We report a case of a 36-year old patient with prior history of thrombosis in a setting of antiphospholipid antibody syndrome (APS) as well as pregnancy-associated catastrophic antiphospholipid syndrome (CAPS), resulting in multi-organ infarction and pregnancy loss. The episode of CAPS occurred while she was receiving antepartum low-dose aspirin and therapeutic-dose enoxaparin. This patient presented again at 6 weeks gestation and ultrasounds were consistent with fetal growth restriction, concerning for placental insufficiency and thrombosis. This time, hydroxychloroquine and monthly intravenous immunoglobulin (IVIG) infusions were added to her prophylaxis regimen, resulting in a successful delivery. Platelet count and antiphospholipid antibody titers were routinely monitored throughout pregnancy as markers of disease activity for APS. Current thromboprophylaxis guidelines do not address therapeutic options to prevent further pregnancy morbidity in women who develop recurrent episodes of thrombosis or CAPS despite receiving adequate anti-thrombotic treatment. Use of hydroxychloroquine and IVIG has been associated with good outcomes in this subset of patients.
Lower gastrointestinal bleeding (LGIB) is a common symptom for which patients present to emergency departments and healthcare providers for evaluation. The management approach to LGIB differs according to the clinical presentation and the source of bleeding. For instance, mild hemorrhoidal bleeding can be managed in the outpatient setting, whereas severe diverticular bleeding may require intensive care unit monitoring and urgent therapeutic interventions. However, triaging patients to the appropriate level of care is not always straightforward, and urgent colonoscopy is challenging to perform and not appropriate for all patients. Therefore, prediction tools would be useful to facilitate the identification of high-risk and low-risk patients and in turn to improve the use of healthcare resources and achieve optimal patient outcomes. The largest prospective study to date on this topic by Oakland et al 1 identified 7 predictors of safe discharge in 2336 patients from 143 institutions in the United Kingdom. These predictors (age, sex, previous LGIB, blood on digital rectal examination, heart rate, systolic blood pressure, and hemoglobin on admission) were used to develop a weighted risk score that was validated in an external cohort. A score of 8 predicted a 95% probability of safe discharge, and this score was better able to predict safe discharge, blood transfusion, and readmission than were 6 other upper GI bleeding (UGIB) and LGIB scores, including the Rockall, et al, 2 Blatchford et al, 3 ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, unstable comorbid disease (BLEED), Kollef et al 4 , albumin < 3.0g/dL, international normalized ratio > 1.5, altered mental status, systolic blood pressure < 90mm Hg, age > 65 years (Aims65), Saltzman JR, et al 5 , Strate et al, 6,7 , and nonsteroidal anti-inflammatory drugs use, no diarrhea, no abdominal tenderness, blood pressure < 100 mm Hg, antiplatelet drug use, albumin < 3.0 g/dL, disease score >2 and syncope (NOBLADS) Aoki et al, 8 scores, as cited by Oakland et al. 1 However, this score was intended to predict safe discharge, not specifically the need for therapeutic interventions such as urgent colonoscopy and angiography. The question whether to pursue intensive monitoring and urgent interventions is a
Background & Aims: In the esophagogastroduodenoscopy (EGD) to diagnose upper gastrointestinal disorders, there is a difference in the detection rate of the lesion because of differences in proficiency of the endoscopists and anatomical blind spots. The aim of this study is to identify gaze pattern and blind spot by analyzing the gaze of endoscopist during real-time EGD according to endoscopic proficiency by applying eye-tracking technique. Methods: In this study, 5 endoscopists consist of 3 experts and 2 novices performed 37 EGDs. The measured gaze across the endoscopy monitor acquired by performing EGD while wearing eye-tracker was matched with medical photos taken during EGD. Interval where the analysis was performed among the observation ranges includes from Z-line to 2 nd portion of duodenum during insertion, stomach and to Z-line during withdrawal of the scope, not including the esophagus. The frequency and observation time of the gaze are visualized as heatmaps, and gaze movements as gaze plots. The observation time (OT), duration of fixation (FD), FD to OT ratio, gaze pattern and blind spot were analyzed. Results: In five endoscopists, the mean of OT from Z-line to Z-line was 2.38 AE 0.53 min, FD was 1.80 AE 0.51min, and fixation to observation time ratio was 74.8%. The 34.3% of the time was spent to observe antrum. Although the total OT and FD were longer in novice (9.7AE8.3 vs 12.58AE13.31, P Z 0.006, 7.2AE6.3 vs 9.6AE10.9, P Z 0.004), the FD to OT ratio showed no difference between experts and novices (73.0% vs 72.0%, P Z 0.360). When comparing the gaze pattern observed at the same time for the same area, experts observe linearly while the gaze of novice was scattered (Figure 1). When observing the body in the retroflexion view, experts observed the overall well without blind spot, but the novice showed a limited observation in the posterior wall of body (Figure 2). Conclusion: It is necessary to minimize the distraction of gaze and to pay attention to the observation of the posterior wall with the retroflexion view in novice. Also, the eye-tracking technique may be useful for endoscopic training in the future.
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