Medicine by Sfakianakis Alexandros: 09/27/17

Τετάρτη 27 Σεπτεμβρίου 2017

Stent-assisted coiling of a ruptured vertebrobasilar junction aneurysm via direct vertebral artery puncture

A 78-year-old patient was admitted with subarachnoid hemorrhage caused by rupture of a broad-based vertebrobasilar junction aneurysm. Direct endovascular access to the vertebrobasilar circulation was not possible due to chronic occlusion of the proximal dominant left vertebral artery (VA), hypoplastic right VA and posterior communicating arteries. The distal cervical left VA was reconstituted by muscular branches of the ascending cervical artery. Therefore, endovascular access was gained by direct percutaneous VA puncture guided by a roadmap-controlled anterior approach at the level of C5 proximally to the main reconstituting collateral feeders. Successful endovascular treatment of the aneurysm was performed by stent-assisted coiling. Closure of the puncture site at the cervical VA level was achieved by occluding the proximal part of the VA with coils. The post-interventional clinical course was uneventful; early post-interventional CT showed no evidence of cervical hematoma.

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Intrapartum assessment of fetal well-being

1A012A043J02

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Earliest depiction of vitiligo in “Venus at a Mirror” (1615) by Peter Paul Rubens (1577–1640)

Summary

The 1615 painting of Venus at a Mirror by Peter Paul Rubens is considered a powerful example of the Flemish Baroque movement. Recently it has been identified that the Venus character in the image has a goitre, however on studying the image further, I note dermato-pathology in another of the painting's main characters; the dark-skinned female typically described as the Venus' maidservant who clearly demonstrates patches of skin pigment loss on her face and neck with a concurrent streak of white hair. Together these suggest the underlying diagnosis of vitiligo. There is also a goitre in this individual suggesting thyroid disease. This new finding may offer additional insight into the historical epidemiology of disease in northern Europe but also offers further understanding of the method, origin, and pathological associations of this prominent painting from a genius artist.

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Brain functional connectivity differentiates dexmedetomidine from propofol and natural sleep

Abstract

Background.

We used functional connectivity measures from brain resting state functional magnetic resonance imaging to identify human neural correlates of sedation with dexmedetomidine or propofol and their similarities with natural sleep.

Methods.

Connectivity within the resting state networks that are proposed to sustain consciousness generation was compared between deep non-rapid-eye-movement (N3) sleep, dexmedetomidine sedation, and propofol sedation in volunteers who became unresponsive to verbal command. A newly acquired dexmedetomidine dataset was compared with our previously published propofol and N3 sleep datasets.

Results.

In all three unresponsive states (dexmedetomidine sedation, propofol sedation, and N3 sleep), within-network functional connectivity, including thalamic functional connectivity in the higher-order (default mode, executive control, and salience) networks, was significantly reduced as compared with the wake state. Thalamic functional connectivity was not reduced for unresponsive states within lower-order (auditory, sensorimotor, and visual) networks. Voxel-wise statistical comparisons between the different unresponsive states revealed that thalamic functional connectivity with the medial prefrontal/anterior cingulate cortex and with the mesopontine area was reduced least during dexmedetomidine-induced unresponsiveness and most during propofol-induced unresponsiveness. The reduction seen during N3 sleep was intermediate between those of dexmedetomidine and propofol.

Conclusions.

Thalamic connectivity with key nodes of arousal and saliency detection networks was relatively preserved during N3 sleep and dexmedetomidine-induced unresponsiveness as compared to propofol. These network effects may explain the rapid recovery of oriented responsiveness to external stimulation seen under dexmedetomidine sedation.

Trial registry number.

Committee number: 'Comité d'Ethique Hospitalo-Facultaire Universitaire de Liège' (707); EudraCT number: 2012-003562-40; internal reference: 20121/135; accepted on August 31, 2012; Chair: Prof G. Rorive. As it was considered a phase I clinical trial, this protocol does not appear on the EudraCT public website.

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Procaine and Local Anesthetic Toxicity: A Collaboration Between the Clinical and Basic Sciences.

In 1924, the Therapeutic Research Committee of the American Medical Association appointed a special committee to investigate deaths following the administration of local anesthetics. The Committee for the Study of Toxic Effects of Local Anesthetics found procaine, although a safer clinical alternative to cocaine, was capable of causing death when large doses were injected into tissues and advised that it should be used with caution. This article describes a collaboration beginning in 1928 between Dr John Lundy of the Mayo Clinic and Dr Robert Isenberger of the University of Kansas, which arose from a controversy surrounding systemic adverse reactions to procaine. Isenberger then traveled to the Mayo Clinic to conduct research on various procaine local and spinal anesthesia doses and sodium amytal's protective effect against procaine-induced toxicity. Lundy and Isenberger's work would add to the ongoing discovery of systemic reactions to local anesthetics. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Impact of Regional Anesthesia on Recurrence, Metastasis, and Immune Response in Breast Cancer Surgery: A Systematic Review of the Literature.

Background and Objectives: The perioperative period is critical in the long-term prognosis of breast cancer patients. The use of regional anesthesia, such as paravertebral block (PVB), could be associated with improvements in long-term survival after breast cancer surgery by modulating the inflammatory and immune response associated with the surgical trauma, reducing opioid and general anesthetic consumption, and promoting cancer cells death by a direct effect of local anesthetics. Methods: A systematic literature search was conducted for studies of patients who received PVB for breast cancer surgery. The Jadad score and Ottawa-Newcastle scale were used to assess the methodological quality of randomized controlled trial and observational retrospective studies, respectively. Only high-quality studies were considered for meta-analysis. The selected studies were divided into 3 groups to determine the impact of PVB on (a) recurrence and survival, (b) humoral response, and (c) cellular immune response. Results: We identified 467 relevant studies; 121 of them underwent title and abstract review, 107 were excluded, and 15 studies were selected for full text reading and quality assessment. A meta-analysis was not conducted because of low-quality studies and lack of uniform definition among primary outcomes. Thus, a systematic review of the current evidence was performed. Conclusions: Our study indicates that there are no data to support or refute the use of PVB for reduction of cancer recurrence or improvement in cancer-related survival. However, PVB use is associated with lower levels of inflammation and a better immune response in comparison with general anesthesia and opioid-based analgesia. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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The role of the ugly duckling sign in patient education

The ABCDE (with A standing for asymmetry, B for border irregularity, C for color variegation, D for diameter larger than 6 mm, and E for evolution) rule for melanoma (MM) recognition is widely taught in the general population. The ugly duckling (UD) sign is an alternate MM recognition strategy that is not generally taught.

