Dr Paws’ Post

The impact of diabetes mellitus on foot perfusion measured by ICG NIR fluorescence imaging Introduction: Diabetes Mellitus (DM) is a common chronic disease, affecting 435 million people globally. Impaired vasculature in DM patients leads to complications like lower extremity arterial disease (LEAD) and foot ulcers, often resulting in amputations. DM causes additional peripheral neuropathy leading to multifactorial wound problems. Current diagnostics often deem unreliable, but Near-Infrared Fluorescence with Indocyanine Green (ICG NIR) can be used to assess the foot perfusion. Therefore, this study explores DM's impact on foot perfusion using ICG NIR. Results: Among 109 patients (122 limbs) of the included patients, 32.8% had DM. Six of ten perfusion parameters, mainly inflow-related, differed significantly between DM and non-DM patients (p-values 0.007-0.039). Fontaine stage 4 DM patients had the highest in- and outflow values, with seven parameters significantly higher (p-values 0.004-0.035). Conclusion: DM is associated with increased in- and outflow parameters. Patients with- and without DM should not be compared directly due to different vascular pathophysiology and multifactorial wound problems in DM patients. Quantified ICG NIR fluorescence imaging offers additional insight into the effect of DM on foot perfusion. https://lnkd.in/erVQGV2m Stefan Koning Just van Kersen Floris Tange Mo Kruiswijk Roderick Peul Jan van Schaik Abbey Schepers Alex Vahrmeijer Jaap Hamming Pim Van Den Hoven Joost van der Vorst Leiden University Medical Center #ICG #indocyaninegreen #fluorescence #fluorescent #guidedsurgery #surgery #surgeon #imaging #thinkgreen #safety #surgical #patient

Do you have a thyroid condition? Was your thyroid removed and are you not feeling well with your thyroid replacement? I am glad, that as an Integrative Endocrinologist, I’ve actually listened to my patients and supported them in their quest to feel well when hypothyroid. I have used combination therapy wisely, for decades. Often in this space I am seen as an odd ball by my colleagues because I have used combination therapy. In my chapter on integrative care of patients who’ve undergone thyroid surgery, which is featured in my LinkedIn in featured books this is discussed. I describe various ways to treat these patients, using combination therapy with and without desiccated thyroid. I strive to provide thyroid replacement that meets patient’s needs, is safe, and creates wellbeing. This matters and is life giving. We must help and not cause harm. My great university colleagues and related practices cannot prescribe or support patients who have been well on desiccated thyroid. This is a complicated issue and there are no good or bad guys here. There are clear reasons for the boundaries we face as physicians and our willingness or courage to go beyond. This is tough for us endocrinologists. I know reposts are not often seen or are not don’t pay attention, but this one is an important post. I highlight my collaboration with my colleagues Sanziana Roman MD Julie Ann Sosa and were my two Endo surgeons at Yale, now they are my USF colleagues, and also 2/3 editors of this great book. It was forward thinking and evidence- based publication then and now. #hypothyroid #thyroidsurgery #endocrinesurgery #combinationthyroidtherapy #thyroidcancer #dessicatedthyroid #hypothyoidtreatment #ATA #thyroidnerds #thyroidologist #integrativeendocrinologist

A total of 4917 patients were included in the analysis, 3909 (79.5%) patients without and 1008 (20.5%) patients with preoperative septic cerebral embolism. Patients with preoperative septic cerebral embolism had more baseline comorbidities. Mitral valve endocarditis (44.1% vs. 33.0% p < 0.001), large vegetations >10mm (43.1% vs. 30.0%,p<0.001), and Staphylococcus species infection (42.3% vs. 21.3%, p < 0.001) were more frequent in the cerebral embolism group. Among patients with preoperative cerebral embolism, 286 (28.4%) patients had no stroke signs (silent stroke). After matching (1008 matched pairs), there was no statistically significant difference in 30-day mortality (20.1%. vs. 22.8%; p = 0.14) and 5-year survival (47.8% vs. 49.1%; stratified log-rank p = 0.77) in patients with and without preoperative cerebral embolism, respectively. Preoperative septic cerebral embolism in patients with infective endocarditis requiring valve surgery does not negatively affect early or late mortality, therefore, it should not play a major role in deciding if surgery is to be performed.

📃Scientific paper: Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report Abstract: Background Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. Case presentation The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of ... Continued on ES/IODE ➡️ https://etcse.fr/x0Z3G ------- If you find this interesting, feel free to follow, comment and share. We need your help to enhance our visibility, so that our platform continues to serve you.

