SUMMARYA 27-year-old woman with a history of recurrent nausea and vomiting in the setting of idiopathic intracranial hypertension (IIH) was admitted for control of unremitting nausea and vomiting. Initial antiemetic therapy included optimisation of IIH therapy by titrating acetazolamide, in addition to using ondansetron and metoclopramide as needed, with minimal relief. She was ultimately treated with palonosetron with complete resolution of her acute nausea. Nausea, often treated with 5-hydroxytryptamine (5-HT3) receptor antagonists, approved for perioperative and chemotherapy-induced nausea, are used off-label to treat nausea and vomiting outside of those settings. The efficacy of different regimens has been compared in the literature and continues to remain controversial. When choosing from different 5-HT3 antagonists there are other considerations, in addition to efficacy to consider: dosing schedule, half-life, time of onset, duration and cost-tobenefit ratio, and although one 5-HT3 antagonist may not have been effective, another one may be. In our case palonosetron, with a significantly longer half-life than other 5-HT3 antagonists, was effective in resolving nausea when compared with the more commonly used ondansetron. BACKGROUND
SUMMARYA restrained motor vehicle accident victim suffered from delayed onset left pectoralis myospasms refractory to multiple treatments: behavioural, conservative, physical therapy, opiate, muscle relaxer and incomplete response to invasive pain management spinal blocks. After conduction of a literature review, several authors had noted the mechanism of α-γ loop dysfunction resulting in myospams, and also case studies which described painful postsurgical myospasms that were treated with neurectomy and/or botulinum toxin A with successful results. The patient in this case underwent an initial lidocaine injection to observe response to treatment, followed by two treatments with botulinum toxin A treatment with subsequent resolution of symptoms. Successful therapy and previous research supports that botulinum toxin A can be an effective treatment for myospasms secondary to trauma-induced α-γ dysfunction, as suggested by the cellular pathophysiology. BACKGROUND
A 72-year-old man with a past medical history significant for chronic obstructive pulmonary disease (COPD), witnessed nocturnal apnea and persistent 80-pack-year tobacco use presented with a new-onset of aphasia. MRI brain demonstrated restricted perfusion in the left temporoparietal area and insular cortex, consistent with subacute embolic strokes. Investigation for the etiology was notable for secondary polycythemia and non-specific mitral valve thickening on transthoracic echocardiography (TTE). Subsequent transesophageal echocardiography (TEE) showed a heterogenous, 1.1 cm mass on the anterior mitral valve leaflet. Following warfarin bridge therapy, surgical resection revealed a sterile thrombus, consistent with nonbacterial thrombotic endocarditis (NBTE). Chronic hypoxia has been implicated in the pathogenesis of NBTE in both human and animal studies. While animal models have suggested a direct causal relationship, human studies are largely limited to isolated case reports, which have almost uniformly been confounded by the presence of other disorders of hypercoaguability, such as malignancy or disseminated intravascular coagulation (DIC). Unique in comparison to prior studies, this report demonstrates a case of NBTE in the setting of chronic oxygen deprivation and secondary polycythemia in a patient without any additional major risk factors.
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