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This case highlights the potential benefit of a triple strategy of NAC, fomepizole, and early hemodialysis in massive acetaminophen overdose, potentially sparing complications of prolonged intubation and ICU hospitalization.Hiatal hernia is a not uncommon anatomic disorder resulting in portions of the bowel occupying space in the thoracic cavity. There are a number of antecedent risk factors including obesity but not hiatal hernias resulting in symptoms. When symptoms do occur, they can include chest pain, nausea, abdominal pain, and gastroesophageal reflux. Cardiac arrhythmias have also been reported as associated conditions resulting from a hiatal hernia. To date, however, a complete heart block secondary to a hiatal hernia has not been reported. An 88-year-old female with a history of GERD (gastroesophageal reflux disease) was found to have a large hiatal hernia at endoscopy after she presented to the emergency department with nausea and abdominal pain. Prior to her scheduled surgical repair, she developed symptomatic third degree heart block which resolved with nasogastric tube deflation of the gastric contents. After surgical repair of the hiatal hernia, she developed episodes of atrial fibrillation with rapid ventricular response and was started on diltiazem. She eventually converted back to normal sinus rhythm and remained dysrhythmia free. [https://www.selleckchem.com/products/nx-5948.html NX-5948 datasheet] In addition to other known arrhythmias associated with hiatal hernia, a complete heart block can also be seen. Acute management requires deflation of the chest occupying hernia. This appears to be the one of the first reported cases of complete heart block caused by hiatal hernia.There are several recent reports of tetrahydrocannabinol vaping-related sudden cardiac arrest, and the mechanisms are unclear. We report a unique case of a 19-year-old female who suffered documented prolonged QTc leading to Torsades de pointes and cardiac arrest in the setting of frequent marijuana wax vaping. While she demonstrated normal baseline QTc measurements years earlier, she was found to have a genetic predisposition to QTc prolongation (genetic mutation, family history of prolonged QTc), suggesting that specific patient populations are at higher risk of these adverse events. The patient was acutely managed with isoproterenol to increase the heart rate and was discharged on nadolol after placement of an implantable cardioverter-defibrillator. Marijuana wax vaping and dabbing may cause fatal Torsades de pointes in susceptible patients, and further research is required to identify these patients a priori.A 50-year-old male presented for loss of consciousness. He was initially treated with intravenous epinephrine and fluids, and an electrocardiogram (ECG) displayed an ST-segment elevation in lead aVR with global ST-segment depressions. A subsequent left heart catheterization revealed that the middle segment of the left anterior descending artery (LAD) demonstrated severe stenosis during systole but would become patent during diastole, which was suggestive of myocardial bridging. After stopping the epinephrine and increasing the fluid infusion, the ECG changes rapidly resolved. The patient had later admitted to significant dehydration all day. Myocardial bridging is a congenital anomaly in which a coronary artery segment courses through the myocardium instead of the usual epicardial surface. Occasionally, myocardial bridging may present similarly to acute coronary syndrome in severe dehydration or hyperadrenergic states. The diagnosis can be made through coronary angiography, which reveals a dynamic vessel obstruction pattern corresponding with the cardiac cycle. Long-term effects may also include accelerated atherosclerosis. Treatment consists of reversing precipitating causes during acute presentations and decreasing the risk of coronary artery disease on a chronic basis.Lactococcus garvieae is a fish pathogen and an uncommon cause of human infections. There is a growing body of evidence showing its potential for causing endocarditis especially in those with prior valve surgery. In this case report, we present what we believe is the first case of endocarditis by L. garvieae affecting a valve-in-valve transcatheter aortic valve replacement that was successfully treated. Specific guidelines for the management of these patients are lacking. Our experience can contribute to the current knowledge regarding this life-threatening infection as well as to the future care of these patients. We aim to emphasize that despite not being recognized as a typical endocarditis microorganism by the Duke Criteria, the possibility of endocarditis needs to be highly entertained in patients with L. garvieae bacteremia, especially when prosthetic valves are present. Consequently, clinicians should pursue further this diagnosis with transesophageal echocardiogram and/or alternative imaging modalities (e.g., PET-CT scan and MRI) regardless of an initial negative transthoracic echocardiogram. Reaching a diagnosis of L. garvieae endocarditis led us to the decision of prolonging the antibiotic course for 6 weeks with successful results. Ultimately, surgery was not required owing to the absence of prosthetic aortic valve dysfunction and paravalvular extension of the infection.Prosthetic valve thrombosis is a potentially life-threatening complication diagnosed by a combination of clinical features and imaging modalities, but the optimal management in high bleeding risk patients remains controversial. Current treatment options for prosthetic valve thrombosis included surgery, thrombolytic therapy, and anticoagulation. We present a very unusual case of a patient with a recent ST-elevation myocardial infarction complicated by contained left ventricle free wall rupture and mechanical mitral valve thrombosis. Deemed a high surgical risk candidate, low-dose tissue plasminogen activator was used despite significant bleeding risk from contained left ventricle free wall rupture, which resulted in resolution of the thrombus. To the best of our knowledge, this is the first report of successful thrombolytic therapy for prosthetic mechanical mitral valve thrombosis in a patient with recent postmyocardial infarction contained left ventricular free wall rupture.