastroscopy are often at risk of hypoxia, which can result in serious complications. Fortunately, more anesthesia providers have recognized this problem. Therefore, it is essential for anesthesia providers to identify risk factors to prevent hypoxemia. In conclusion, this review highlights the assessment of risk factors for hypoxemia in painless gastroscopy and common airway management methods to prevent and treat hypoxemia in high-risk populations during painless endoscopy.

What we are going to present is the case of a 65-year-old male patient affected by renal and hepatic disease without checking other cases in his family history. He had been submitted to maintenance hemodialysis for 4 months because of an autosomal recessive polycystic kidney disease. At the start of the hemodialysis session, he reported general malaise, abdominal pain, fever, and, during the last two days, even diarrhea. Laboratory workup showed neutrophilic leukocytosis and an increase in serum amylase and C-reactive protein. Abdominal contrast-enhanced CT scan and MRI cholangiography showed hepatic cysts with marked dilatation of the intra- and extrahepatic bile ducts. The patient underwent cholecystectomy with hepatic-jejunal anastomosis on the loop of Roux and was discharged with oral ciprofloxacin. Histology confirmed marked cystic dilatation of biliary ducts and choledochus. Similar episodes continued, and every time ciprofloxacin was prescribed. After 4 months, a retrograde-endoscopic-pancreatography was undertaken, which led to the diagnosis of Caroli’s syndrome associated with polycystic kidneys.
Given the rarity of the disease and the difficulty of diagnosis, it is our opinion that when patients with polycystic kidneys and liver cysts undergo recurrent episodes of septic fever of unknown origin, Caroli’s disease should be considered, and the appropriate tests should be carried out to confirm the diagnosis.

Background: Vildagliptin/Metformin (EquMet) and imeglimin (Twymeeg) are effective oral hypoglycemic agents (OHAs) for patients with type 2 diabetes (T2D).
Case Presentation: The patient was a 68-year-old male with T2D and fatty liver for several years. In November 2022, his HbA1c had increased to 8.2%, and he was started on Twymeeg, followed by EquMet.
Results: Over the course of four months, the patient’s HbA1c value successfully decreased from 8.2% to 6.7%, and he did not experience any gastrointestinal adverse effects (GIAEs).
Discussion and Conclusion: The combined treatment of EquMet and Twymeeg demonstrated clinical efficacy without any adverse effects. The Trials of IMeglimin for Efficacy and Safety (TIMES) provided various evidence of imeglimin’s effectiveness.

Vogt-Koyanagi-Harada disease (VKH) is a central nervous system condition that specifically affects vision and hearing. Descriptions of this disease date back to the 12th century, but the disease is named after three 20th-century physicians who described the collective manifestations of this disease. Alfred Vogt initially described bilateral iridocyclitis and eyebrow depigmentation in 1906, followed by Yoshizo Koyanagi’s 1926 description of bilateral serous detachments in association with cerebrospinal fluid (CSF) pleocytosis. Einosuke Harada identified the integumentary symptoms of the condition shortly thereafter. The disease presents with signs and symptoms of a loss of immune tolerance to melanocytes within the meninges, eyes, skin, hair, and ears [1]. The exact etiology of VKH is not firmly established, but current theories posit that patients develop T cell-mediated immunity against melanocytes following recovery from an inciting viral environmental factor [2]. Recent genetic studies have implicated the presence of human leukocyte antigen (HLA) cell surface markers HLA-DRB4, HLA-DRB1-04*05, and HLA-DRB-04*01, as well as non-HLA genes involving lymphocyte regulations in IL-12 production and IL-17 production [3,4]. Downregulation of microRNA in the production of interleukins and changes in non-coding RNA may also play a role in this condition [5].

Postoperative pain management after varicocele surgery poses a challenge for pediatric patients. The quadratus lumborum block (QLB) is a novel regional analgesia technique that entails injecting a local anesthetic around the quadratus lumborum muscle using ultrasound guidance. In this study, we present the utilization of a single transmuscular QLB in two children as an effective postoperative analgesic method for laparoscopic extraperitoneal high ligation of the spermatic vein (LEHLSV).

