Hypocalcemia in Patients With Osteoporosis and Normal Renal Function, Treated With Denosumab, a Retrospective Analysis.

Objective: The reported hypocalcemia in postmenopausal women with osteoporosis who received Denosumab was low (0.05%-1.7% to 7.4%). The major prediction factors were vitamin D and calcium levels and renal function. The objective is to evaluate the incidence of hypocalcemia in patients with osteoporosis, normal renal function, and vitamin D who received Denosumab. Method: A retrospective analysis was conducted using the medical records (2022-2023). We looked for hypocalcemia (albumin-adjusted calcium lower than 2.2 mmol/L). Results: Two hundred one postmenopausal women diagnosed with osteoporosis and received denosumab treatment were included. All patients received vitamin D3 capsules and calcium supplementation. The mean age of the patient was 75.7 ± 7.0 years (56-91 years). Hypocalcemia was observed in 46 (23%) patients following a subcutaneous dose of Denosumab 60 mg. Median calcium was 2.25 mmol/L (minimum: 0.890 mmol/L, maximum: 2.6 mmol/L). Fourteen (30.4%) patients had severe hypocalcemia (<1.8 mmol/L) and required parenteral correction. A comparison between hypocalcemia and patients with normal calcium indicated that the significant predictor of hypocalcemia was pretreatment parathyroid hormone levels (9.9 ± 11.8vs 7.6 ± 2.56 pmol/L, respectively; P < .005). The prognostic role of parathyroid hormone for the denosumab-associated hypocalcemia was assessed using ROC curve analysis. For the cut-off value of Parathyroid hormone = 6.8 pmol/L, giving serum parathyroid measurement an AUC of 0.668 (0.599-0.737) - P = .0007; sensitivity 85%; specificity 52%. Conclusion: Hypocalcemia induced by the denosumab treatment is more prevalent than previously shown in patients with osteoporosis receiving adequate calcium and vitamin D supplements. An elevated parathyroid hormone predicts hypocalcemia related to denosumab therapy in patients with normal calcium and vitamin D levels.

Necrotizing fasciitis following gastrostomy tube placement, detected by point-of-care ultrasound, case report.

INTRODUCTION: Necrotizing fasciitis is a recognized rare complication of gastrostomy tube replacement, but if it occurs and is not discovered early, a lethal outcome is possible. CASE PRESENTATION: We present a woman in her 80s who was known to have chronic atrial fibrillation with ischemic heart disease. She was fed through percutaneous endoscopic gastrostomy after brain injury. Erythema was observed around the stoma of the gastrostomy tube, which was later removed, and erythema extended to the left anterior abdomen. The patient was diagnosed with cellulitis. Point-of-care ultrasound examination suspected necrotizing fasciitis and, confirmed later by computerized tomography of the abdomen. The case was managed surgically. DISCUSSION: Patients with a high clinical suspicion of necrotizing fasciitis should undergo early surgical debridement with antibiotic administration. Necrotizing fasciitis starts with a clinical picture indistinguishable from other skin infections, such as cellulitis, and imaging modalities are important for confirmation and early diagnosis. We present a case of necrotizing fasciitis after gastrostomy tube replacement for which point-of-care ultrasound played a pivotal role in confirming the diagnosis early. CONCLUSION: Point-of-care ultrasound is a useful adjunct tool for clinical evaluation and assessment in diagnosing early critically ill patients with life-threatening necrotizing infections.

Detecting spontaneous retroperitoneal hemorrhage using a modified RUSH protocol: a case report.

INTRODUCTION: Bleeding in the retroperitoneal space is a serious complication. Hypovolemia and shock develop late after losing a large volume of blood. However, point of care ultrasound (POCUS) examinations in adult patients with shock do not include the retroperitoneal space. CASE PRESENTATION: We present the case of a 74-year-old male with ischemic heart disease on dual antiplatelet. He developed vague abdominal pain and hemoglobin drop without overt bleeding source until he developed shock. Modified POCUS examination that included the retroperitoneal space detected the bleeding source and confirmed later by computerized tomography of the abdomen. The case was managed conservatively. CLINICAL DISCUSSION: The risk factors associated with the formation of spontaneous retroperitoneal hematomas are age above 70 years and dual antiplatelet therapy. The initial integration of point-of-care ultrasound into the assessment of shocked patients leads to an earlier and accurate initial diagnosis with a clear patient care plan. POCUS should include the retroperitoneal space examination in every patient presenting with shock. CONCLUSION: In patients with unexplained hemorrhagic shock, a modified POCUS protocol could help by including an examination of the retroperitoneal space in the assessment.

Sodium-glucose cotransporter-2 inhibitors induced euglycemic diabetic ketoacidosis: Two case reports and a review of the literature.

If not detected early, euglycemic diabetic ketoacidosis can be a serious adverse effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors. Unfortunately, euglycemic diabetic ketoacidosis is underreported in recent trials and missed because of normal blood sugar levels and nonspecific symptoms on presentation. We present two patients with type 2 diabetes mellitus who developed dapagliflozin-associated euglycemic diabetic ketoacidosis followed by hyperglycemic ketoacidosis. The second patient had euglycemic ketoacidosis twice despite instructions to stop using the medication dapagliflozin.

Hepatic portal vein gas detected by point of care ultrasound.

INTRODUCTION: Portal venous gas is a rare finding in adults and is typically associated with underlying intestinal ischemia. Portal venous gas can be detected by a bedside point of care ultrasound (POCUS) examination in adult patients in critical care units (CCU). Findings include echogenic bubbles flowing centrifugally throughout the portal venous system. CASE PRESENTATION: We present the case of a 73-year-old female with advanced ischemic cardiomyopathy and cardiorenal syndrome who was managed in the CCU. She developed vague abdominal pain and respiratory depression requiring intubation and dialysis during her course of treatment in the CCU. Her findings were consistent with portal venous gas upon POCUS, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have nonobstructive mesenteric ischemia. CLINICAL DISCUSSION: PVG is an ominous radiological sign and reflects intestinal ischemia in up to 72% of cases. Acute mesenteric ischemia of the small bowel could be due to occlusive or nonocclusive obstruction of the arterial blood supply or obstruction of venous outflow. Nonocclusive obstruction accounts for 5% to 15% of patients with acute mesenteric ischemia. CONCLUSION: With the increasing use of POCUS, critical care physicians should be aware of findings consistent with portal venous gas as a bedside tool for directing the treating physician toward an ominous diagnosis in patients with shock.

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension.

INTRODUCTION: The Abdominal Compartment Society (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) ≤ 15 mm Hg. The role of point-of-care ultrasound (POCUS) as a bedside modality in the critical care patients is not well studied in relation to the intra-abdominal hypertension (IAH) management algorithm. AIM: To test the role of point-of-care ultrasound (POCUS) in the medical management of patients with intra-abdominal hypertension (IAH). METHOD: We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management. RESULTS: A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65 ± 22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (five cases). Ultrasound and abdominal X-rays were comparable in confirming correct NGT position, but the ultrasound was superior in determining the gastric content (fluid vs. solid) and diagnoses of gastric paresis in two cases. Small bowel obstruction was present in four patients and confirmed with abdominal CT; two of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely 72%, 56%, and 42% of the time on days 1, 2, and 3, respectively. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites, and US-guided paracentesis was performed. CONCLUSION: POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH.