Redwood Memorial Hospital

A patient with a 4-month history of unexplained nausea and vomiting is reported. The only abnormality found initially was severe gastroparesis found by gastric emptying scan. Subsequently, a posterior fossa tumor was found. The pathogenesis of this unusual presentation and the role of the gastric emptying scan is discussed.

Introduction: Myocarditis is an inflammation of the myocardial layer of the heart. It is a clinical syndrome, and an inflammation secondary to infection (such as viral, bacterial, fungal), inflammatory diseases of the other organs such as inflammatory bowel disease (IBD), autoimmune disease, toxins, and medications' adverse effects. Mesalamine is a 5-aminosalicylate medication that can cause myocarditis. This medication is indicated in patients with mild to moderate ulcerative colitis sometimes as the first-line treatment. Mesalamine-induced myocarditis is rare but can be fatal. In addition, inflammatory diseases such as ulcerative colitis can have extra-intestinal complications such as myocarditis. Case Description/Methods: We report a case of a White man with past medical history of ulcerative colitis (UC) who presented with a chief complaint of typical chest pain. Patient's latest UC's flare up was 3 weeks before this admission when he was started on Mesalamine. Laboratory results revealed an elevated troponin and N-terminal prohormone of brain natriuretic peptide levels. Electrocardiography (ECG) was unremarkable. Echocardiogram revealed a new onset of heart failure with reduced ejection fraction. Patient was started on medical management with the diagnosis of non ST elevation myocardial infarction however his symptoms continued and repeated ECG revealed diffuse ST elevation in less than 12 hours. Patient underwent the left heart catheterization and coronary artery disease was ruled out. Patient's chest pain improved after discontinuation of mesalamine and the initiation of high dose corticosteroids. Discussion: Mesalamine-induced myocarditis can be a fatal complication. Therefore, it should be included in the differential diagnosis for patients with IBD who are on mesalamine and present with new-onset chest pain. Prompt discontinuation of mesalamine and initiation of corticosteroids can effectively control symptoms especially if extra-intestinal manifestations of IBD are suspected or during a flare-up episode. While many facilities, including ours, lack cardiac magnetic resonance devices to confirm the diagnosis, this should not delay appropriate management in these patients. This case report underscores the importance of recognizing mesalamine-induced myocarditis and the extra-intestinal manifestations of IBD, such as myocarditis, in patients with typical chest pain.

THIS paper reviews common-bile-duct injuries treated at the Henry Heywood Memorial, a 120-bed hospital,1 from January 1, 1941, through December 31, 1950, during which there were 539 consecutive operations on the gall bladder or biliary tree, with 4 cases of loss of continuity of the biliary tract. In a review of our experience with gall-bladder surgery, it was disturbing to find that in each of 4 cases, a patient entered the hospital with biliary disease that appeared to be a straightforward problem, only to go through a long period of additional surgical procedures crippling to his health, morale and financial . . .

This paper reports the results of a global expert panel utilising a modified Delphi technique, to reach consensus on the use of mouldable ostomy technologies in ostomy practice.The aim of this document is to describe the current state-of-the science related to product selection in current ostomy practice.The objective of the project was to determine the best available evidence describing the use of mouldable stoma baseplate technologies in ostomy care compared to traditional cut-to-fit appliances.The rates of peristomal ostomy complications reported in the literature are unacceptable and reflect many factors such as lack of appropriate education, access to stoma care certified providers and the selection of appropriate ostomy products.The purpose of using the Delphi technique was to accomplish three specific objectives: 1) summarise the current state of mouldable ostomy technology knowledge, based on a scoping review of the literature; 2) formulate recommendations for clinical practice change in ostomy care; 3) consider expert experience to guide practice where published evidence could not be found.Six consensus statements with their aggregate level of evidence, risk of bias, and recommendations for clinical practice are presented herein.

It was a bright fall morning and Ms. H, 78, had been with us for just over a week. Her sweet disposition and quiet resolve to recover from her admitting diagnosis of left lower lobe pneumonia made her a unit favorite. During my morning assessment, I auscultated only mild inspiratory wheezes in her left lower lobe. She needed only supplemental oxygen at 1 L/min via nasal cannula at this point, and her SpO2 was stable at 95%. Her white blood cell count was back in the normal range, confirming the clinical observation that Ms. H was getting better. Feeling confident in her recovery, the nurses joked about how we were going to miss our favorite patient when she was discharged to home later that day. What happened next made me appreciate the value of teamwork in a crisis. Sudden change I had just left Ms. H's room and started my next patient assessment when my pager went off. I could hear Ms. H across the hall trying to answer the unit secretary's cheerful, “How can I help you?” “I. Can't. Breathe,” I heard Ms. H gasp. This was clearly not the woman I had just left. Apologizing to my current patient, I practically ran across the hall. I found Ms. H sitting on the edge of her bed, gasping for air. She was tachycardic, tachypneic, and hypotensive, and her SpO2 had dropped to 85%. I auscultated her lungs and heard bilateral inspiratory crackles up to the apices. I quickly activated the rapid response team (RRT) while continuing to monitor and support Ms. H. Quick action When the RRT arrived, I quickly gave the hospitalist a summary of Ms. H's history. One nurse obtained a second peripheral venous access, while another placed Ms. H on a cardiac monitor and obtained another set of vital signs. The respiratory therapist placed Ms. H on a 100% non-rebreather mask and an ECG, chest X-ray, and arterial blood gases were obtained. Ms. H's attending physician arrived and we promptly administered I.V. furosemide as prescribed. As Ms. H's clinical status stabilized, we all began to relax a little. Although I continued to reassess Ms. H frequently, I was able to finish administering my morning medications and continue my other patient assessments. A team victory Somewhere in the middle of this crisis, I could see we were all working as a team, and I was very proud to be part of that team. Each of us was able to anticipate what to do next to help the patient and each other, and did it without being asked. With heartfelt gratitude, I thank all my colleagues who helped save Ms. H's life on that bright fall morning.

In Brief When a previously stable patient “crashes,” this clinical nurse appreciates the value of teamwork.