This article stipulates the airway management in a patient requiring cranial debridement and cranioplasty with a Montgomery T-tube (MTT) in situ. Anesthetic techniques that have been previously described for surgeries with MTT in situ which can be managed by applying a laryngeal mask or intubating a trachea tube easily. The airway management of patients with an MTT in situ, requiring a supine position with the head rightly tilted and flexed, has not yet been addressed. In this article, we explored some possible approaches to cope with this arising problem. We present how we managed to intubate a double-lumen endotracheal tube onto the superior tracheal limb of the T-tube since the 5.0 mm ID tracheal tube (equivalent to a 6.9 mm ED) could not pass through the tube readily. This technique could possibly be considered for patients in similar clinical scenarios.

With the arrival of an aging society and the progress of surgical procedures, total hip arthroplasty (THA) has been carried out more and more. However, postoperative pain severely affected the patient’s recovery, and there is currently no reliable analgesic method available. Evidence-based international expert consensus also recommends, compared to LIA, peripheral nerve block (PNB) as a central analgesic approach use in THA for improved outcomes [1]. In this case report, we described 4 cases of postoperative analgesia with pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve block (LFCNB) in patients undergoing THA.

Expiratory central airway collapse (ECAC) comprises tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). ECAC is a progressive disease that can be congenital or acquired, and it can be confirmed by inspiratory-dynamic expiratory chest CT or dynamic bronchoscopy. We present the case of a 65-year-old man who underwent radiofrequency ablation for hepatocellular carcinoma under general anesthesia. After tracheal intubation in the operating room, the respiratory sound in the left lung disappeared, and the respiratory sound in the right lung was clear during chest auscultation. Bronchoscopy revealed complete collapse of the left main bronchus. Intraoperative bronchoscopy confirmed that the patient had ECAC (both TBM and EDAC).

The case involves a 70-year-old female with Type 2 Diabetes (T2D) who had been prescribed EquMet (vildagliptin/metformin) and had a stable HbA1c. In August 2022, she tested positive for real-time polymerase chain reaction (RT-PCR) without showing any symptoms. By November 2022, her HbA1c had increased to 7.4%, and a chest CT scan revealed a consolidation lesion in her left lower lung, suggesting post-inflammatory pathology of COVID-19. Imeglimin (Twemeeg) was added to her treatment regimen, and it proved effective, resulting in a 0.9% reduction in HbA1c over 4 months without any gastrointestinal adverse effects (GIAEs). The combined treatment of EquMet and Twymeeg was effective, and the interrelationship between T2D and COVID-19 will be followed up.

The trichilemmal proliferating cyst is a member of the group of adnexal tumors arising from the hair follicle, more specifically from the isthmic trichilemmal segment of the external epithelial sheath of the hair follicle. It is most often located on the head and neck, but case reports of extracephalic localization are described in the literature. We report a case of a proliferating trichilemmal cyst on the back, where the diagnosis was made after the anatomopathological study of the excised specimen.

Azithromycin 1.5% ophthalmic solution is a viable and well-tolerated treatment option for bacterial conjunctivitis and blepharitis, offering the advantage of a shorter treatment duration compared to other topical antibiotics. While acute-type allergic reactions to topical azithromycin eye drops may be rare, it is important for ophthalmologists to be aware of this possibility and to inform patients about the potential occurrence of such reactions. We present three cases of unusual acute-type allergic reactions to topical azithromycin eye drops. These reactions manifested as epiphora, eyelid edema, pruritus, and hyperemia.

Background: Venous thrombosis is a common complication among critically ill patients with intracerebral hemorrhage, which may lead to pulmonary embolism.
Case Presentation: In this report, we present a case of a man who was diagnosed with left basal ganglia region hemorrhage, hypertension, and venous thromboembolism. Considering the risks, including rebleeding and the expansion of the hematoma, he did not receive any anticoagulation after onset. The thrombus located in the pulmonary artery was found by transesophageal echocardiography after he suffered cardiac arrest during the craniotomy. Additionally, a thrombus attached to the central venous catheter was observed by ultrasound. Unfortunately, he died of PE without receiving any effective treatment.
Conclusions: This case emphasizes the importance of prophylactic and therapeutic strategies for thromboembolic events among critically ill populations. It also underscores the critical role of perioperative ultrasound.

The patient is a 66-year-old female being treated for hypertension. She developed a cerebral vascular accident (CVA) in October 2019, and was subsequently diagnosed with type 2 diabetes (T2D) due to an HbA1c level of 9.8%. She began a low carbohydrate diet (LCD) and started taking oral hypoglycemic agents (OHAs) such as metformin and linagliptin. From July 2021, she occasionally experienced anxiety and palpitations, leading to a diagnosis of reactive depression (adjustment disorder). Despite treatment with etizolam as needed, these symptoms persisted. In December 2022, due to an increase in HbA1c levels to 7.7%, metformin was switched to imeglimin (Twymeeg). By April 2023, her HbA1c had decreased to 6.9%, and she reported a sustained sense of well-being without psychosomatic symptoms.

