The diagnosis of methemoglobinemia should be considered in patients presenting with cyanosis and hypoxia. A variety of frequently used medications are capable of inducing methemoglobinemia, with dapsone and benzocaine being common culprits. Unique features, such as a saturation gap and chocolate-brown-colored blood, can raise suspicion for methemoglobinemia. Typically, symptoms correlate with the methemoglobin level, and treatment with methylene blue is reserved for patients with significantly elevated methemoglobin levels. In the presence of comorbid conditions that impair oxygen transport, however, low-grade methemoglobinemia can become symptomatic and may warrant treatment.

After traumatic brain injury, a 12-week course of AMH was safe and, according to parent report, improved behavior. AMH may have the potential to improve cognition in more recently injured children.

Methemoglobinemia occurs when hemoglobin is oxidized to form methemoglobin (MetHb) rendering it incapable of oxygen transport and leading to tissue hypoxia. Typically, protective mechanisms keep MetHb levels below 1%, but a variety of compounds are capable of inducing methemoglobinemia including dapsone. Normally, symptoms correlate with MetHb level and treatment with methylene blue is reserved for patients with significantly elevated MetHb levels. We present a case of symptomatic low-grade methemoglobinemia because of dapsone therapy. This case illustrates a multiple hit hypothesis where comorbid conditions prompt symptoms at a low MetHb level. Understanding the impact of comorbid conditions in exacerbating low-grade methemoglobinemia is important in diagnosing and managing this condition. Treatment with methylene blue should be guided by the whole clinical picture rather than by the MetHb level alone.

SummaryEach year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.Clin J Am Soc A left heart catheterization with percutaneous intervention to an occluded coronary artery is performed. Anuric renal failure occurs from acute tubular necrosis soon after and dialysis is initiated. He also has complications of postanoxic encephalopathic seizures, lower gastrointestinal bleeding, and laboratory values consistent with shock-liver. He remains intubated without sedation. At both 24 and 72 hours-off sedation-the patient lacks corneal reflexes and has only extensor motor responses to pain. The neurology consultants diagnose him with severe anoxic brain injury and state in the medical record that the patient has a "poor prognosis." Two weeks after arrest, the patient is transferred from the initial hospital to a second hospital at the family's request. At the new hospital, the pulmonary and critical care team consults the neurology, renal, and palliative care teams to discuss the patient's care plan. Dialysis and ventilator support are continued. The primary team schedules a family meeting for the next day with palliative care, patient advocacy, social services, and the patient's wife and two grown children. The meeting centers on discussing the patient as a person, and the medical providers learn that Mr. A. was...