This paper diabetic ketoacidosis (DKA). Previous literature describes these two disease states presenting together, but most reports describe the etiology as uncontrolled diabetes leading to thyroid storm. After literary review, we present what we believe to be the first case of thyroid storm and DKA occurring in the same person on multiple occasions with an insulin pump. Additionally, we provide evidence that points to the thyroid storm being caused by DKA versus the traditional teaching of DKA precipitating thyroid storm.
Suicide pacts among elderly couples afflicted by a terminal disease process present a significant challenge to emergency clinicians. If one member of the pair aborts their attempt, the surviving member of a dual suicide attempt can present a complex case with numerous clinical issues reflected by Hickam's dictum rather than by Occam's razor. Thus, emergency clinicians must keenly search for a multitude of concomitant but compounding conditions, potentially projected onto pre-existing comorbidities in an elderly population. The authors present a case of a suicide pact in which one member of the couple completed the attempt while the surviving member experienced carbon monoxide toxicity, compartment syndrome, rhabdomyolysis, and renal failure following her aborted suicide attempt.
Intraspinal extradural synovial cysts are a rare occurrence at the spinal cord level and thus a rare cause of myelopathy. Synovial cysts usually present in the more mobile lumbar and cervical parts of the spine; however, they may also arise in the thoracic spine. We present a case of a 59-year-old male with a left upper thoracic synovial cyst at T2-3 causing disabling, progressive myelopathy, and an incomplete spinal cord injury syndrome with inability to ambulate. An urgent decompressive laminectomy with bilateral facetectomies, cyst excision, and posterior fusion was performed. Subsequently, the patient recovered full function. Synovial cysts should be considered in the differential diagnosis of progressive thoracic myelopathy. This is only the sixth reported case of a synovial cyst of this kind occurring between the levels of T1 and T7. Urgent surgical decompression is the recommended treatment.
First, we would like to thank Dr. Bonilla et al for submitting this letter to the editor and for their academic critiques of our article [[1]Griffiths S. Post Z. Buxbaum E. Paziuk T. Orozco F. Ong A. et al.Predictors of perioperative vancouver B periprosthetic femoral fractures associated with the direct anterior approach to total hip arthroplasty.J Arthroplasty. 2019; ([Epub ahead of print])https://doi.org/10.1016/j.arth.2019.12.009Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. In reference to their initial point discussed on the miscalculation of our overall fracture incidence, we are in agreement that the value was miscalculated. The Vancouver B periprosthetic femoral fracture incidence following the direct anterior approach (DAA) total hip arthroplasty (THA) has been corrected to 0.4% in the published article. We agree that our initially reported value would have been misleading and offer thanks for the attention to detail in their assessment. Second, they brought up the concern of further underestimating the periprosthetic fracture incidence by not reporting the total number of patients who were lost to follow-up and question the relevance of this statement in our discussion. We introduced this as a limitation because of the retrospective nature of our study and the fact that patients sustaining such fractures may not always present to their primary institution. While the exact number of patients lost to follow-up is not known, we would argue that the number of missed fractures in the early perioperative period, including those that occur less than 6 weeks postoperatively, the timeline during which we noted greater than 85% of these fractures occurred, is likely minimal in comparison with those occurring later. All of our surgical patients followed up at this early time point. This is relevant as our study looks to identify those fractures that could potentially be related to predisposing risk factors or perioperative causes, and not secondary to later trauma. So although we cannot extrapolate the potential effect on overall fracture incidence due to lost follow-up, and this is clearly mentioned as a limitation in our discussion, we do believe this number is only a small underestimation for these perioperative fractures. Dr. Bonilla then spoke to the point of surgeon experience, stating that we are unable to conclude that surgeon experience is not associated with increased fracture risk. We respectfully disagree; in our study, all of the surgeons are outside of their learning curve as specifically stated in the methods section; therefore those reading