Benign Paroxysmal Positional Vertigo After Joint Replacement Surgeries: Case Series.

Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo triggered by changes in head position caused by the displacement of otoliths from the utricle to the semicircular canals, particularly the posterior canal. This study explored the potential link between BPPV, the patient's preexisting conditions, and surgery-related factors including surgical positioning, duration of the procedure, exposure to vibratory forces, and anesthesia effects. This report presents two cases of BPPV following major joint replacement surgery. The first case involved a 65-year-old male with a history of diet-controlled diabetes who had undergone right-sided total hip replacement. The second case was that of a 60-year-old female with a history of osteoporosis managed with bisphosphonate therapy and left-sided knee replacement. Both patients developed vertigo symptoms one day postoperatively and were diagnosed with BPPV. In both cases, the Dix-Hallpike test confirmed the right-sided posterior canal BPPV diagnosis, and the patients were successfully treated using the Epley maneuver. Notably, there was no recurrence of vertigo at the four-week follow-up. These cases highlight the importance of considering BPPV in patients presenting with vertigo symptoms after joint replacement surgery, especially in the presence of comorbidities like diabetes and osteoporosis which possibly increase susceptibility to BPPV. This article presents two cases of benign paroxysmal positional vertigo (BPPV) following non-otologic surgery. It explores the pathophysiological mechanism underlying BPPV after such surgeries and also discusses the diagnosis and treatment approaches. This underscores the need for prompt diagnosis and treatment of BPPV to improve postoperative outcomes.

Traumatic lung laceration secondary to avulsed lung adhesion - A case report.

Background: Pulmonary lacerations caused by an avulsion force on an adhesion between the lung and chest wall following blunt thoracic injury are very rare. They may result in pneumothorax and/or hemothorax and may not be immediately apparent clinically or radiologically. Case presentation: We present the case of a healthy 34-year-old male who sustained blunt thoracic injury. He was clinically stable, and his initial routine images were unremarkable. The patient was discharged home on the same day. He presented a week later with a massive hemothorax requiring surgical intervention which revealed bleeding from an avulsed adhesion between the lung and chest wall. Bleeding was successfully controlled by hemostatic agent, and the patient had an uneventful recovery. Conclusion: Hemothorax requiring intervention from an avulsed adhesion may occur following blunt thoracic trauma. Initial imaging and clinical finding may be misleading. Close follow up and adequate patient education should be ensured prior to discharge following seemingly trivial trauma.

Trouble in Tiger country: isolated traumatic pancreatic transection - a case report.

Isolated pancreatic transection is a rare surgical condition that occurs more commonly following blunt abdominal trauma. It carries a high degree of morbidity and mortality, and the management remains a source of debate as universally accepted guidelines are not well established owing to the paucity in clinical experience and large series. We presented a case of an isolated pancreatic transection following blunt abdominal trauma. The surgical management of pancreatic transection has evolved over the decades from aggressive approaches to more conservative measures. Given the lack of large series and clinical experience, no universal consensus exists, except for applying damage control surgery and resuscitation principles in critically unstable patients. For transections of the main pancreatic duct, most recommend excision of the distal pancreas. Concerns over the iatrogenic complications of wide excisions, particularly diabetes mellitus, have led to reconsideration and more conservative approaches, but it may fail in some cases.

Clinical Characteristics and Risk Factors for Early versus Late Pulmonary Embolism in Trauma Patients: A Retrospective, Observational Study.

Background: We sought to evaluate the clinical characteristics and risk factors for early versus late pulmonary embolism (PE) in trauma patients. Methods: This was a retrospective analysis of injured patients who presented with a confirmed PE between 2013 and 2019. Data were analysed and compared for patients with early PE (≤4 days) versus late PE (>4 days post-trauma). Results: The study included 82 consecutive trauma patients with confirmed diagnosis of PE. The mean age of patients was 42.3 ± 16.2 years. The majority were males (79.3%) and the median time from injury to PE was 10 days. Of the PE cases, 24 (29.3%) had early PE, while 58 (70.7%) had late PE. The early PE group had higher rates of surgical intervention within 24 hours of admission than the late PE group (p = 0.001). Also, the rate of sub-segmental thrombi was significantly higher in the early PE group (p = 0.01). The late PE group sustained more moderate-to-severe injuries ie, GCS ED <13 (p = 0.03) and the median time from injury to PE diagnosis was 15 days (p = 0.001). After adjusting for the potential covariates, surgery within 24 hours of admission [adjusted odds ratio 37.58 (95% confidence interval 3.393-416.20), p = 0.003] was found to be significant independent predictor of early PE in trauma patients. Conclusion: One-third of post-trauma PEs occurs early after trauma and the surgical intervention within the first 24 hours of admission is a major risk factor. A prospective study is needed to develop an objective risk assessment for the prevention and detection of early and late PE post-trauma.