Adrenal cysts less than 10 cm can be safely observed Abstract Background Adrenal cysts are rare and appropriate management is unclear due to a lack of data on their natural history. Understanding adrenal cyst growth patterns would assist in clinical management. Methods This single-institution study included all adult patients diagnosed with simple adrenal cysts between 2004 and 2021. Baseline characteristics and outcomes of those who underwent resection (ADX) or observation (OBS) were compared using the chi-squared test, student's t-test, and Wilcoxon rank-sum test. Growth curves and sensitivity analysis were plotted for all patients who had follow-up imaging. Results We identified 77 patients with imaging-confirmed adrenal cysts. The majority were female (75.3%) and more than half were white (55.8%). One-third of patients underwent ADX, and the remaining were observed. ADX patients were younger (median age [IQR]: 55.5 y [45.0–68.2 y] vs. 44.2 y [38.7–55.0 y], p = 0.01) and more likely to be Hispanic (12% vs. 0%, p = 0.05). ADX patients presented with larger cysts (5.6 vs. 2.6 cm, p = 0.002). The median time from diagnosis to last follow-up was 1.1 y for ADX and 4.1 y for OBS. Average growth for OBS was 0.3 cm/y, while average growth for ADX was 3.9 cm/y. In ADX patients, cysts >10 cm grew significantly faster than cysts <10 cm (median growth rate 13.2 cm/y vs. 0.3 cm/y, p < 0.05). There was no adrenal malignancy diagnosis, hyperfunctionality, or observation-related complications (e.g., rupture). Conclusion While size >4–6 cm has guided surgical referral for solid adrenal masses, this study demonstrates a size threshold of 10 cm, below which asymptomatic, simple adrenal cysts can safely be observed.

📃Scientific paper: Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report Abstract: Background Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. Case presentation The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of ... Continued on ES/IODE ➡️ https://etcse.fr/x0Z3G ------- If you find this interesting, feel free to follow, comment and share. We need your help to enhance our visibility, so that our platform continues to serve you.

#Hematologyeducationseries #Bleedingdisorders Part 2 Diagnosis of bleeding disorders 🩸Medical History and Physical Exam Family History: Some bleeding disorders, like hemophilia and von Willebrand disease, are hereditary. 🩸Personal History: Includes questions about easy bruising, nosebleeds, prolonged bleeding after injury or surgery, heavy menstrual bleeding, or blood in urine or stool. 🩸Medications: Certain medications, like blood thinners or NSAIDs, can increase bleeding risk. Physical Signs: Look for bruising patterns, petechiae (small red spots), joint swelling, and overall signs of bleeding. 🩸 🩸Laboratory Tests Complete Blood Count (CBC): To evaluate platelet levels and other blood cell counts. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT): Measure clotting times and can indicate abnormalities in certain clotting factors. Platelet Function Tests: Evaluate the ability of platelets to clump together and form clots. Fibrinogen Levels: Low fibrinogen can lead to poor clot formation. Von Willebrand Factor Assay: Tests for von Willebrand disease, a common hereditary bleeding disorder. Mixing Studies: Distinguish between clotting factor deficiencies and inhibitors. 🩸🩸🩸Specialized Tests (If Needed) Genetic Testing: Used if there's a strong family history or suspicion of an inherited disorder. Factor Assays: Measure levels of specific clotting factors, particularly in cases where hemophilia is suspected. Platelet Aggregation Tests: Analyze platelet functionality in more detail.

📃Scientific paper: Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report Abstract: Background Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. Case presentation The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of ... Continued on ES/IODE ➡️ https://etcse.fr/x0Z3G ------- If you find this interesting, feel free to follow, comment and share. We need your help to enhance our visibility, so that our platform continues to serve you.

Angioedema is commonly associated with swelling of the face, lips, or limbs, but when it affects the gastrointestinal tract, it presents a significant diagnostic challenge. A recent clinical case published in NEJM Group highlights this often-overlooked condition. https://lnkd.in/dmvMJ66r In the case, a 53-year-old woman presented with recurrent episodes of severe abdominal pain over the course of a month. Despite extensive evaluation, including abdominal imaging and colonoscopy, no obvious cause for her symptoms was found. However, further testing revealed low levels of C1 inhibitor and C1q, suggesting acquired C1 inhibitor deficiency—a known cause of gastrointestinal angioedema. The symptoms of intestinal angioedema can mimic more common conditions, such as irritable bowel syndrome (IBS), leading to delays in diagnosis or unnecessary surgical interventions. In the case presented in NEJM, computed tomography (CT) revealed segmental thickening of the intestinal wall and mesenteric edema, but biopsies showed no mucosal abnormalities. The patient was ultimately diagnosed with intestinal angioedema due to acquired C1 inhibitor deficiency. After treatment with danazol, she experienced complete resolution of symptoms. This case serves as an important reminder that, although rare, intestinal angioedema should be considered in patients presenting with unexplained abdominal pain, especially when accompanied by imaging findings like bowel wall thickening or mesenteric edema. Early recognition and appropriate treatment can prevent unnecessary surgeries and improve patient outcomes.

📃Scientific paper: Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report Abstract: Background Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. Case presentation The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of ... Continued on ES/IODE ➡️ https://etcse.fr/x0Z3G ------- If you find this interesting, feel free to follow, comment and share. We need your help to enhance our visibility, so that our platform continues to serve you.