Cocaine Use and Incarceration: A Rare Cause of Bowel Ischemia, Perforation, and Gastrointestinal Hemorrhage.

Cocaine use is rising in persons ≥50 years old and in black and socioeconomically disadvantaged communities. Cocaine-induced bowel ischemia and gastrointestinal injury are deadly findings that have been previously described in the literature. In this report, we present a case of small bowel ischemia, perforation, and upper gastrointestinal hemorrhage co-occurring in a 62-year-old incarcerated male with a 15-year history of cocaine use. The patient presented from jail, peritonitic in septic shock, and was promptly taken for emergent surgical exploration. He was found to have massive fecal peritonitis secondary to full-thickness ischemia and perforation of the jejunum and ileum. Immediately postoperatively, the patient developed a large volume of hemorrhage from multiple gastric and duodenal ulcers refractory to endoscopic intervention, ultimately requiring emergent embolization of the gastroduodenal artery. His course was further complicated by severe septic shock with a blunted response to catecholamine vasopressors. Early recognition and aggressive treatment of the gastrointestinal complications and the unique critical care challenges associated with cocaine use facilitated this patient's eventual full recovery.

Hiatal Hernia With Gastric Perforation.

A 63-year-old male with a history of hiatal hernia presented with one day of hematemesis and acute peritonitis. Computed tomographic imaging revealed perigastric pneumoperitoneum concerning perforated viscus. Exploratory laparotomy revealed a Type III hiatal hernia with a perforated posterior gastric ulcer, which was reduced and repaired. This report describes a case of acute abdomen secondary to hiatal hernia, a rare presentation of hiatal hernia, along with its surgical management and postoperative care.

A rare case of large left internal maxillary artery pseudoaneurysm secondary to mandibular fracture: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Pseudoaneurysms secondary to traumatic vessel wall disruption are a rare but potentially fatal complication after traumatic injury. The majority of the cases are found incidentally. CASE PRESENTATION: An 80-year-old woman was brought into our Level 1 Trauma Center after sustaining a ground-level fall with significant facial swelling. Her imaging revealed an acute traumatic comminuted fracture of the right mandibular condyle and left mandibular ramus. The patient underwent closed maxillomandibular fixation (MMF) to stabilize fractures, and allow the swelling to decrease for definitive fixation. During the definitive procedure, profuse bleeding was encountered. CT angiography evaluation was immediately performed and determined the presence of a left internal maxillary artery pseudoaneurysm which was successfully treated by coil and glue embolization. CLINICAL DISCUSSION: This case highlights an unusual presentation of a vascular injury following major traumatic mandibular fracture and its management. Mandibular fractures have been reported in a series of cases to be a risk factor for vascular injuries. When a vascular injury is suspected, or the evaluation is unclear, surgeons should carefully determine the necessity to perform additional studies like CT angiogram. Vascular injuries secondary to mandibular fractures can be fatal if left unrecognized and untreated. Hence adequate recognition and treatment are warranted to avoid prolonged length of stay with bad outcomes. CONCLUSION: Optimal management of pseudoaneurysms is achieved by endovascular approach with prior resuscitation and adequate hemodynamic stabilization. Open surgical management is deferred only for those cases where endovascular treatment is not available, or disruption is found intraoperatively.

A rare case of low voltage electrical injury leading to bilateral femur fractures and vertebral body fractures: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Low voltage electrical injuries (less than 1000 V) can produce enough tetany to cause fractures, usually of the upper extremities. Simultaneous bilateral fractures of the femoral neck are an extremely rare occurrence. It is even more uncommon for a young healthy male to suffer significant fractures from a low voltage injury. CASE PRESENTATION: A 25-year-old male attempted suicide by filling a bathtub with water and getting into it prior to dropping a blender into the water. He experienced full body convulsions but remained awake throughout the entire event. In the trauma bay his primary complaints were bilateral hip pain and back pain, without neurologic deficit. Radiological studies confirmed bilateral sub-capital femur fractures and thoracic vertebral fractures (compression fractures of T3, T4, T5, T6, T7, T9, and T11). The patient underwent bilateral open reduction and internal fixation (ORIF) of the femurs, while the spine fractures were treated with a thoracic-lumbar-sacral orthosis TLSO brace. CLINICAL DISCUSSION: Low voltage electrical injury is more likely to lead to fractures in patients with chronic renal failure and metabolic conditions such as hypocalcemia, osetomalacia, and osteoporosis. Fractures after low voltage electrical injury are extremely uncommon and a high suspicion for these injuries should be maintained because if missed there is a high risk of morbidity and mortality. CONCLUSION: We present a rare case of low voltage electrical injury by 120 V from a domestic US power supply, amplified by water conduction resulting in bilateral femoral neck fractures and vertebral body fractures.

