Life-Threatening Cardiac Arrhythmias in a Case of Undetected Myxedema Coma: Importance of Early Detection and Medication Adherence.

BACKGROUND Myxedema coma is a rare, life-threatening condition caused by a severe form of hypothyroidism. The dangerously low levels of circulating thyroid hormone can lead to progressive mental status changes and numerous organ dysfunctions, including serious cardiac abnormalities. CASE REPORT We present a case of a 59-year-old woman who presented with altered mental status and fall who was originally thought to have a cerebrovascular accident but was later diagnosed with myxedema coma, after multiple cardiac arrests. It was discovered that the patient had not been taking any of her medications for the last several weeks, after her primary care provider retired from practice. Initial laboratory evaluation was significant for a TSH level of 159.419 mIU/L and an undetectable free T4 level. Complications of the myxedema coma resulted in QTC interval prolongation, causing torsades de pointes and sustained polymorphic ventricular tachycardia, requiring cardioversion. CONCLUSIONS This case demonstrates the importance of early detection and treatment of myxedema coma, as it can cause life-threatening cardiac arrhythmias. It also emphasizes the need to ensure proper medication adherence in patients with chronic medical conditions, as non-compliance can result in dire consequences.

Real world validation of an adjunctive gene expression-profiling assay for melanoma diagnosis and correlation with clinical outcomes at an academic center.

A commercially available diagnostic gene expression profiling (GEP) assay (MyPath™) reportedly has high sensitivity and specificity in distinguishing nevi from melanoma based on manufacturer-conducted studies. However, data regarding the performance of this GEP assay in routine clinical practice are lacking. The purpose of this study was to better assess the real-world performance of GEP in a large academic practice. Retrospective review of GEP scores were compared with final histomorphologic interpretation on a wide spectrum of melanocytic lesions demonstrating some degree of atypia. In a sample of 369 lesions, the sensitivity (76.1%) and specificity (83.9%) of the GEP test as compared with final dermatopathologist-rendered diagnosis in our dataset was appreciably lower than that reported in the prior manufacturer-conducted validation studies. Limitations of this study were that it was a single-center study, its retrospective nature, nonblinded nature of GEP test result, concordance of only two pathologists, and limited follow-up time.The sensitivity and specificity of a commercially available GEP diagnostic assay for melanoma may be lower in routine clinical practice, where melanocytic lesions typically exhibit some degree of histomorphologic atypia. Reported cost effectiveness of GEP testing is questionable if all ambiguous lesions that undergo such testing are re-excised in clinical practice.

The impact of tongue dimension on air volume in brachycephalic dogs.

OBJECTIVE: To compare the dimensions and density of the tongue in brachycephalic and mesaticephalic dog breeds and to document the relative extents of the nasopharyngeal and oropharyngeal airways occupied by the tongue and palatal tissues. STUDY DESIGN: Case control study. ANIMALS: Sixteen brachycephalic dogs and 12 mesaticephalic dogs. METHODS: The volume of the tongue was measured with computed tomography in all dogs. Cross-sectional areas of tongue, oropharynx, nasopharynx, and palatal soft tissue were evaluated at two levels, the caudal aspect of the hard palate and the level of the hamulae of the pterygoid. Density of the tongue and soft palate were measured. All variables were compared between brachycephalic and mesaticephalic dogs (P ≤ .05). RESULTS: Absolute tongue volumes did not differ between groups, the volume of the tongue was greater in brachycephalic dogs than in mesaticephalic dogs when expressed relative to (a) body weight (median 5650, interquartile range [IQR] 4833-6522 vs median 4454, IQR 4309-4743, respectively), (b) ratio between skull length/width (70 833, IQR 62490-126 209 vs 48 064, IQR 22984-64 279, respectively), and (c) skull length (689.93, IQR 618.55-970.61 vs 460.04, IQR 288.77-561.69, respectively). The proportion of air (oropharyngeal and nasopharyngeal)/soft tissue (tongue and palatal tissue) in brachycephalic dogs was decreased by approximately 60%, and the tongue was approximately 10 times denser in brachycephalic dogs than in mesaticephalic dogs. CONCLUSION: A relative macroglossia was detected in brachycephalic dogs along with reduced air volume in the upper airway. Tongues of brachycephalic dogs were denser than those of mesaticephalic dogs. CLINICAL SIGNIFICANCE: The relative macroglossia in brachycephalic breeds may contribute to upper airway obstruction.

Surgical and endoscopic treatment of bladder exstrophy-epispadias complex in a female dog.

CASE DESCRIPTION A 14-week-old 7.7-kg (16.9-lb) sexually intact female Golden Retriever was evaluated because of urine dripping from the caudoventral aspect of the abdomen. CLINICAL FINDINGS Ultrasonography, radiography, excretory CT urography, and vaginocystourethroscopy were performed. Results indicated eversion of the bladder through the ventral abdominal wall with exposure of the ureterovesicular junctions, pubic diastasis, and an open vulva and clitoral fossa. Clinical findings were suggestive of bladder exstrophy, a rare congenital anomaly. TREATMENT AND OUTCOME The dog was anesthetized and bilateral ileal osteotomies were performed. Two ureteral catheters were passed retrograde into the renal pelves under fluoroscopic guidance. The lateral margins of the bladder, bladder neck, and urethra were surgically separated from the abdominal wall, and the bladder was closed, forming a hollow viscus. The symphysis pubis was closed on midline with horizontal mattress sutures. The defects in the vestibule and clitoral fossa were closed. Lastly, the iliac osteotomies were stabilized. The dog was initially incontinent with right hind limb sciatic neuropraxia and developed pyelonephritis. Over time, the dog became continent with full return to orthopedic and neurologic function, but had recurrent urinary tract infections, developed renal azotemia likely associated with chronic pyelonephritis, and ultimately was euthanized 3.5 years after surgery because of end-stage kidney disease. CLINICAL RELEVANCE Bladder exstrophy and epispadias is a treatable but rare congenital abnormality. The procedure described could be considered for treatment of this condition, but care should be taken to monitor for urinary tract infections and ascending pyelonephritis.