A Rare Case of Chemical Peritonitis Following Intravesical Botulinum A Injection for Detusor Overactivity

A 72 year old lady attended for elective administration of intravesical Botulinum A toxin (Botox 200iu) injections, as a daycase procedure, for the treatment of detrusor over activity. The procedure was undertaking without any complications. A few hours after the operation the patient developed severe constant generalized abdominal pain and distension. There were no other associated features. She underwent a computerized tomography (CT) scan of her abdomen and pelvis which was normal, followed by a Cystogram which was also normal. The only abnormal finding was that of an elevated CRP (380 mg/L). She was treated empirically with intravenous Cefuroxime and Metronidazole for twenty-four hours. Her symptoms slowly resolved and she was discharged home on the 3rd post-operative day with oral antibiotics. She experienced no further complications. Although the exact cause of her symptoms was not found, the timing of this complication means it is highly probable to be due to the intravesical Botox injection. Given the above findings, the most likely diagnosis is that chemical peritonitis. This has not previously been reported in the literature as a side effect of intravesical Botox.&nbsp;</p

Clinical profile of refractory intradialytic hypertension due to a giant AV fistula

An arteriovenous fistula (AVF) aneurysm extending from the cubital region to the clavicle over the left arm which presented with interdialysis hypertension and high-output cardiac failure showing a reduction of blood pressure and improvement of ejection fraction after the construction of a new AVF in the other arm

Possible mechanisms responsible for acute coronary events in COVID-19

The novel coronavirus (SARS-CoV-2) is primarily a respiratory pathogen and its clinical manifestations are dominated by respiratory symptoms, the most severe of which is acute respiratory distress syndrome (ARDS). However, COVID-19 is increasingly recognized to cause an overwhelming inflammatory response and cytokine storm leading to end organ damage. End organ damage to heart is one of the most severe complications of COVID-19 that increases the risk of death. We proposed a two-fold mechanism responsible for causing acute coronary events in patients with COVID-19 infection: Cytokine storm leading to rapid onset formation of new coronary plaques along with destabilization of pre-existing plaques and direct myocardial injury secondary to acute systemic viral infection. A well-coordinated immune response is the first line innate immunity against a viral infection. However, an uncoordinated response and hypersecretion of cytokines and chemokines lead to immune related damage to the human body. Human Coronavirus (HCoV) infection causes infiltration of inflammatory cells that cause excessive production of cytokines, proteases, coagulation factors, oxygen radicals and vasoactive molecules causing endothelial damage, disruption of fibrous cap and initiation of formation of thrombus. Systemic viral infections also cause vasoconstriction leading to narrowing of vascular lumen and stimulation of platelet activation via shear stress. The resultant cytokine storm causes secretion of hypercoagulable tissue factor without consequential increase in counter-regulatory pathways such as AT-III, activated protein C and plasminogen activator type 1. Lastly, influx of CD4+ T-cells in cardiac vasculature results in an increased production of cytokines that stimulate smooth muscle cells to migrate into the intima and generate collagen and other fibrous products leading to advancement of fatty streaks to advanced atherosclerotic lesions. Direct myocardial damage and cytokine storm leading to destabilization of pre-existing plaques and accelerated formation of new plaques are the two instigating mechanisms for acute coronary syndromes in COVID-19

Analysis of the impact of COVID-19 pandemic on house-staff in the USA: addressing the ripple effects

Background: The novel corona virus has changed the way individuals interact with each other and society. In the medical sector, this has affected the residents and fellows who spend the majority of their time on the front lines. Methods: We conducted a cross-sectional survey to assess the impact of the COVID-19 pandemic on the lives and training of house-staff across the USA. Respondents in our survey reported feeling significantly overwhelmed by the ongoing pandemic. Results: The majority of house-staff were significantly concerned about the lack of protective equipment, inability to safeguard themselves from infection and inability to look after their families. Concerns regarding contracting the infection and transmitting it to their loved ones were reported as a cause of mental distress among resident physicians. Increasing patient load, lack of protective equipment, and disruption of educational and academic activities during the COVID-19 pandemic have all reportedly affected the training and overall well-being of resident physicians. Conslusion: Our study adds further support for measures to safeguard house-staff with proper protective equipment and ensure adequate support for both mental and physical well-being during these challenging times