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Cultural competence for the 21st century dermatologist practicing in the United States

Significant health disparities exist among under-represented minorities in the Unites States, which can partially be accounted for by the quality of patient-physician interaction. A distinguishing factor of this interaction is the ability of the provider to demonstrate cultural competence, or address the social, cultural, and community influences on healthcare behaviors and incorporate these elements into patient care. However, this practice has yet to be universally implemented in our healthcare system.

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Gefitinib for patients with incurable cutaneous squamous cell carcinoma: A single-arm phase II clinical trial

Preclinical data demonstrate a key role for the epidermal growth factor receptor (EGFR) in the carcinogenesis of cutaneous squamous cell carcinomas (CSCCs). There are, however, limited data on the efficacy of EGFR inhibitors in incurable, recurrent, and/or metastatic CSCC.

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Recurrent scarring papulovesicular lesions on sun-exposed skin in a 22-year-old man

A 22-year-old white man has been followed in the Clinical Center at the National Institutes of Health (NIH) for recurrent outbreaks of scarring herpetiform lesions on sun-exposed areas. The patient and/or parents signed consent forms and were followed under NIH protocols that were approved by the institutional review boards of the National Human Genome Research Institute, National Institute of Allergy and Infectious Diseases, and National Cancer Institute.

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Cardiovascular comorbidities of pediatric psoriasis among hospitalized children in the United States

Psoriasis has been shown to be associated with cardiovascular disease in adults. Little is known about cardiovascular risk in pediatric psoriasis.

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Racial and ethnic differences in health care utilization for childhood eczema: An analysis of the 2001-2013 Medical Expenditure Panel Surveys

Eczema is a common chronic inflammatory disease of the skin. Studies suggest differences in disease prevalence and severity by race/ethnicity. Our knowledge of health care utilization for eczema among different racial/ethnic groups remains limited.

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Comparison of snoring sounds between natural and drug-induced sleep recorded using a smartphone

Snoring is an important clinical feature of obstructive sleep apnea (OSA), and recent studies suggest that the acoustic quality of snoring sounds is markedly different in drug-induced sleep compared with natural sleep. However, considering differences in sound recording methods and analysis parameters, further studies are required. This study explored whether acoustic analysis of drug-induced sleep is useful as a screening test that reflects the characteristics of natural sleep in snoring patients.

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The Role of Allergy in Chronic Rhinosinusitis

The role of allergy in chronic rhinosinusitis (CRS) has long been debated and remains controversial. The 2 diseases frequently co-occur; however, direct causality has never been proved. The literature is largely mixed as to the manner and degree by which allergy contributes to CRS and this is in large part due to heterogeneity in the definitions of allergy and of CRS. In this review, the potential role of allergy in the disease processes of CRS without polyps, CRS with polyps, and allergic fungal rhinosinusitis is discussed.

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Advances in Food Allergy

Food allergy has been increasing in prevalence for the last few decades, and numerous studies have evaluated ways of improving the allergy practitioner's ability to accurately diagnose patients who are truly food allergic, rather than sensitive but able to tolerate food. Once diagnosed, the current standard treatment is food elimination and avoidance, but other potential treatment options like oral immunotherapy, sublingual immunotherapy, and epicutaneous immunotherapy are becoming promising alternatives. Due the health care costs and potential for life-threatening adverse reactions, much attention has been given to the prevention of food allergies, resulting a shift in recent guideline recommendations.

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Efficacy and Safety of Subcutaneous and Sublingual Immunotherapy for Allergic Rhinoconjunctivitis and Asthma

Allergic rhinitis is often associated with asthma and has significant impacts on health care costs and productivity in the United States. Although allergen avoidance and pharmacotherapy are effective, allergen-specific immunotherapy is the only treatment that may lead to improved allergy symptoms even after treatment is discontinued. Subcutaneous immunotherapy has been the mainstay of allergen-specific immunotherapy in the United States for decades, but sublingual immunotherapy has recently become available. This review discusses the use of subcutaneous immunotherapy and sublingual immunotherapy in the treatment of allergic rhinitis and asthma and reviews the current evidence regarding the safety and efficacy of both formulations.

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Immunotherapy

Polysensitization, sensitization to more than one allergen, is a common feature of patients with allergic rhinitis, and may be a risk factor for subsequent development of allergic diseases, especially allergic asthma. However, a polysensitized patient does not necessarily have polyallergy, a documented, causal relationship between exposure to 2 or more specific, sensitizing allergens and the subsequent occurrence of relevant clinical symptoms of allergy. Allergen immunotherapy treatment strategy for the polysensitized patient in Europe is to treat the single or 2 most clinically relevant allergen(s), whereas patients in the United States are usually treated for all potential clinically relevant allergens.

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Contemporary Pharmacotherapy for Allergic Rhinitis and Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) are chronic conditions causing nasal inflammation. CRS is increasingly recognized as a chronic inflammatory process rather than a chronic infection. Although the primary initiating factors in CRS remain unclear, AR is driven by IgE-mediated hypersensitivity to environmental allergens. Understanding the underlying inflammatory pathways and disease endotypes are driving innovation toward novel pharmacotherapies targeting critical mediators implicated in CRS and AR, including IL-4, IL-13, IL-5, IgE, and epithelial initiators IL-33 and TSLP. Extensive investigations are needed to determine the role, timing, predictive prognostic factors and long-term safety and efficacy of these agents.