The perioperative management of pulmonary hypertension continues to be a great challenge for anesthesiologists. Among the various types of pulmonary hypertension, pulmonary hypertension associated with left heart disease is the most common, while pulmonary hypertensive crisis is one of the causes of perioperative mortality in these patients. We present the case of a 54-year-old female with severe valvular heart disease complicated by severe pulmonary hypertension and massive hemothorax, who underwent emergency exploratory thoracotomy, mitral valve replacement, and tricuspid valvuloplasty. The patient was in critical condition and suspected to have a pulmonary hypertension crisis. The rationale for this case report is to learn about the anesthetic management of patients with severe pulmonary hypertension.

The case involves a 74-year-old male with type 2 diabetes (T2D), hypertension, dyslipidemia, and diabetic kidney disease (DKD) at nephropathy stage G3b. He has been receiving treatment with insulin and anti-hypertensive agents (AHAs). In July 2021, his HbA1c was elevated to 7.9%. As a result, the extent of his low carbohydrate diet (LCD) was increased, and insulin doses were raised. The AHAs were changed from Olmesartan to Valsartan/Amlodipine, and Irbesartan/Amlodipine until 2023. By January 2023, his HbA1c had decreased to 6.8%, and his eGFR (CKD-EPI) had remained stable at 34-48 mL/min/1.73/m² for 4 years. A recent study demonstrated clinical improvement in renal function through continuous LCD in patients with DKD.

FMD is a rare systemic vascular disease characterized by abnormal cell proliferation in the artery walls, leading to artery narrowing, twisting, or bulging. It commonly affects the carotid and renal arteries and can result in renal diseases and stroke. This paper presents a case study of a 39-year-old unhoused female patient who experienced a stroke secondary to fibromuscular dysplasia (FMD) and left ventricular thrombus. The patient presented with asymmetric movement of the extremities and psychosis, so intoxication was initially suspected. However, further examination revealed facial asymmetry and motor weakness. CT scans showed a left anterior cerebral artery infarction and irregular contour of the cervical internal carotid arteries, consistent with FMD and carotid thrombus. Management involved stabilizing the patient, providing supportive treatment, and controlling blood pressure. Thrombolytic therapy was not administered due to the time elapsed since symptom onset. The patient was started on anticoagulation for the carotid plaque and left ventricular thrombus. A transthoracic echocardiogram revealed a large left ventricular thrombus and left atrial enlargement, and the patient was started on heart failure medications.
FMD and left ventricular thrombus are not directly related, but FMD can contribute to thrombus development through its impact on the cardiovascular system, including hypertension, arterial wall damage, aneurysm development, or dissection. Treatment for FMD may involve medication, observation, or surgical interventions like angioplasty and stenting. Anticoagulation therapy is essential for managing the left ventricular thrombus.
This case highlights the importance of early diagnosis and treatment of FMD to prevent complications such as stroke. It is important to consider FMD in the diagnosis of younger patients with a stroke, especially those with a history of hypertension, substance abuse, or other risk factors. Further research is needed to better understand the relationship between FMD and stroke and to optimize treatment strategies for these patients.

Background: The humanitarian situation in Somalia is characterized by unstable government, insecurity, fragility, and limited investments in funding essential public services and maternal newborn and health services are not spared. The health system in Somalia remained under-resourced to meet the urgent lifesaving, essential, and preventive health services. This study sought to assess the access and utilization of maternal and newborn child health services in Somalia.
Methodology: A cross-sectional design was used in this study. Descriptive and inferential statistical data analysis was conducted to establish the performance of indicators and relationships. The study targeted mothers of children 0-59 months.
Results: The results show a low (13.1%) attendance of focused (4^th visit) antenatal care among the mothers. 23.3% of the mothers from Somaliland attended at least three antenatal care visits, while the rest of the states only achieved less than 10%. At least 41.5% of the deliveries occurred at the health facility. Skilled attendants assisted 42.7% of the deliveries. No significant difference was observed in the number of women having an extra meal during pregnancy or delivery at the health facility or in predicting the number of ANC visits. Nonetheless, 43.2% of the infants in Somalia had not been exclusively breastfed for the first six months of life. The results equally demonstrated poor nutritional index with only 38.4% of the pregnant women having an extra meal during pregnancy. In Somalia, early health care seeking for common childhood illnesses is still low, with Respiratory Tract infections (RTIs) at 40%, malaria at 56.6%, and diarrhea at 63.4%.
Conclusion and Recommendations: There is a need for deliberate efforts to improve low-performing indicators and hence improve the survival of mothers and children.