Thrombosis of Bilateral Profunda Femoris, Anterior Tibial, and Tibioperoneal Arteries in a Patient With COVID-19 Infection.

COVID-19, also known as severe acute respiratory distress syndrome coronavirus 2, mostly affects the respiratory system causing acute respiratory syndrome. It not only targets lungs but also causes vascular endothelial disruption, which can lead to arterial or venous thrombosis causing ischemia, which increases the morbidity and mortality in some patients, if not recognized and treated in a timely manner. We present an interesting case of a patient recovering from COVID-19 pneumonia , who developed bilateral foot ischemia due to thrombosis of bilateral profunda femoris, bilateral anterior tibial, and tibioperoneal arteries. A 44-year-old gentleman presented to the emergency department complaining of severe bilateral foot pain, which progressively got worse. Upon examination he had blue toes bilaterally with absent dorsalis pedis and posterior tibial pulse. CT angiogram was performed, which showed severe multilevel lower limb arterial occlusions involving bilateral profunda femoris, bilateral anterior tibial, and tibioperoneal arteries. The patient was initially thrombolyzed and later underwent thrombectomy with the assistance of interventional radiologist. Hospital course was uneventful, and the patient was discharged on warfarin following complete resolution of symptoms.

Abdominal Pain Caused by Occlusion of the Celiac Trunk and Superior Mesenteric Artery in Addition to Irritable Bowel Syndrome: Case Series and Literature Review.

Irritable bowel syndrome (IBS) is a benign condition of the gastrointestinal tract causing abdominal pain, bloating, diarrhea, and/or constipation. Symptoms of IBS usually improve on passing flatus and defecation. There is no known identifiable underlying pathology; however, several risk factors are known to contribute to the development of IBS, which include a stressful lifestyle and certain foods such as bread, coffee, alcohol, pasta, and chocolates. Intestinal bacteria may also contribute to symptoms of IBS. IBS is diagnosed clinically and treated with various medications to control the symptoms. On the other hand, celiac and mesenteric artery thrombosis (CAMAT) is a condition that may cause significantly higher mortality and morbidity if not recognized early. CAMAT leads to the blockage of major blood vessels to the intestine and several abdominal viscera leading to abdominal pain, nausea, sweating, and, in some cases, symptoms of shock. CAMAT is most likely caused by thrombosis; however, occasionally, embolisms from distant sources in patients with atrial fibrillation can also contribute to the development of CAMAT. CAMAT is usually diagnosed with a computed tomography angiogram (CTA) and treated either surgically or medically with anticoagulants. Vascular thrombus in the thoracic and abdominal region causing ischemia of the stomach and abdominal pain in patients with a history of IBS can easily be missed and cause grave complications with high morbidity and mortality. We present two cases who were initially diagnosed and treated for IBS and later diagnosed with serious intra-abdominal pathology of CAMAT thrombosis. The first case is of a 55-year-old female who was previously diagnosed with IBS and was treated with mebeverine 200mg twice daily and esomeprazole 20mg once daily for 10 weeks. Her pain continued to get worse and she presented to the emergency department by ambulance. She underwent CTA, which showed occlusion of the celiac trunk and superior mesenteric artery causing liver and splenic infarcts. The patient received heparin and underwent a thrombectomy and embolectomy of the superior mesenteric and celiac arteries. No significant abnormality was found in the blood results. Thrombophilia screening was negative. The patient was discharged on warfarin. The second case is of a 53-year-old man who was also initially diagnosed with IBS and was treated with mebeverine 200mg twice daily for eight weeks before presenting to the emergency department with worsening abdominal pain. He underwent a CTA with contrast, which showed occlusion of the common hepatic artery and stenosis of the splenic artery leading to multiple splenic infarcts. No significant abnormality was found in blood test. Thrombophilia screening was negative. He was treated with new anticoagulant medication, dabigatran 150 mg orally twice daily. Both patients were managed with successful outcomes and were discharged home on anticoagulants. There was no recurrence of symptoms at three-month follow-up. These cases highlight that a secondary cause of symptoms such as vascular thrombosis must be sought for patients who fail to improve with conservative management of IBS.