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Editorial Board

Publication date: October 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 134, Issue 5

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Publication date: October 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 134, Issue 5

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The Effect of Prophylactic Phenylephrine and Ephedrine Infusions on Umbilical Artery Blood pH in Women With Preeclampsia Undergoing Cesarean Delivery With Spinal Anesthesia: A Randomized, Double-Blind Trial.

BACKGROUND: Spinal anesthesia for cesarean delivery is associated with a high incidence of hypotension. Phenylephrine results in higher umbilical artery pH than ephedrine when used to prevent or treat hypotension in healthy women. We hypothesized that phenylephrine compared to ephedrine would result in higher umbilical artery pH in women with preeclampsia undergoing cesarean delivery with spinal anesthesia. METHODS: This study was a randomized double-blind clinical trial. Nonlaboring women with preeclampsia scheduled for cesarean delivery with spinal anesthesia at Prentice Women's Hospital of Northwestern Medicine were randomized to receive prophylactic infusions of phenylephrine or ephedrine titrated to maintain systolic blood pressure >80% of baseline. Spinal anesthesia consisted of hyperbaric 0.75% bupivacaine 12 mg, fentanyl 15 [micro]g, and morphine 150 [micro]g. The primary outcome was umbilical arterial blood pH and the secondary outcome was umbilical artery base excess. RESULTS: One hundred ten women were enrolled in the study and 54 per group were included in the analysis. There were 74 and 72 infants delivered in the ephedrine and phenylephrine groups, respectively. The phenylephrine:ephedrine ratio for umbilical artery pH was 1.002 (95% confidence interval [CI], 0.997-1.007). Mean [standard deviation] umbilical artery pH was not different between the ephedrine 7.20 [0.10] and phenylephrine 7.22 [0.07] groups (mean difference -0.02, 95% CI of the difference -0.06 to 0.07; P = .38). Median (first, third quartiles) umbilical artery base excess was -3.4 mEq/L (-5.7 to -2.0 mEq/L) in the ephedrine group and -2.8 mEq/L (-4.6 to -2.2mEq/L) in the phenylephrine group (difference -0.6 mEq/L, 95% CI of the difference -1.6 to 0.3 mEq/L; P = .10). When adjusted for gestational age and infant gender, umbilical artery pH did not differ between groups. There were also no differences in the umbilical artery pH stratified by magnesium therapy or by the severity of preeclampsia. CONCLUSIONS: We were unable to demonstrate a beneficial effect of phenylephrine on umbilical artery pH compared with ephedrine. Our findings suggest that phenylephrine may not have a clinically important advantage compared with ephedrine with regard to improved neonatal acid-base status when used to prevent spinal anesthesia-induced hypotension in women with preeclampsia undergoing cesarean delivery. (C) 2017 International Anesthesia Research Society

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In Response.

No abstract available

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Understanding the Significance of Aerosolized Vasodilator Use in Pulmonary Hypertension: What Is Numerically, Statistically, and Clinically Meaningful?.

No abstract available

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Mechanisms Supporting Astrocyte-Mediated Neuroprotection.

No abstract available

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The Effect of Zinc Lozenge on Postoperative Sore Throat: A Prospective Randomized, Double-Blinded, Placebo-Controlled Study.

BACKGROUND: Postoperative sore throat (POST) is commonly seen after endotracheal intubation, and oral zinc prevents oral mucositis associated with chemotherapy. This study is designed to evaluate the effects of administration of zinc lozenges on POST. METHODS: Seventy-nine patients undergoing low- or moderate-risk surgery with endotracheal intubation were randomly assigned into 2 groups: Control group received placebo and zinc group received 40-mg zinc lozenges 30 minutes preoperatively. Patients were assessed for incidence and severity (4-point scale, 0-3) of POST at 0, 2, 4, and 24 hours postoperatively. The primary outcome was incidence of POST at 4 hours after surgery. The secondary outcomes were the incidence of POST at 0, 2, and 24 hours and the severity of POST. RESULTS: At 4 hours, there was a significantly lower incidence of POST in the zinc group, 7%, than the control group, 29% (P = .046). The incidence of POST at 0 hour was 0% in zinc group and 24% in control group (P = .004). The highest incidence of POST occurred at the second hour after surgery, with the rate of 10% in the zinc group and 34% in the control group (P = .0495). The incidence of POST at 24 hours was 13% in zinc group and 24% in control group (not significant). The severity of POST was significantly lower in the zinc group for mild (P = .003) and moderate (P = .004) POST. CONCLUSIONS: The administration of a single dose of 40-mg zinc lozenge 30 minutes preoperatively is effective to reduce both incidence of POST in the first 4 hours and severity of mild and moderate POST in the immediate postoperative period. (C) 2017 International Anesthesia Research Society

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How Safe Are Various Systemic Therapies for Pediatric Psoriasis?

Reuters Health Information

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The sex-shift in single disease and multimorbid asthma and rhinitis during puberty

Abstract

Background

Cross-sectional studies suggested that allergy prevalence in childhood is higher in boys compared to girls, but it remains unclear if this inequality changes after puberty. We examined the sex-specific prevalence of asthma and rhinitis as single and as multimorbid diseases before and after puberty-onset in longitudinal cohort data.

Methods

In six European population-based birth cohort studies we assessed the outcomes current rhinitis, current asthma, current allergic multimorbidity (i.e. concurrent asthma and rhinitis), puberty status, and allergic sensitization by specific serum antibodies (immunoglobulin E) against aero-allergens. With generalized estimating equations we analysed the effects of sex, age, puberty (yes/no), and possible confounders on the prevalence of asthma and rhinitis, and allergic multimorbidity in each cohort separately and performed individual participant data meta-analysis.

Findings

We included data from 19,013 participants from birth to age 14-20 years. Current rhinitis only affected girls less often than boys before and after puberty onset: adjusted odds ratio for females vs. males 0.79 (95%-confidence interval 0.73-0.86) and 0.86 (0.79-0.94) respectively (sex-puberty interaction p= 0.089).

Similarly, for current asthma only, females were less often affected than boys both before and after puberty-onset: 0.71, 0.63-0.81 and 0.81, 0.64-1.02, respectively (sex-puberty interaction p=0.327).

