BMJ case reports
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Flow diversion for the management of intracranial aneurysms represents a paradigm shift in how aneurysms are managed. The Pipeline embolization device (PED) is, to date, the only flow diverter approved for use in the USA by the Food and Drug Administration. Limitations and complications with new treatment strategies are inevitable, and with the PED there have been reports of complications, most commonly with challenging deployments. ⋯ A second-generation Pipeline has been developed that addresses these concerns. We report the first use in North America of this second-generation Pipeline device: the Pipeline Flex. We discuss our rationale for using the device, our impressions of its operation, and the relevant literature concerning the current state of flow diversion.
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In patients suffering from pulmonary haemorrhage, or in patients who recently received a tracheostomy, acute occlusion of the endotracheal tube due to a blood clot is a rare, but well-known complication. Acute and complete occlusion of the tube is easily recognisable. There are various methods of removing the obstructive clot, such as using a bronchoscope with forceps, topical thrombolysis, saline lavage and suctioning. ⋯ When there is a partial obstruction of the endotracheal tube, ventilation is possible, although high inspiratory pressures are necessary. If the clot functions as a ball valve ventil, raised intrathoracic pressure will cause right-sided heart failure or tension pneumothorax. It is important to recognise a partially obstructed tube in time and remove the obstruction.
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Review Case Reports
Airway compromise due to adenoid cystic carcinoma obstructing the distal trachea: a review of current management and clinical trials.
An 84-year-old man presented with a 2-month history of intermittent stridor and worsening difficulty in breathing. Chest X-ray and flexible nasendoscopy were unremarkable but following further deterioration a CT scan revealed an obstructing lesion in the distal trachea. Bronchoscopy revealed an infiltrative tumour arising 3 cm above the carina causing 90% obstruction. ⋯ Histological analysis revealed a diagnosis of adenoid cystic carcinoma. Transthoracic surgical resection was unsuccessful and the patient continues to be effectively managed with periodic bronchoscopic debulking and radiotherapy. This case highlights the diagnostic and therapeutic dilemmas posed by distal tracheal lesions and the need for specialist input for effective management.
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Pregabalin is widely used for treatment of neuropathic pain and is only approved for oral use. This is the first reported case of using pregabalin by the rectal route for treatment in a 70-year-old patient with chronic neuropathic pain and complete intestinal failure. ⋯ Serum levels were measured to assess absorption. Within a few weeks of starting the treatment, the patient had improved pain control and appeared more comfortable and calm.