Patient: Male, 63-year-old Final Diagnosis: Electrical storm Symptoms: Hypotension • syncope Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Pheochromocytomas are catecholamine-secreting tumors that develop within the chromaffin cells of the adrenal glands. They most commonly present with hypertension, and the classic triad of symptoms is headaches, palpitations, and diaphoresis. Electrical storm (ES) is defined as at least 3 sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate shocks from an implanted cardioverter-defibrillator (ICD) within 24 h. We discuss the case of a 63-year-old man with known bilateral pheochromocytomas who presented with ES prompting multiple ICD shocks, possibly exacerbated by catecholamine surge from his adrenal tumors. Case Report: The patient was a 63-year-old man with an extensive medical history including ischemic cardiomyopathy and congestive heart failure with reduced ejection fraction presented with multiple syncopal episodes secondary to persistent monomorphic ventricular tachycardia (MMVT), polymorphic ventricular tachycardia (PMVT), and VF requiring ICD shocks. He had known bilateral pheochromocytomas. ES was attributed to catecholamine excess in the setting of these tumors, so VT ablation was deferred pending tumor removal. Alpha blockade was initiated preoperatively, and the patient subsequently underwent bilateral adrenalectomy; however, he continued to sustain tachyarrhythmias and eventually died despite resuscitative efforts. Conclusions: Bilateral pheochromocytomas are rare adrenal tumors. In even more infrequent situations, they can cause ES secondary to adrenergic stimulation from catecholamine surges. It is worth considering pheochromocytoma in patients with refractory ES, as treating these tumors could potentially reduce the frequency of this dangerous arrhythmia.

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Glycosylated hemoglobin (HbA1c) reflects how well blood glucose is controlled and is one of the strongest predictors of chronic complications of diabetes mellitus. The degree of acidosis helps determine the severity of diabetic ketoacidosis (DKA) (mild: pH 7.2–7.3; moderate: pH 7.1–7.2; severe: pH <7.1) and guides the level of care and predicts outcome. Many studies have implicated that higher HbA1c levels lead to recurrent DKA. However, there is no description of the association of higher HbA1c with the severity of DKA. One hundred thirty-eight electronic medical records of patients aged 1 to 21 years admitted to the pediatric intensive care unit with DKA between 2011 and 2015 were analyzed. We excluded 50 patients because the HbA1c level was not available. Spearman correlation analyzed the data for 88 patients included in the study. The mean HbA1c was 13.3, with female patients having more admissions compared with male patients (58% vs 42%). The age group from 13 to 21 years accounted for 77.3% of the patients. The duration of type 1 diabetes mellitus did not affect the HbA1c level. Likewise, the blood glucose and serum creatinine level did not show a statistical correlation with blood pH levels. Mean HbA1c for mild, moderate, and severe DKA groups were 11.4%, 12.2%, and 14.8%, respectively. Blood pH and HbA1c returned a negative correlation (correlation coefficient, −0.557; P = 0.005). The HbA1c level correlated positively with the 3 groups of DKA (correlation coefficient, 0.595; P = 0.01). A higher A1c was associated with more severe DKA.

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Background: High quality bowel preparation is crucial for an effective examination of the colon during colonoscopy. Diabetes, chronic constipation, spinal cord injury, and the use of medications such as narcotics and tricyclic antidepressants are well known predictors of inadequate bowel preparation. The 2014 US Multi-Society Task Force guidelines do not recommend the use of a specific bowel regimen in high risk patients, and limits its statement to the favorable use of additional purgatives in this group of patients (weak recommendation, low quality evidence). We aimed to identify the rate of inadequate bowel preparation in high risk patients and to compare the efficacy of different types of bowel preparations in this population. Methods: We identified colonoscopies (nZ3651) performed at our institution between January 2019 until November 2019. Patients at high risk for inadequate preparation were identified by specific ICD-10 codes for constipation, diabetes or spinal cord injury or by review of outpatient pharmacy orders for narcotics, antidepressants or laxatives. Bowel preparation adequacy was reported according to the 4-point Boston Bowel Preparation Scale. Mid-P Exact test was used to compare the rates of poor bowel preparation in constipated patients according to the bowel preparation received. Results: The majority of patients were male (92.3%) with a mean age of 64.2+10.4. Approximately 65% of patients received a split dose PEG electrolyte solution with ascorbic acid (Moviprep), 25% received 1 week of PEG 3350 (Miralax) prior to a split dose Moviprep or PEG electrolyte solution (Golytely), and 9.5% prepped with Golytely. Overall, 680 colonoscopies (18.6%) had inadequate bowel preparation of which 235 (6.4%) were deemed poor. A total of 2166 colonoscopies (59.3%) were performed on high risk patients (table). Among high risk patients, the rate of inadequate bowel preparation was 24.5% (figure). In a subgroup analysis on patients with constipation who were prescribed laxatives (nZ984), the rate of poor bowel preparation was significantly reduced in patients who received 1 week of Miralax followed by split dose Moviprep or Golytely (13.9%) compared to Split dose Moviprep or Golytely alone (19.9%) ORZ 0.65(95% CI: 0.46-0.91, pZ0.006). Conclusion: High risk patients have an increased rate of inadequate bowel preparation. One week of Miralax followed by split dose Moviprep or Golytely reduced the rate of poor bowel preparation in constipated patients on laxatives. If proven beneficial in large randomized controlled trials, this method of preparation will reduce repeated colonoscopies and wasted capacity in endoscopy unit.