The prevalence of allergic multimorbidity showed the strongest sex-effect before puberty onset (female-male-OR 0.55, 0.46-0.64) and a considerable shift towards a sex-balanced prevalence after puberty onset (0.89, 0.74-1.04); sex-puberty interaction: p<0.001.

Interpretation

The median follow-up was 35.9 months. The 3-year OS of the IMRT, 3D conformal RT, and total groups was 81.6%, 57.2%, and 66.6%, respectively. Pulmonary toxicity was not observed with IMRT. Six of 62 cases (9.6%) with nodal involvement developed upper cervical node recurrence outside the prophylactic region. Ten patients in the IMRT group were salvaged, and 60% survived without recurrence; 20% of the 3D conformal RT group was salvaged.

Conclusion

The IMRT group was comparable with 3D conformal RT group, with a better salvage rate. We recommend extended cervical irradiation for nodal involvement.

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Prior Authorizations for Diagnostic Skin Biopsies

This Viewpoint outlines how managed care policies on prior authorization for diagnostic skin biopsies are affecting costs, access to care, and quality of care for patients.

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Nonhealing Leg Ulcer in a Middle-aged Indian Man

A middle-aged Indian man with multiple, ill-defined, hypopigmented, asymptomatic lesions on his face and scalp presents with a painful foot ulcer having well-defined margins and a yellowish slough that remained unhealed after 1 year. Treatment with rifampicin, dapsone, and clofazimine after an earlier diagnosis of multibacillary leprosy failed. What is your diagnosis?

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Thyroid Function in Children With Alopecia Areata

This study characterizes thyroid function in children with alopecia areata to establish guidelines for thyroid dysfunction screening.

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Descriptive Error in the Text

In the Original Investigation titled "Prevalence of Pubic Hair Grooming–Related Injuries and Identification of High-Risk Individuals in the United States," published online August 16, 2017, there was a descriptive error in the text. The term vagina was used rather than the more accurate labia majora in 4 instances. This article has been corrected online.

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Use of a Physician Extender and Dermatology Appointment Wait Times

This cross-sectional analysis of responses to a telephone algorithm finds that dermatology appointment wait times have doubled over the past decade and appointment wait time may have an influence on dermatology office management.

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Chronic Urticaria in Children

Six years ago, we reviewed what was then known about chronic urticaria (CU) in children. We came to the conclusion that many important and interesting questions were unanswered. These included, but were not limited to, how common chronic spontaneous urticaria (CSU) and inducible urticaria are in children, the clinical presentation, underlying causes, impact on everyday life of CU in children, and the natural course of pediatric CU. We also suggested strategies to address and answer these questions and encouraged further studies to do so.

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Sclerotherapy for Reticular Veins in the Lower Limbs

This randomized clinical trial compares sclerotherapy of reticular veins of the lower limb with 2% polidocanol diluted in 70% hypertonic glucose vs hypertonic glucose alone.

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Factors Associated With Chronic Urticaria in Children

This cohort study examined the resolution rate of chronic urticaria in children and whether there are biomarkers that can predict resolution.

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Airway pathology in severe asthma is related to airflow obstruction but not symptom control

Abstract

Background

Patients with asthma present structural and inflammatory alterations that are believed to play a role in disease severity. However, airway remodeling and inflammation have not been extensively investigated in relation to both symptom control and airflow obstruction in severe asthmatics. We aimed to investigate several inflammatory and structural pathological features in bronchial biopsies of severe asthmatics that could be related to symptom control and airflow obstruction after standardized treatment.

Methods

50 severe asthmatics received prednisone 40 mg/day for 2 weeks and maintenance therapy with budesonide/formoterol 400/12 μg twice daily + budesonide/formoterol 200/6 μg as needed for 12 weeks. Endobronchial biopsies were performed at the end of 12 weeks. We performed extensive immunopathological analyses of airway tissue inflammation and remodeling features in patients stratified by asthma symptom control and by airflow obstruction.

Results

Airway tissue inflammation and remodeling were not associated with symptom control. Asthmatics with persistent airflow obstruction had greater airway smooth muscle (Asm) area with decreased periostin and transforming growth factor beta positive cells within Asm bundles, in addition to lower numbers of chymase positive mast cells in the submucosa compared to patients with non-persistent obstruction.

Conclusions

Symptom control in severe asthmatics was not associated with airway tissue inflammation and remodeling, although persistent airflow obstruction in these patients was associated with bronchial inflammation and airway structural changes.

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The roadmap for Allergology in Europe: the subspecialty of Allergology as ‘stop-over’ on the way to a full specialty. An EAACI position statement

Abstract

The vision of EAACI and the UEMS Section and Board (S&B) on allergology is to promote and to establish a full specialty of allergology in all European countries. In many European countries a full specialty does not exist. In those countries organ-based (sub)specialists or paediatricians and internists with an expertise in allergology may deliver allergy care. There are no generally accepted requirements for the training of subspecialists available. To fill the gap between the need and availability of experienced and accredited physicians who can deliver optimal care to the allergic patients the EAACI Specialty Committee proposes the minimal requirements for training and certification of subspecialists in allergology. This paper describes the required theoretical knowledge, skills, competences and training facilities (staff and institution). The subspecialist as described in this paper should ideally show the necessary competence in providing good quality care to patients in an environment lacking those full specialists in allergology or tertiary care paediatric subspecialists in allergy.

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Iridociliary epithelial cyst

Description

A 26-year-old male patient presented for routine ocular evaluation; visual acuity was 20/20 in each eye with +0.75 dioptre sphere. Bilateral anterior segment examination showed a clear cornea and a normal central anterior chamber depth. In the right eye towards the periphery on temporal aspect, anterior surface of the iris showed irregular anterior elevation (figure 1A, red and yellow arrows) without any loss of its contour or endothelial touch. Lens was crystalline clear, and the pupil was reactive in absence of any posterior synechiae or anterior chamber cells; intraocular pressures were 16 and 14 mm Hg in right and left eye, respectively. Left eye anterior segment and retina in both the eyes were essentially within normal limits. Gonioscopy in both the eyes showed open angles without any identifiable pathology. Anterior segment optical coherence tomography (ASOCT) confirmed the anterior elevation of the iris at two sites (figure 1B,...