Postoperative recurrence and metastasis of papillary thyroid carcinoma (PTC) to the superior vena cava (SVC) and right atrium (RA) are rare. The application of Extracorporeal Jugular-femoral Vein Bypass and anesthesia management for SVC reconstruction in this rare situation holds instructive significance. In this case, we describe the successful anesthesia management of a patient with multiple tumor thrombi due to postoperative recurrence of PTC. The diagnosis was based on computed tomography of the chest and blood vessels, revealing three-dimensional SVC, postoperative recurrence of PTC, and multiple tumor thrombi in the internal jugular vein (IJV), subclavian vein, brachiocephalic vein, SVC, and RA. An experienced multidisciplinary team was established, and a detailed plan was made for respiration and circulation support, with cardiopulmonary bypass on standby.

Objective: Direct radiologist to patient communication has been linked to higher levels of patient satisfaction, compliance, and overall treatment outcomes. Recent studies examining patient expectations in breast imaging indicate that 90% of women prefer result communication and review of imaging directly from their radiologist. Though the primary components of diagnostic breast imaging are patient centered, supplemental data suggests that screening mammography result consultation may represent an additional opportunity for engagement in the new era of patient-experience driven care. The primary aim of our study was to examine patient preferences for receiving real time screening mammography result communication (RTRC) and characteristics that may influence their willingness to participate.
Material and Methods: This quality-improvement based, IRB-approved, study was performed at three community-based academic breast radiology centers in a large metropolitan area between October 5, 2020, and January 2, 2021. Female patients presenting for screening mammography were invited to opt in for RTRC and/or participate in an electronic, HIPAA-compliant, simple survey that could be completed on the personal subject’s phone or tablet. Subjects opting in for RTRC were invited to wait in a consultation room during staff radiologist review. Once interpreted, the radiologist would discuss the results and next step recommendations with the patient. Self-reported patient demographic characteristics and RTRC preferences by age, race, ethnicity, level of education, household income, prior personal or family history of breast cancer, active (non-breast) cancer history and prior history of abnormal mammogram were assessed by categorical variable analysis using Chi-squared tests. A p-value <0.05 was determined to be statistically significant.
Results: 1714 screening mammograms were performed across our three community-based breast imaging centers and 11% (186/1714) of women completed the survey during the study timeframe. White women (92%) were statistically more likely to opt in for RTRC when compared with non-white (80%) counterparts (p=.026). Patients with a personal history (p=0.001) or family history (p=0.006) of breast cancer were statistically more likely to opt in for RTRC when compared with other cohorts. A positive correlation was observed between prior history of abnormal mammogram and preference for receiving RTRC (93%) but did not achieve statistical significance (p=.082). There was no correlation observed between RTRC preference and an active (non-breast) cancer diagnosis (p=0.415).
Conclusion: Our study confirms previous data suggesting that patients vastly prefer direct verbal communication ahead of written letter result notification. Our study also suggests that screening mammography RTRC may be of particular interest in patients with higher (personal or familial) risk for developing breast cancer. While this service may operationally add demand on radiologist-patient face time and cost to care delivery, an awareness of patient preferences and cohorts that may find value in this service option can be prioritized to optimize both patient experience and clinical workflow. Additional studies are warranted to further validate which practice models would achieve most benefit from this tailored service offering.

Serious anaphylactic reactions to anesthetics can be life-threatening events. Vecuronium is promoted as a neuromuscular blocking drug that is least likely to cause anaphylaxis due to its low histamine-releasing potential. Perioperative hypoxemia in patients with tetralogy of Fallot (TOF) due to anaphylactic reactions can be easily misdiagnosed as anoxic spells. We report a patient with TOF who suffered from symmetrical peripheral gangrene after undergoing catecholamine-refractory anaphylactic shock to vecuronium perioperatively. CPB (cardiopulmonary bypass) is the most effective support for severe anaphylactic shock during the perioperative period. Intradermal test screening for anaphylaxis to anesthetics is an effective method for prevention and diagnosis.