<br /><br /> Gastropericardial fistula, a connection between the upper gastrointestinal tract and pericardium, is a rare clinical finding most commonly associated with postsurgical complications, as well as direct tissue invasion from gastric cancer. <br /><br /> . We report a case of a 58-year-old Caucasian woman with metastatic colon cancer treated with FOLFOX, a combination chemotherapy regimen, and bevacizumab who presented with chest pain. She was ruled out for acute coronary syndrome, aortic dissection, or pulmonary embolism. A computed tomography (CT) scan of her chest showed pneumopericardium. A barium swallow ruled out esophageal ulceration, and esophagogastroduodenoscopy (EGD) showed a large penetrating gastric ulcer with no evidence of gastric dysplasia or malignancy or evidence of Helicobacter pylori (H. pylori). The patient underwent median sternotomy with gastric ulcer resection and repair, as well as pericardial washout and pericardial chest tube placement. After an uncomplicated course, she was safely discharged home.<br /><br /> Given that gastrointestinal ulceration and perforation are known phenomena in patients taking vascular endothelial growth factor (VEGF) inhibitors, surveillance endoscopy may be beneficial to discover them before they result in potentially fatal complications such as gastropericardial fistulas.<br /><br />Given that gastrointestinal ulceration and perforation are known phenomena in patients taking vascular endothelial growth factor (VEGF) inhibitors, surveillance endoscopy may be beneficial to discover them before they result in potentially fatal complications such as gastropericardial fistulas.<br /><br /> Although not all children can be cured yet, much more emphasis is placed on the quality of life during and after cancer treatment. In the case of recurrence, mutilating treatment is still the prevalent option. In our study, we explored the role of limb salvage surgery for young patients with metastatic malignant bone tumors after endoprosthesis reconstruction during the first line of treatment and evaluated the impact of the local control modality in disease control and functional outcomes.<br /><br /> Eleven patients with bone tumor treated between 2007 and 2018 were included in this study. Both during primary treatment and during recurrence, limb salvage surgery was performed using a modular or expandable custom-made replacement system. Peri- and postoperative care for both surgeries were similar. All patients were given chemotherapy before and after both surgeries, according to the oncological guidelines.<br /><br /> Seven patients (63.6%) are alive with a median follow-up of 6.5 years from diagnosis. None had local recurrence. Five-year estimates of event-free survival and overall survival were 36.27% and 79.55%, respectively. Median time between the first and second surgery was 2.7 years. Three patients presented with postoperative complications following both surgeries and required resurgical intervention. Three months following the second surgery, the Musculoskeletal Tumor Society Scale (MSTS) scores were 15-27 points (21 points on average-60%).<br /><br /> Limb salvage surgery is feasible and offers good chance of cure with a reasonable rate of complications and good function in patients with recurrent bone sarcoma after endoprosthesis reconstruction during the first line of treatment.<br /><br />Limb salvage surgery is feasible and offers good chance of cure with a reasonable rate of complications and good function in patients with recurrent bone sarcoma after endoprosthesis reconstruction during the first line of treatment.<br /><br /> The treatment of long bone shaft nonunions is challenging. The technique of osteoperiosteal decortications flap for approaching the nonunion site coupled with fixation modalities was first described by Judet in 1963. Despite promising clinical and radiological union, this technique is not popular among orthopaedic surgeons. Our study aimed to evaluate the radiological union and functional results of shaft tibia nonunions treated by the osteoperiosteal decortication approach.<br /><br /> This retrospective study included all the cases with established tibial shaft nonunion following stringent inclusion and exclusion criteria and operated upon by following the principle of osteoperiosteal flap technique from April 2015 to July 2019. Further subgroups were made based on nonunions complexity based on nonunion scoring system (NUSS) score. The outcome measures included radiological union scale in tibial fractures (RUST) and lower extremity functional scale (LEFS). The preoperative scores for union and function were recordeonunion of long bones. NUSS scoring is an essential tool for prognosticating nonunion cases. This score is inversely related to the radiological union (RUST score) of the bone and functional recovery (LEFS score) of the patient.<br /><br />Osteoperiosteal decortication remains a highly effective surgical technique in the management of nonunion of long bones. NUSS scoring is an essential tool for prognosticating nonunion cases. This score is inversely related to the radiological union (RUST score) of the bone and functional recovery (LEFS score) of the patient.