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Spontaneous intramural small bowel hematoma in a patient with acute myeloid leukaemia receiving chemotherapy and nilotinib

Spontaneous intramural small bowel hematoma (SISBH) is a rare, acute abdominal condition, with increasing incidence in recent years. Excessive anticoagulation with vitamin K antagonists is the most common aetiology. We report the case of a large acute jejunal intramural hematoma in a patient with newly diagnosed acute myeloid leukaemia receiving chemotherapy and nilotinib. The patient presented with abdominal pain, haematochezia, acute anaemia and thrombocytopenia. CT of the abdomen and pelvis revealed SISBH. The patient was managed conservatively with supportive management and cessation of nilotinib therapy. The patient's symptoms improved, with subsequent CT imaging confirming resolution. This case highlights an uncommon cause of gastrointestinal bleed usually diagnosed only after radiological imaging. A correct diagnosis is important as SISBH usually responds to conservative measures, and may obviate the patient from unnecessary invasive investigations.

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Ventricular tachycardia after initiation of fingolimod

Fingolimod, a sphingosine-1-phosphate receptor modulator, is used for the treatment of relapsing-remitting multiple sclerosis. It is well known to cause bradyarrhythmias. We present a 63-year-old woman who was admitted to the hospital with sustained monomorphic ventricular tachycardia 2 weeks after fingolimod initiation. Further evaluation showed that the patient's ventricular tachycardia was most likely secondary to her medication. Medical practitioners need to be aware of such possible life-threatening side effects while using fingolimod.

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Unusual combination of bilateral ischaemic optic neuropathy following cardiac surgery

Ischaemic optic neuropathy is a rare but serious complication post cardiopulmonary bypass in cardiac surgery patients. It presents with visual loss either unilaterally or bilaterally, and it can be anterior or posterior in type depending on the segment of the optic nerve involved. In non-ocular surgery patients, the most common type is called non-arteritic ischaemic optic neuropathy. We report a case of bilateral non-arteritic ischaemic optic neuropathy following coronary artery bypass grafting and mitral valve surgeries and review the published literature for the aetiology, management and prognosis of this rare complication.

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Dementia with Lewy bodies presenting as probable epileptic seizure

We discuss the case of an 83-year-old man admitted to the hospital after losing control of his vehicle due to an unexplained episode of altered consciousness. This occurred on a background of multiple similar episodes associated with acute confusion, superimposed on a gradual cognitive decline spanning 6 years. Organic aetiologies for delirium were excluded and CT and MRI of the brain were negative for cerebrovascular accidents or other epileptogenic foci. Electroencephalogram (EEG) was negative for epileptiform activity. A diagnosis of seizure in the setting of dementia with Lewy bodies (DLB) was deemed probable. Subsequent brain single-photon emission computed tomography (SPECT) and flurodeoxy glucose-positron emission tomography (FDG-PET) studies supported the underlying diagnosis of DLB. Acute changes in consciousness or cognition are often related to strokes or seizures in the older person. As illustrated in this case, however, it is important to consider alternative comorbidities that may coexist.

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Primary cutaneous Ewing sarcoma presenting as a chest wall lesion

A 10-year-old boy presents with a rare case of primary cutaneous Ewing sarcoma. The left-sided chest wall lesion was initially thought to be a benign haemangioma and treated with cryotherapy. Within 4 months, the lesion returned and post excision was found to be primary cutaneous Ewing sarcoma on histology. Few cases of primary cutaneous Ewing sarcoma exist in the literature, and although it is a rare differential for paediatric skin lesions, it is an important consideration due to the associated mortality risk in this young cohort.

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Recurrent gastric metal bezoar: a rare cause of gastric outlet obstruction

A 52-year-old male patient with psychiatric medical history who presented to the emergency department five times during a period of 5 years due to gastric outlet obstruction manifested mainly by abdominal pain, vomiting and haematemesis after intentionally ingesting metals and which necessitate several surgical interventions. Lately, he presented with generalised peritonitis due to gastric perforation from metal bezoars. Chronic abdominal symptoms in patient having a psychiatric disorder can be due to foreign body ingestion. Treatment is often surgical and the whole digestive tract should be explored to avoid retained bezoars.

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Traumatic elbow arthrotomy after motorcycle accident not evident on CT

An 84-year-old man sustained a motorcycle accident resulting in a left elbow laceration. Orthopaedics was consulted to rule out traumatic arthrotomy. Radiographs and CT of the left elbow showed no acute osseous abnormalities and no evidence of traumatic arthrotomy. The wound was irrigated, dressed and splinted. On follow-up, the patient reported that he had been given clindamycin on a return visit to the emergency department for increased drainage. On inspection, the patient's wound was found sutured and draining purulent fluid. The patient persistently had no pain on axial loading or range of motion since his injury and no evidence of intra-articular air on initial CT. However, given the mechanism of injury, irrigation and debridement (I&D) in the operating room was immediately performed revealing purulent joint fluid and a traumatic arthrotomy. I&D was carried out for the second time in the joint. After an extended hospital stay and antibiotics, the infection resolved.

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Laparoscopic removal of migrated intrauterine device

Intrauterine device (IUD) is a popular long-acting reversible contraceptive device with an estimated rate of use of about 5.3%. It is highly effective but not without complications, one of which is uterine perforation. The patient was a 32-year-old female who presented with nausea, vomiting and right upper quadrant abdominal pain that was tender on palpation. CT scan was performed and they found signs of acute calculous cholecystitis with incidental finding of a migrated IUD in the left lateral mid-abdomen within the peritoneal cavity. She underwent a laparoscopic cholecystectomy followed by a successful IUD retrieval. Most uterine perforations occur at the time of insertion; however, partial perforation with subsequent delayed complete perforation may also occur. This case emphasises the importance of a full workup for a missing IUD and that, if incidentally found, IUDs can be removed safely laparoscopically in conjunction with another procedure.

