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Objective: Rare coexistence of disease or pathology Background: Many patients experiencing acute coronary syndrome (ACS) present in cardiac arrest. Mechanical chest compressions are a common tool in cardiopulmonary resuscitation (CPR) and have their benefits as well as disadvantages and reported complications. In recent years, veno-arterial extracorporeal oxygenation membrane (VAECMO) has proven to be a promising tool in these circumstances and is now considered part of the treatment algorithm in emergent and refractory cases. The combination of mechanical compressions and the ECMO lead to "new" complicated situations in the patients. We discuss such a patient, who required emergent surgery due to complications from his resuscitation, while under ECMO. Case Report: A 56-year-old man, with medical history of cardiovascular risk factors, presented to our facility due to ST segment elevation myocardial infarction. During his catheterization, he went into cardiac arrest and needed cardiopulmonary resuscitation (CPR) using a LUCAS3™ device. Because no rhythm was restored, he was promptly placed on VA-ECMO support with immediate, albeit transient, stabilization. After transportation to our Intensive Care Unit (ICU), he quickly deteriorated again hemodynamically and after imaging workup it was discovered he had a major laceration to his liver and was rushed emergently to the operating room where he underwent partial hepatectomy, while on full anticoagulation due to the ECMO support. Conclusions: Complications from mechanical CPR are common, including liver laceration. Patients who are placed on ECMO following such measures should be carefully evaluated for such complications as they might affect the treatment and prognosis. [ABSTRACT FROM AUTHOR]

Objective: Rare disease Background: Atrial fibrillation is a common arrhythmia worldwide. The number of patients undergoing ablation as treatment is increasing, as is the incidence of complications from ablation. One such complication is atrio-esophageal fistula, which is rare but life threatening. We discuss 2 cases of patients that presented with a fistula several weeks following atrial fibrillation ablation. Case Reports: A 67-year-old man and 64-year-old woman both had cardiovascular morbidity and chronic kidney disease, diabetes, and other chronic illnesses. Both patients presented approximately 6 weeks after radiofrequency atrial fibrillation ablation and were admitted with varying symptoms, including fever and neurological deficits mimicking a cerebrovascular accident or massive bleeding. Both patients deteriorated very rapidly in the department, especially after certain interventions, such as endoscopy, and exhibited deteriorating neurological signs, including loss of consciousness and basic brain stem reflexes, and head computed tomography (CT) showed widespread infarcts and hemorrhages. Owing to their history, a chest CT was performed at the same time, revealing an atrio-esophageal fistula, which was determined to be the cause of their illness and led to their eventual deaths. Conclusions: A rare complication of atrial fibrillation ablation procedure is atrio-esophageal fistula, which if left untreated, is almost uniformly fatal, and even survivors are usually left with significant sequelae. It is important to recognize the rapid deterioration and possible signs and symptoms, such as gastrointestinal bleeding, fever, or even neurological abnormalities, and make the connection to the ablation procedure in terms of timeline for rapid diagnosis and prompt treatment. [ABSTRACT FROM AUTHOR]

In nonpregnant patients high insulin requirements are associated with hypoglycemia and weight gain but not with improvement in glucose control. The effect of insulin requirement on maternal and neonatal outcomes in gestational diabetes mellitus (GDM) is yet unknown. We conducted a retrospective cohort study of maternal and neonatal outcomes of pregnancy according to insulin requirements in women with GDM who were followed and delivered at the Yitzhak Shamir Medical Center between 2006 and 2016. The daily insulin dose in units per body weight was divided into quartiles and analyses were performed to compare the lowest, highest, and two middle quartiles. The primary outcome was a composite of any of the following: cesarean-section (CS), preeclampsia, macrosomia and large for gestational age (LGA) birth weight, neonatal intensive care unit admission, need for phototherapy, and neonatal hypoglycemia. Women were divided according to their insulin requirements as follows: 79 (24.8%) women who needed <0.13 IU/kg/day of insulin (insulin-sensitive group), 160 (50%) women who needed 0.14–0.42 IU/kg/day of insulin (comparison-group), and the rest who needed >0.43 IU/kg/day of insulin (insulin resistant group). There were no differences in the composite outcome between the groups (64.6, 61.3, and 69.6% for the insulin sensitive-, comparison- and resistant- groups, respectively, p =.44). Women in the insulin-resistant group had higher fasting glucose levels in the first trimester (91, 98 and 102 mg/dL for women in the insulin sensitive-, comparison- and insulin-resistant groups, respectively; p =.01). Women in the insulin-sensitive group had significantly better glycemic control (fasting glucose levels ≤90 mg/dL and 1-hour and 2-hour postprandial glucose levels ≤140 mg/dL and ≤120 mg/dL for more than 80% of measurements) than those in the insulin-resistant group (70.3 versus 29.9%; p <.001). The rate of CS was significantly higher in the insulin-resistant group (42.3 versus 24.1%; p =.03), but the rate of LGA birth weight was surprisingly higher in the insulin-sensitive group (29.5 versus 16.7%, p =.04). After controlling for confounders, women in the insulin-sensitive group had a decreased risk for CS in relation to the comparison group (OR = 0.46, 95%CI 0.23–0.9, p =.025). We found no association between insulin requirements and adverse composite outcome in women with GDM. However, those with higher insulin requirements have poorer glucose control and higher rates of CS than those with lower insulin requirements. Larger studies are needed to inquire short- and long-term outcomes of insulin requirements on fetal and maternal outcomes. [ABSTRACT FROM AUTHOR]

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