BACKGROUND: High-grade atrioventricular block is the primary reason for epicardial permanent pacemaker implantation during the perioperative period in patients with congenital heart disease. Due to the smaller diameter of venous vessels in children, epicardial permanent pacemaker implantation is usually a preferred choice, we report one pediatric patient who received epicardial permanent pacemaker implantation using a new approach.
METHODS: We present the case of a 2-year-old girl who underwent the modified Konno procedure and Pulmonary valvuloplasty surgery and presented after surgery with a High-grade atrioventricular block. At over 20 days after the patient underwent a redo-sternotomy which epicardial permanent pacemaker implantation. Medtronic Model 4965 Capsure Epi ® steroid-eluting unipolar epicardial pacing lead was immobilized on the surface of the right ear. The Medtronic 3830 pacing lead was screwed obliquely and clockwise under direct view from the surface of the right ventricle to the endocardium near the interventricular septum. The patient\'s recovery was uneventful.
CONCLUSIONS: In this case report, we demonstrate the feasibility and potential benefits of using the Medtronic 3830 lead for epicardial pacing in a pediatric patient with severe cardiac complications following surgery for congenital heart disease. This approach offers a viable alternative to traditional epicardial pacing methods, particularly in complex cases where conventional leads fail to provide stable pacing thresholds.

COVID-19 might present with a wide range of clinical manifestations, from mild respiratory distress to severe multi-organ dysfunction. We present a unique case of complex COVID-19 presentation in a 45-year-old female who initially developed general symptoms such as fever, cough, headache, and weakness, which escalated to coma, requiring intubation and ICU admission. A brain MRI revealed lesions compatible with encephalitis, the cause of which remained unexplained after an in-depth clinical, laboratory, and imaging investigation. While in the ICU, the patient also developed cardiac tamponade, requiring pericardiocentesis, and atypical electrocardiographic changes. After treatment with steroids, her condition improved, and the patient was extubated and transferred to the ward. Upon checkup, cardiac MRI revealed fibrous tissue in the inferior cardiac wall and the adjacent intraventricular septum. In the absence of an alternative diagnosis, it might be important to consider the central nervous system and cardiac involvement in patients with COVID-19.

UNASSIGNED: This case study portrays an unusual case of treatment-induced neuropathy of diabetes (TIND) in a patient with uncontrolled type 2 diabetes (T2D) who achieved rapid improvement in glucose control primarily with dietary intervention. Initial presentation was 50-year-old white male with a long-standing history of obesity and a family history of T2D with a screening glucose level >500mg/dL by glucometer, HbA1c of 14.9%, and initial weight 213 lbs.
UNASSIGNED: The initial intervention included a low-carbohydrate diet, metformin, and a continuous glucose monitor (CGM). Semaglutide was added after seven days.
UNASSIGNED: His glycemia was within the target range within three weeks. Four weeks after initiation of therapy, he developed TIND symptoms consisting of burning, tightness, and numbness of bilateral feet along with 10/10 pain. At three months, his HbA1c dropped to 6.9% and his weight to 195 lbs. Treatment of his TIND reduced his pain from 10/10 to 2/10.
UNASSIGNED: Whereas TIND is commonly associated with the use of insulin or sulfonylureas, this study adds evidence to the paucity of literature regarding TIND precipitated by dietary intervention.

METHODS: Prospective study.
OBJECTIVE: To evaluate the influence of preoperatively assessed psychosomatic traits on postoperative pain, disability, and quality of life outcomes.
BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a widely employed surgical procedure for treating cervical spondylosis. Despite its effectiveness, various studies have reported non-success rates in terms of alleviating disability and pain. Psychological factors have become increasingly recognized as critical determinants of surgical outcomes in various medical disciplines. The full extent of their impact within the context of ACDF remains insufficiently explored. This case series aims to assess the influence of preoperative psychological profiling on long-term pain, disability and quality of life outcomes.
METHODS: We conducted a prospective cohort study of prospectively collected data from 76 consecutive patients who underwent ACDF with PEEK inter-fixed cages from July 2019 to November 2021. The preoperative psychological traits were assessed using the Symptom Checklist 90 (SCL-90) questionnaire. The Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Neck Disability index (NDI), EuroQol-5D (EQ-5D), and Short Form-36 (SF-36) were collected preoperatively, one month postoperatively, and at least one year after the surgical procedure.
RESULTS: The correlation analyses revealed associations between psychosomatic traits and multiple preoperative and postoperative outcome measures. The univariate analyses and linear regression analyses demonstrated the influence of the Global Severity Index (GSI) over the final follow-up scores for the ODI, VAS, NDI, EQ-5D, and SF-36. The GSI consistently exhibited a stronger correlation with the final follow-up pain, disability, and quality of life outcomes with respect to the correspondent preoperative values.
CONCLUSIONS: This study highlights the importance of psychosomatic traits as predictive factors for ACDF outcomes and emphasizes their relevance in preoperative assessment for informing patients about realistic expectations. The findings underscore the need to consider psychological profiles in the preoperative workup, opening avenues for research into medications and psychological therapies. Recognizing the influence of psychosocial elements informs treatment strategies, fostering tailored surgical approaches and patient care.

This case report demonstrates the difficulty of diagnosing and managing the pharyngeal-cervical-brachial (PCB) variant of Guillain-Barré syndrome (GBS), as well as the rare complication of intracerebral hemorrhage (ICH). A male patient in his mid-60s, presented with bilateral upper limb weakness, bilateral ptosis, and bulbar symptoms. The clinical presentation combined with paraclinical findings supported the diagnosis of PCB. During the course of PCB, the patient required tracheostomy and gastrostomy due to the worsening of his symptoms. Eleven days after hospitalization, and six days after the course of intravenous immunoglobulin (IVIG), the patient developed intracranial bleeding. All clinicians should consider the PCB syndrome in patients with bilateral upper extremity weakness and oropharyngeal involvement, in order to develop a personalized treatment plan and closely monitor potential life-threatening complications such as ICH.