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Gastric necrosis and perforation in a patient with Aspergers syndrome

Acute gastric necrosis is a very rare but potentially fatal condition which has been reported in patients with abnormal eating behaviours.We describe the case of a 24-year-old female with a background of Asperger's syndrome, who presented with abdominal pain and gross distension. She underwent an emergency exploratory laparotomy and was found to have a massively distended, necrotic stomach. A total gastrectomy was performed with interval reconstruction planned. This case reports the surgical management of a rarely seen condition and highlights the importance of recognising gastric necrosis and its causes, which include patients with abnormal eating behaviours, the majority of whom are young females. This is the first report highlighting gastric necrosis in a patient with Asperger's syndrome and coincides with a growing recognition of the association between eating disorders and the autistic spectrum. It is also a rare example of patient survival following total gastric necrosis with perforation.

http://ift.tt/2wVtd8s

Multimodality cardiac imaging of submitral left ventricular aneurysm with concurrent descending aorta mycotic aneurysm

We present a case of a 20-year-old Malay man with underlying tuberculous (TB) lymphadenitis who presented with shortness of breath and found to have submitral left ventricular aneurysm (SLVA). SLVA is well recognised but rare. Incidence of SLVA in Malay has never been documented. This is the first reported case of SLVA in Malays with concomitant thoracic aorta mycotic aneurysm. TB has been reported to be associated with SLVA. Treatment is either surgical or conservative. Imaging is required for diagnosis and preoperative assessment. Multimodality imaging include echocardiography (ECHO), cardiac CTangiography and the robust multiparametric cardiac MR (CMR). ECHO is the first line imaging and useful for initial detection of the aneurysm. CMR including the late gadolinium enhancement allows excellent visualisation of the LV aneurysm, tissue characterisation, cardiac function and detection of associated pathology as shown in this case.

http://ift.tt/2yGRGfh

Eosinophilic myocarditis: an often subtle and potentially under-recognised phenomenon

A 34-year-old woman presented to our service with chest pain, a troponin rise and dynamic ECG changes. Of note, she had complained of fatigue, feeling constitutionally unwell and a generalised rash in the days prior to her presentation. Her echocardiogram showed normal wall motion and preserved ejection fraction. Her eosinophil count, normal at presentation, rose to a peak of 12.21x10⁵/L. She was haemodynamically stable throughout with no evidence clinically of congestive cardiac failure. CT coronary angiogram showed no obstructive coronary artery disease. Cardiac MRI demonstrated areas of late gadolinium enhancement consistent with myocarditis. A diagnosis of eosinophilic myocarditis was made. No tissue biopsy was performed due to the patchy myocardial involvement and high potential for low-yield biopsy. Our patient was treated conservatively and has made an excellent recovery.

http://ift.tt/2wVi5c3

Iatrogenic displacement of high-speed bur during third molar removal

Surgical removal of impacted mandibular third molar is a routine procedure in oral surgery. Various iatrogenic complications related to the procedure has been discussed well in the literatures before. Some of these complications are related to the wrong usage of instruments and techniques. Here we discuss a rare complication on a 42-year-old male, related to the use of high-speed handpiece drill in mandibular third molar removal in a general dental office setting. He was referred when a high speed tungsten carbide bur was accidentally broken and displaced into the mandibular bone during surgical procedure. It is not common to use a high-speed handpiece in impacted third molar removal. This iatrogenic complication could have been totally avoided with the use of proper equipment and technique; therefore raising awareness regarding wrong usage of instrument is vital to avoid similar incidents in the future.

http://ift.tt/2yGitbv

Unilateral adrenal mass as the sole initial manifestation of differentiated thyroid cancer

Unilateral adrenal metastases without disseminated disease has rarely been reported in differentiated thyroid carcinoma (DTC). A 72-year-old female presented with vague abdominal discomfort and loss of appetite of 2 months duration. She had undergone left hemithyroidectomy for a benign thyroid nodule 18 years ago. A contrast CT of the abdomen showed a large left adrenal mass measuring 11x9 cm, suspicious of adrenocortical carcinoma. Hormonal evaluation was in keeping with a non-functional tumour. The patient underwent left adrenalectomy, histopathology of which revealed metastatic well-differentiated thyroid carcinoma. Ultrasound of thyroid done postoperatively showed a subcentimetric hypoechoic lesion with increased vascularity and microcalcifications in the right thyroid bed. Histopathology from a completion thyroidectomy specimen was consistent with follicular variant of papillary thyroid carcinoma. She was treated with high-dose radioiodine ablation therapy and has remained disease-free on follow-up for more than a year.

http://ift.tt/2wVF7iJ

Rare presentation of necrotising fasciitis and streptococcal toxic shock syndrome by group A streptococcus

Description

A 44-year-old healthy male presented to the emergency room with a 6-day history of right medial thigh pain and itching. Examination revealed mild erythema with superficial swelling, but no tenderness (figure 1A). Vital signs were stable. White cell count (WBC) was 11.2x10⁹/L with no other significant laboratory abnormality. During the next 6 hours, his erythema and swelling extended to involve the whole thigh with the patient getting septic (spiking 102°F, heart rate 110/min and blood pressure 118/79 mm Hg). WBC trended up to 23x10⁹/L and lactate 4.7 mmol/L. MRI was performed which showed possible myositis (figure 1B). Despite intravenous antibiotics (penicillin and vancomycin) and resuscitation, his clinical condition deteriorated rapidly. In the next 4 hours, patient was taken to the operative room for fasciotomy and exploration. Intraoperatively, patient was found to have fasciitis. Necrotic tissue was removed.

Figure 1

(A) Right medial thigh with mild erythema. (B) MRI of the lower...

http://ift.tt/2yGRxIL

A fatal case of malignant neurocysticercosis

Description

A 43-year-old Muslim woman presented with intermittent fever, lethargy, poor appetite and weight loss for a month and altered behaviour for a week. She had a holiday trip to the provincial town of Hat Yai in South Thailand 7 months prior where she had eaten pork-free street food. On admission, she was confused, lethargic and not obeying command. There was no motor deficit.

