Embolic Strokes in Paroxysmal Atrial Fibrillation: Anticoagulation Failure or Something Else?

Infective endocarditis (IE) often presents with various signs and/or symptoms. However, at times, IE can present without outstanding clinical evidence but may carry devastating consequences if not detected and treated. We present a case of an 81-year-old female with paroxysmal atrial fibrillation who presented to the emergency department with slurred speech. Her National Institutes of Health Stroke Scale (NIHSS) score was one, and her physical examination was unremarkable. Brain imaging revealed bilateral multiple acute supratentorial and infratentorial infarcts. The patient was fully compliant on apixaban and had a dual-chamber pacemaker placed years earlier at an outside facility for unclear reasons. Although initially suspected to have experienced anticoagulation failure (ACF), transesophageal echocardiography (TEE) was ordered to evaluate for possible left atrial appendage closure procedure, which disclosed a mobile, echo-bright structure on the mitral valve consistent with IE. Blood cultures returned positive, the patient was treated with IV antibiotics, and apixaban was resumed. It can be challenging to suspect IE clinically, especially in deceptive or insidious cases with no signs/symptoms. Still, ACF is a diagnosis of exclusion, and all sources of embolic stroke (such as IE) must be thoroughly worked up before assuming treatment failure.

Cardiotoxicity Induced by Capecitabine and Oxaliplatin in Gastric Cancer Treatment: A Rare Case of Cardiac Arrest and Cardiogenic Shock.

Introduction: Combination-based adjuvant chemotherapy utilising capecitabine and oxaliplatin is widely used in gastric cancer treatment. Rare but severe cardiac events such as prolonged QT, cardiac arrest and cardiogenic shock can result from their use. Case description: A 45-year-old female with gastric adenocarcinoma was started on capecitabine-oxaliplatin chemotherapy one week before presenting to the emergency department with weakness. Blood pressure was 78/56 mmHg, heart rate 140 bpm and oxygen saturation 85%. She became unresponsive with pulseless ventricular fibrillation; CPR was initiated with immediate intubation. She received two shocks with a return of spontaneous circulation. Laboratory tests revealed serum potassium (3.1 mmol/l), magnesium (1.1 mg/dl) and troponin (0.46 ng/ml). An EKG revealed sinus tachycardia with a prolonged QT interval (556 ms). The combined effects of capecitabine, oxaliplatin and electrolyte abnormalities likely contributed to the QT prolongation. An echocardiogram demonstrated an ejection fraction of 10%-15%. An emergent right-heart catheterisation showed right atrial pressure of 10 mmHg and pulmonary artery pressure of 30/18 mmHg; cardiac output and index were not recorded. An intra-aortic balloon pump was placed, and she was admitted to the ICU for cardiogenic shock requiring norepinephrine, vasopressin and dobutamine. A repeat echocardiogram showed a significantly improved ejection fraction of 65%, and she was discharged. Discussion: Capecitabine and oxaliplatin cardiotoxicity is an exceedingly rare occurrence, with both drugs reported to cause QT prolongation. Conclusion: Healthcare providers must recognise the QT prolongation effects of capecitabine and oxaliplatin, leading to life-threatening cardiac arrhythmias. LEARNING POINTS: Recognise the QT-prolonging effects of capecitabine and oxaliplatin-based chemotherapy.Recognise that cardiogenic shock and cardiac arrest with capecitabine and oxaliplatin-based chemotherapy can occur in individuals with benign cardiac history, especially early in treatment.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients

Abstract Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid =4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection (p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients.

Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid = 4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection ( p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Management of the facial nerve following temporal bone ballistic injury.

Objective: To understand the patterns of temporal bone fracture and facial nerve injury from ballistic trauma. Study Design: Retrospective case series. Methods: Retrospective review of 42 patients evaluated following temporal bone ballistic injury at a single institution, university-based level-one trauma center between 2012 and 2021. Demographics, facial nerve status, CT images, interventions, complications, and outcomes were reviewed. Results: Mean age 30.3 years (range 5-58 years); 79% male. Racial demographics reflected the surrounding community. Seven mortalities occurred. Nineteen patients (54%) demonstrated facial nerve injury. Of those, 13/19 displayed immediate paralysis, 1 delayed, 5 unknown (due to altered mental status). On consultation, House-Brackmann grade 6 paralysis was common (13/19). Fracture was otic capsule-sparing in 17/19 (90%), universally comminuted, with significant disruption along the mastoid tip (16/19), external auditory canal (EAC) (15/19), and periauricular soft tissues (13/19). Nine patients underwent surgical intervention: Transmastoid facial nerve decompression to remove compressive bony spicules (n = 5); eye protection surgery (n = 3); and peripheral facial nerve exploration (n = 1), noting transection at the pes. One required middle cranial fossa and transmastoid repair of cerebrospinal fistulae in setting of severe meningitis. House-Brackmann scores improved in 80% following transmastoid nerve decompression despite CT evidence of likely additional injury in its extratemporal course. Conclusions: Common patterns of temporal bone fracture seen in blunt trauma (longitudinal/transverse, otic capsule-sparing/disrupting) were not found in patients with ballistic facial nerve injury. Rather, injury was commonly apparent in the EAC, mastoid tip, and periauricular soft tissues. Clinicians should have high suspicion for extratemporal facial nerve injury following ballistic trauma.