In patients admitted for ADHF with reduced ejection fraction and evidence of fluid overload, an increase in loop diuretic dose at discharge was associated with a reduced rate of 30-day hospital readmission.

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A 12-month-old female presented to the emergency department after falling from her 5-year-old sibling's arms onto a blunt tipped pen he was simultaneously holding. She was neurologically intact and clinically stable on arrival. Physical examination was unremarkable aside from a 2-cm laceration in the soft palate without foreign body (FB) visualized on deep exploration. Endoscopy of bilateral nares, nasopharynx, and upper airway was also negative for abnormalities. Lateral neck X-ray demonstrated the pen tip over the right posterior nasopharynx embedded in adenoidal tissue. The patient underwent an extensive soft palate and nasopharyngeal exploration, including partial adenoidectomy under anesthesia that were again unrevealing for an FB. The decision to undergo computed tomography (CT) and CT angiogram (CTA) of the head was made and revealed the FB abutting the right carotid canal in the petrous apex (Figure 1). However, due to significant artifact, vascular injury could not be excluded. Careful management and approach to her FB removal was planned among a multidisciplinary team including neurosurgery, interventional neuroradiology, skull-based rhinology, pediatric otolaryngology, and anesthesiology while the patient was placed on prophylactic antibiotics. Planned diagnostic cerebral angiogram with removal of the pen tip demonstrated a normal right internal carotid artery without evidence of injury, dissection, or pseudoaneurysm (Figure 2). Angiography of the cranial region revealed no evidence of the FB. Subsequent investigation identified a metallic object at the level of the gastroesophageal junction, suggesting dislodgement of the FB from the skull base confirmed by portable chest X-ray (Figure 3). A team consensus for no further intervention was concluded and the patient was extubated and monitored without complications before discharge home.

We present a case of a 2-year-old boy who underwent thoracoscopic resection of a left paraspinal mediastinal mass and developed Harlequin syndrome postoperatively. Harlequin syndrome is a rare neurological condition characterized by unilateral hyperhidrosis and erythema of the head and neck. Our discussion highlights this condition and other differential diagnoses that may present similarly in the postoperative period.

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