Septic workup for bacterial and fungal infections was negative. Cerebrospinal fluid analysis showed pleocytosis with a negative tuberculosis (TB)-PCR result. IgG serology for HIV, Toxoplasma gondii and Taenia solium was negative.

Initial CT brain showed white matter hypodensities at bilateral frontoparietal regions. Several small peripherally enhancing parenchymal lesions seen on contrast-enhanced CT. These lesions were well circumscribed with no calcification or soft-tissue component. No hydrocephalus was seen.

MRI brain later revealed multiple small rim-enhancing cystic lesions in the basal ganglia, grey–white matter junctions and subarachnoid spaces....

http://ift.tt/2wUjmQh

Nephrectomy for infected stag horn calculus confounded by the presence of squamous cell carcinoma

Squamous cell carcinoma of kidney is a rare tumour of the many tumours seen in the kidney. It is usually associated with chronic irritation by a foreign body, which is mostly a stag horn calculus. Diagnosis of carcinoma in the presence of stag horn calculus is bizarre as it is seen in only <1% of patients. After imaging in this patient, the lymph nodes were enlarged and showed necrosis, which favoured the diagnosis of tuberculosis in a country where it is endemic. The pathological examination after surgery has amazed us by the presence of squamous cell carcinoma with lymph nodes positive with metastasis to vertebrae as the patient has presented to us with all symptoms of infection like pain and fever, which never made us think about malignancy preoperatively.

http://ift.tt/2yGRvAD

A case of Potts puffy tumour from primary dental infection

Description

A 45-year-old man presented to the emergency department with a large midline swelling of his forehead (figures 1 and 2). He described 8 months of progressive symptoms starting with anosmia and left-sided nasal discharge. The lump on his head had appeared suddenly 2 weeks prior to presentation and continued to grow before becoming tender.

Figure 1

Initial clinical appearance of midline forehead lump measuring 8 cm x 8 cm.

Figure 2

Lateral view of initial clinical appearance.

Nasendoscopy confirmed extensive left-sided polyps and discharge. A CT scan demonstrated extensive opacification of the left maxillary, sphenoid and ethmoidal sinuses with an 11 mm midline defect in the anterior wall of the frontal sinus at the site of the external mass. The posterior wall was very thin but intact. There was no evidence of intracranial extension.

He was...

http://ift.tt/2wVkhAf

Daunorubicin conjugated with alpha-fetoprotein selectively eliminates myeloid-derived suppressor cells (MDSCs) and inhibits experimental tumor growth

Abstract

Failure of antitumor immunity in cancer was shown to be mediated by myeloid-derived suppressor cells (MDSCs), which are considered to be one of the key factors contributing to the development of malignant diseases. Therefore, the development of pharmacological approaches to effectively eliminate MDSCs in organisms carrying growing tumors is a promising pathway for potential treatment. For this purpose we propose alpha-fetoprotein (AFP) conjugated with a cytotoxic agent as a vector molecule, specifically recognizing MDSCs. The present study was aimed at examination of this suggestion using both in vitro and in vivo approaches. MDSCs, obtained from the spleen of Ehrlich carcinoma bearing mice, selectively bound AFP labeled with fluorescein isothiocyanate. AFP conjugated to daunorubicin (AFP-DR) and DR alone showed similar in vitro cytotoxicity against the granulocytic MDSC subpopulation. The monocytic MDSC subpopulation was resistant to treatment with DR, whereas it was completely depleted in the presence of AFP-DR. Treatment of mice bearing Ehrlich carcinoma with AFP-DR resulted in reduced numbers of splenic MDSCs, normalization of NK cell levels, and inhibition of tumor growth. The obtained results demonstrate that cytotoxic conjugates based on AFP are promising anticancer drugs, which, in addition to the direct effect on tumor cells expressing receptors to AFP, may contribute to elimination of MDSCs.

http://ift.tt/2ysu4tM

Invited Commentary: Mast Cell Activation

http://ift.tt/2wVRCGa

Checkpoint Inhibitors: Applications for Autoimmunity

Abstract

To limit excessive T cell-mediated inflammatory responses, the immune system has a milieu of inhibitory receptors, called immune checkpoints. Cancer cells have evolved to seize those inhibitory pathways and to prevent T cell-mediated killing of tumor cells. Therefore, immune checkpoint inhibitors (ICI) consisting of blocking antibodies against these receptors present an exciting avenue in the fight against cancer. The last decade has seen the implementation of ICI against a variety of cancer indications that have improved the overall anti-tumor responses and patient survival. However, inflammatory toxicities and autoimmunity are a significant adverse event of ICI therapies. In this review, we will discuss the biology of immune checkpoints, highlight research strategies that may help reduce the incidence of immune-related adverse events associated with ICI therapies, and also suggest investigational approaches to manipulate immune checkpoints to treat primary autoimmune disorders.

http://ift.tt/2xFkiXM

Patch testing with the European baseline series fragrance markers: A 2016 update

Summary

Background

Fragrance contact allergy is common and is currently screened for with the European baseline series fragrance markers: Fragrance Mix 1, Fragrance Mix 2, Myroxylon pereirae and hydroxyisohexyl 3-cyclohexene carboxaldehyde.

Objectives

To investigate the validity of patch testing with these fragrance markers in detecting fragrance allergy to 26 individual fragrance substances for which cosmetic ingredient labelling is mandatory in the European Union.

Methods

We conducted a retrospective review of the patch test records of all eczema patients who underwent testing with the European baseline series extended with the individual fragrance substances during the period 2015-2016.

Results

359 patients (17.2%) reacted to one or more allergens from the labelled fragrance substance series and/or a fragrance marker from the European baseline series. The allergens that were positive with the greatest frequencies were oxidised linalool (154; 7.4%, 95% CI 6.3%-8.6%), oxidised limonene (89; 4.3%, 95% CI 3.4%-5.2%) and Evernia furfuracea (44; 2.1%, 95% CI 1.5%-2.8%). Of the 319 patients who reacted to any of the labelled fragrance substances, only 130 (40.8%) also reacted to a baseline series fragrance marker. The sensitivity of our history-taking for fragrance allergy was 25.7%.