Multidisciplinary management of a traumatic posterior meningeal artery pseudoaneurysm: A case report and review of the literature.

BACKGROUND: Meningeal arterial injuries represent <1% of all blunt traumatic brain injuries (TBIs). Middle meningeal artery (MMA) lesions comprise the majority. However, there is little clinical data on posterior meningeal artery (PMA) injuries. CASE REPORT: A 69-year-old man was brought to our trauma center after sustaining a fall inside a warehouse. He was GCS (Glasgow Coma Scale) 3 on arrival. Non-contrast CT (computed tomography) brain showed subarachnoid hemorrhage with diffuse cerebral edema and a basilar skull fracture. The patient subsequently underwent emergency ventriculostomy. Immediately after the procedure, further imaging with CTA (computed tomography angiography) head identified a hyperintense posterior cranial fossa lesion, prompting cerebral angiography with identification and embolization of a traumatic PMA pseudoaneurysm. The patient improved and was discharged to a long-term acute care facility. At 3 months post-discharge, the patient was eating, talking with family, and working aggressively with physical therapy. DISCUSSION: This case represents a functional neurologic outcome from a rare subset of TBI. Early CTA head imaging is not supported by limited literature, but allowed for expedient identification and definitive management of this PMA pseudoaneurysm. In the critical care setting, hyperosmolar therapy, CSF (cerebrospinal fluid) drainage, prompt enteral nutritional support, and early tracheostomy all represent evolving evidence-based strategies to optimize care for severe TBI. CONCLUSIONS: The initial evaluation and management of severe TBI can be nuanced. Future research may refine indications for CTA head to the diagnostic evaluation of patients with both severe TBI and skull fractures.

Identification of molecular signatures of cystic fibrosis disease status with plasma-based functional genomics.

Although cystic fibrosis (CF) is attributed to dysfunction of a single gene, the relationships between the abnormal gene product and the development of inflammation and progression of lung disease are not fully understood, which limits our ability to predict an individual patient's clinical course and treatment response. To better understand CF progression, we characterized the molecular signatures of CF disease status with plasma-based functional genomics. Peripheral blood mononuclear cells (PBMCs) from healthy donors were cultured with plasma samples from CF patients ( n = 103) and unrelated, healthy controls ( n = 31). Gene expression levels were measured with an Affymetrix microarray (GeneChip Human Genome U133 Plus 2.0). Peripheral blood samples from a subset of the CF patients ( n = 40) were immunophenotyped by flow cytometry, and the data were compared with historical data for age-matched healthy controls ( n = 351). Plasma samples from another subset of CF patients ( n = 56) and healthy controls ( n = 16) were analyzed by multiplex enzyme-linked immunosorbent assay (ELISA) for numerous cytokines and chemokines. Principal component analysis and hierarchical clustering of induced transcriptional data revealed disease-specific plasma-induced PBMC profiles. Among 1,094 differentially expressed probe sets, 51 genes were associated with pancreatic sufficient status, and 224 genes were associated with infection with Pseudomonas aeruginosa. The flow cytometry and ELISA data confirmed that various immune modulators are relevant contributors to the CF molecular signature. This study provides strong evidence for distinct molecular signatures among CF patients. An understanding of these molecular signatures may lead to unique molecular markers that will enable more personalized prognoses, individualized treatment plans, and rapid monitoring of treatment response.