the article will have that in mind while critiquing the results. The experience level of our surgeons did not correlate with an increased Vancouver B periprosthetic fracture risk. Finally, there is a concern that we are misleading the orthopedic community by reporting a lower than previously reported fracture incidence. Dr. Bonilla correctly pointed out that we are only assessing perioperative Vancouver B periprosthetic fractures, while other studies to date typically include Vancouver A and C fractures in the incidence as well. We do not feel that our results are misleading as we clearly specify in the title and throughout the article that we are specifically assessing Vancouver B fractures after DAA THA due to the added clinical morbidity and likely revision surgery. In the discussion, we also highlight this point that our report focuses on only one subtype of fracture and hence the apparent low rate of fracture compared with studies looking at all-comers. In summary, although we do thank Dr. Bonilla et al for pointing out a key statistical error that has since been corrected, we do not consider our study misleading. We distinctly evaluated risk factors for Vancouver B periprosthetic femoral fractures following DAA THA performed by surgeons past their learning curve. We believe this work presents an accurate representation of the fracture incidence, risk factors, and time to fracture. Download .pdf (.1 MB) Help with pdf files Conflict of Interest Statement for Ong Download .pdf (.1 MB) Help with pdf files Conflict of Interest Statement for Orozco Download .pdf (.1 MB) Help with pdf files Conflict of Interest Statement for Ponzio Download .pdf (.1 MB) Help with pdf files Conflict of Interest Statement for Post Download .pdf (.17 MB) Help with pdf files Conflict of Interest Statement for Buxbaum Download .pdf (.17 MB) Help with pdf files Conflict of Interest Statement for Griffiths Download .pdf (.11 MB) Help with pdf files Conflict of Interest Statement for Paziuk Letter to the Editor on “Predictors of Perioperative Vancouver B Periprosthetic Femoral Fractures Associated With the Direct Anterior Approach to Total Hip Arthroplasty”The Journal of ArthroplastyVol. 35Issue 6PreviewWe had the opportunity to read the article by Dr. Griffiths et al [1] and we did it with great interest because the authors address the risk of perioperative periprosthetic fractures which is not only a relevant issue, but also remains to be one of the most concerning complications; We acknowledge this effort and congratulate the authors for an article of this magnitude. However, it is our opinion that the way the results and conclusions are presented could be misleading for the medical community. Full-Text PDF
Abstract Introduction Procollagen-N-terminal-peptide (P1NP) is a bone formation marker. Bisphosphonates lead to a reduction in P1NP levels and levels are significantly elevated shortly after fracture. In older patients taking bisphosphonates who have had a further osteoporotic fracture there is a lack of evidence to guide ongoing osteoporotic management. Objectives To assess if measuring P1NP in patients receiving Bisphosphonates treatment who develop neck of femur fractures helps guide further management in regards to long term bone protection treatment. Method Retrospective descriptive cohort study of P1NP levels for the patients who presented with NOF# (>60yrs) and who were taking anti-resorptive medications. Cases were discussed in our complex bone health MDM and patient specific plans made accordingly. Results 60 patients were identified between March 2017 and Sept 2021 had P1NP tested (2.6 % of the 2,303 total fractures in this time). Mean age 83 years (F:M – 54:6 / # type - IC:EC – 34:26). Overall: 17 (28%) patients had significantly elevated PINP with identifiable reasons. 39 (65%) patients had supressed P1NP levels (< 35mcg/L) and 5(7 %) between 36-39 mcg/L. Of those with supressed P1NP: Patients taking treatment >5 years (n=9) – Treatment stopped for 6 patients, 2 changed treatment following DXA and 1 continued. On treatment 3-5 years (n=8) – 5 continued with treatment, 1 had further ix and 2 treatments changed On treatment 1-3 years (n=17) – 14 continued treatment, 2 treatments stopped, 1 treatment changed On treatment <1 year (n=16) – all continued the same treatment Conclusion The measurement of P1NP has been helpful in making patient centred decisions in this cohort. It has added to the detailed discussions in the hip fracture bone health MDM and for 23% of patients with supressed bone turnover contributed to a change in management. Most changes occurred in those patients taking treatment for more than 5 years where the evidence of bone turnover suppression gives confidence to stop or change treatment.
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