An Unusual Case of Thyroid Storm Masquerading as an Intestinal Obstruction in a Patient With Malrotation of the Gut.

Gut malrotation is usually a pediatric condition that presents mainly in the first month of life. It rarely presents in adults and is often a significant diagnostic dilemma to the surgeon. Failure to diagnose and treat this condition early may result in dire consequences like small gut gangrene. A previously healthy, 41-year-old female patient presented to the emergency department with a three-day history of lower abdominal pain and constipation. On examination, she had tachycardia, and her abdominal examination was soft, with mild tenderness in the hypogastric region and scanty bowel sounds. Urine pregnancy and dipstick were unremarkable. The patient was diagnosed with small bowel obstruction (malrotation of the small bowel loops with twisting of the mesenteric vessels). The patient was found to have thyrotoxicosis, which was the cause of the intestinal obstruction. She received conservative treatment and specific thyrotoxicosis management (carbimazole, cholestyramine, Lugol's iodine, and intravenous hydrocortisone). The symptoms resolved entirely after a two-day stay at the intensive care unit. Small bowel malrotation is a congenital anomaly and can present with abdominal pain and obstruction in adulthood. Thyrotoxicosis can cause small bowel obstruction if there is underlying malrotation.

Impact of Online Knowledge and Skills Learning on Millennial Learners Within Emergency Medicine: A Retrospective Data Review.

BACKGROUND: Emergency Medicine didactic teaching has traditionally been delivered through face-to-face (F2F) lectures. However, during the pandemic of COVID-19, the didactic teaching was switched to online through using Microsoft Teams. The aim of this study was to assess the impact of online learning in the knowledge and skills acquisition of millennial learners based within emergency medicine. METHODOLOGY: This was a retrospective review of assessment data. Over a period of 10 months (August 2019 to June 2020), each resident was exposed to traditional F2F teaching for a period of four months and then online teaching in a crossover manner. After each method, there were two types of assessments, multiple-choice questions (MCQs) and computer-based objective structured clinical examination (OSCE). A total of 20 MCQs with one correct answer, totaling 20 marks, and 20 OSCEs consisting of an image or a video with five options, each option carrying one mark, totaling 100 marks were used at each assessment point. A student t-test was used to compare the two groups of results. RESULTS: The total number of participants was 49 (n=49). All residents belonged to the millennial generation. Fourteen were female and 35 were male. The mean MCQ 1 score after F2F teaching was 12.16 (SD=1.688), whilst the mean MCQ 2 score after online teaching was 13.40 (SD=1.861). The mean computer-based OSCE 1 score after F2F teaching was 64.45 (SD=5.895), whilst the mean OSCE 2 score after online teaching was 65.57 (SD=5.969). Ten out of 49 students (20.4%) failed the MCQ exam after F2F teaching, whilst 6/49 students (12.2%) failed the MCQ test after online teaching. Seven out of 49 students (14.3%) failed the OSCE exam after F2F teaching, while six out of 49 students (12.2%) failed the OSCE exam after online teaching. There was a statistically significant improvement in the MCQ score after online teaching as compared to F2F teaching (P-value 0.0003), whilst there was no statistically significant change in the OSCE between the two-teaching methods (P-value 0.3513). CONCLUSION: Both F2F and online teaching methods resulted in a significant improvement in the knowledge and skills of emergency medicine residents. Online education resulted in a statistically significant improvement of MCQ score as compared to F2F teaching. The difference in MCQ score may be due to millennial learners, who traditionally benefit proportionately more from self-learning that is primarily online.