UNASSIGNED: Current guidelines recommend proceeding with cardioversion, without the explicit need for preprocedural transesophageal echocardiography (TEE), in patients compliant with oral anticoagulation for at least 3 weeks. The relevance of these guidelines remains unclear in those undergoing repeat cardioversion.
UNASSIGNED: A 66-year-old male with a history of atrial fibrillation (AF) and a left atrial appendage occlusion (LAAO) device, compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm, 10 days before symptom onset, with TEE unremarkable at the time. An ECG revealed that the patient converted back into AF and a repeat cardioversion was scheduled. At the patient\'s request, a TEE was obtained, revealing a new 2 cm×1 cm thrombus in the left atrium above the WATCHMAN device. Cardioversion was canceled and the patient was hospitalized for AF management.
UNASSIGNED: Cardioverted patients are at risk for thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium, which occurs immediately after cardioversion and can persist for several weeks. The likelihood of a thrombus is further propagated by individual risk factors for stroke.
UNASSIGNED: Anticoagulation does not eliminate the risk of thrombus formation in those with increased risk factors for stroke. Further studies are warranted to assess the need for routine TEE, after cardioversion, in those with stroke risk factors on anticoagulation or who have LAAO.

暂无摘要。

OBJECTIVE: N-piperidinyl etonitazene (etonitazepipne) is a newly synthesized opioid related to the 2-benzylbenzimidazole analog class. Etonitazepipne has been formally notified and placed under intensive monitoring in Europe in January 2022. Nitazenes have high affinity at µ-opioid receptor (MOR). Etonitazepipne, specifically shows a EC50 of 2.49 nM, suggesting about 50 times higher potency combined with higher efficacy compared to morphine. Antinociceptive potency l (\'hot plate test\' with rats) was 192-fold greater than that of morphine.
METHODS: Here we report on a post-mortem case involving etonitazepipne and its quantification using a standard addition method (SAM) through liquid chromatography tandem mass spectrometry (LC-MS/MS). In addition, characterization and identification of phase I human metabolites using in vitro assay based on pooled human liver microsomes (pHLM) was performed along with the analysis of authentic urine samples by means of high-performance liquid chromatography high-resolution tandem mass spectrometry (LC-HRMS/MS).
RESULTS: The concentration of etonitazepipne in post-mortem blood and urine was 8.3 and 11 ng/mL, respectively. SAM was validated by assessing the following parameters: intraday and interday repeatability, matrix effect and recovery rate in post-mortem blood. A total of 20 and 14 metabolites were identified after pHLM incubation and urine analysis, respectively. Most pronounced in vitro and in vivo transformations were O-deethylation, hydroxylation, ketone reduction, and combinations thereof.
CONCLUSIONS: Considering small traces of the parent drug often found in real cases, the identification of metabolic biomarkers is crucial to identify exposure to this drug. O-deethylated, oxidated metabolites, and combination thereof are proposed as urinary biomarkers along with the parent compound.

We explored the first evidence of a single-session neuromuscular biofeedback effect on motor unit properties, neuromuscular activation, and the Achilles tendon (AT) length 12 days after undergoing AT surgical repair. We hypothesized that immediate neuromuscular biofeedback enhances motor unit properties and activation without causing AT lengthening. After 12 days AT surgical repair, Medial Gastrocnemius (MG) motor unit decomposition was performed on a 58-year-old male before and after a neuromuscular biofeedback intervention (surface electromyography (sEMG) and ultrasonography), involving unressited plantar flexion. The analysis included motor unit population properties, sEMG amplitude, force paradigm, and AT length. There were increased MG motor unit recruitment, peak and average firing rate, coefficient of variation, and sEMG amplitude, and decreased recruitment and derecruitment threshold in the repaired AT limb. The non-injured limb increased the motor unit recruitment, and decreased the coefficient of variation, peak and average firing rate, inter-pulse interval, derecruitment threshold and sEMG amplitude. The AT length experienced -0.4 and 0.3 cm changes in the repaired AT and non-injured limb, respectively. This single-session neuromuscular biofeedback 12 days after AT surgery shows evidence of enhanced motor unit properties and activation without signs of AT lengthening when unresisted plantar flexion is performed in the repaired AT limb.

BACKGROUND: Hemopericardium is a serious complication that can occur after cardiac surgery. While most post-operative causes are due to inflammation and bleeding, patients with broken sternal wires and an unstable sternum may develop hemopericardium from penetrating trauma.
METHODS: We present the case of a 62-year-old male who underwent triple coronary bypass surgery and presented five months later with sudden anterior chest wall pain. Chest computed tomography revealed hemopericardium with an associated broken sternal wire that had penetrated into the pericardial space. The patient underwent a redo-sternotomy which revealed a 3.5 cm bleeding, jagged right ventricular laceration that correlated to the imaging findings of a fractured sternal wire projecting in the pericardial space. The laceration was repaired using interrupted 4 - 0 polypropylene sutures in horizontal mattress fashion between strips of bovine pericardium. The patient\'s recovery was uneventful and he was discharged on post-operative day four without complications.
CONCLUSIONS: Patients with broken sternal wires and an unstable sternum require careful evaluation and management as these may have potentially life-threatening complications if left untreated.