Conclusions

With the evolving trends in fragrance allergy patch testing with Fragrance Mix 1, Fragrance Mix 2, Myroxylon pereirae and hydroxyisohexyl 3-cyclohexene carboxaldehyde are no longer sufficient for screening for fragrance allergy.

http://ift.tt/2xKxCdY

Incidence of Hidradenitis Suppurativa among Tobacco Smokers: a population based retrospective analysis in the United States

Summary

Background

The relationship between tobacco use and hidradenitis suppurativa (HS) is controversial.

Objective

To determine incidence of HS among tobacco smokers.

Methods

Retrospective cohort analysis identifying incident HS cases among adult tobacco smokers and non-smokers sampled from a demographically heterogeneous population-based sample of over 50 million unique patients across all census regions.

Results

We identified 3,924,310 tobacco smokers, among whom were 7,860 patients newly diagnosed with HS. Tobacco smokers diagnosed with HS were most commonly aged 18-39 years (3795/7,860; 48.3%), women (5,640/7,860; 71.8%), Caucasian (5,200/7,860; 66.2%), and those with BMI ≥30 (5,690/7,860; 72.4%). Overall incidence of HS was 0.20% (7,860/3,924,310) among tobacco smokers and 0.11% (8,430/8,027,790) among non-smokers (p< 0.0001). Incidence was greatest among tobacco smokers who were aged 30-39 years (0.35%), women (0.28%), African Americans (0.46%), and those with BMI ≥30 (0.33%). Overall adjusted odds of developing HS was 1.90 [95% CI 1.84-1.96] among tobacco smokers, compared to non-smokers (p<0.0001). HS incidence among tobacco smokers remained increased within each demographic subgroup.

Conclusions

Incidence of HS appears to be doubled among tobacco smokers. These findings may support evidence-based counseling efforts on cessation of smoking for populations at risk for HS.

http://ift.tt/2fxKjSy

Toxic shock syndrome: A dermatological emergency

http://ift.tt/2xx1aM8

MYC protein expression is associated with poor prognosis in cutaneous diffuse large B-cell lymphoma

http://ift.tt/2fQUoqJ

Aryl hydrocarbon receptor (AhR) transcription is decreased in skin of vitiligo patients

http://ift.tt/2xzTJBp

Primary cutaneous diffuse large B-cell lymphoma presenting as a solitary subcutaneous nodule with TP53 and FBXW7 mutations

http://ift.tt/2ysocRg

Body dysmorphic disorder in female Swedish dermatology patients

Abstract

Background

Individuals with body dysmorphic disorder (BDD) are highly distressed and impaired owing to perceived defects in their physical appearance that are not noticeable to others. They are frequently concerned about their skin and often present to dermatologists rather than psychiatrists. However, BDD patients attending dermatology clinics may be at risk of not receiving an appropriate assessment and beneficial treatment. The aims of this study were to estimate the BDD prevalence rate among Swedish female dermatology patients and to assess the psychological condition of BDD patients compared to that of other dermatology patients.

Methods

The occurrence of BDD was estimated using the Body Dysmorphic Disorder Questionnaire (BDDQ), a validated self-report measure for BDD. Symptoms of depression and anxiety were measured by the Hospital Anxiety and Depression Scale (HADS), and quality of life was assessed using the Dermatology Life Quality Index (DLQI).

Results

The prevalence rate of BDD among female Swedish dermatology patients was 4.9% (95% CI 3.2–7.4). Anxiety (HADS A ≥ 11) was 4-fold more commonly reported by patients with positive BDD screening (48% vs. 11%), and depression (HADS D ≥ 11) was over 10-fold more common in patients with positive BDD screening (19% vs. 1.8%) (P < 0.001). The median DLQI score was 18 in the BDD group, compared to a score of 4 in the non-BDD group (P < 0.001).

Conclusions

Our results indicate that BDD is fairly common among female Swedish dermatology patients (4.9%) and that BDD patients have high levels of depression and anxiety and severely impaired quality of life.

http://ift.tt/2xAxmvT

Eruptive nevi in a patient with metastatic breast cancer

http://ift.tt/2ysKKS3

Mucocutaneous manifestations in human immunodeficiency virus (HIV)-infected patients in Nouakchott, Mauritania

Abstract

Background

Mucocutaneous manifestations are one of the first clinical signs in patients infected with human immunodeficiency virus (HIV). To the best of our knowledge, there has been no previous study describing dermatologic manifestations in Mauritanians infected with HIV. The aim of the present study was to determine the profiles of mucocutaneous manifestations in relation to CD₄ T cell count in HIV-positive Mauritanian patients.

Methods

A total of 86 adult patients aged > 18 years old attending the Ambulatory Treatment Center of the National Hospital of Nouakchott, Mauritania, with newly diagnosed HIV and who were not under antiretroviral treatment were included in the study in 2015. Dermatologic manifestations were documented before initiating antiretroviral treatment.

Results

Most of the included patients were in clinical stage 3 of the World Health Organization classification at initial diagnosis, with the mean CD₄ T cell count (± SD) of 514 ± 319 cells/mm³ (range, 2–1328 cells/mm³), and 19 of 86 (22.1%) patients had CD₄ T cell counts below 200 cells/mm³. More than half (64%) of newly diagnosed HIV-infected patients had dermatoses, including the following: pruritic papular eruption (44.2%), seborrheic dermatitis (4.7%), Kaposi's sarcoma (3.5%), extensive xerosis cutis (2.3%), drug-induced skin reactions (1.2%), and various infectious dermatoses (dermatophyte infections [16.3%], oral candidiasis [11.6%], herpes zoster [8.1%], and scabies [2.3%]). A low CD₄ T cell count (< 200 cells/mm³) was significantly correlated (P < 0.05) with the presence of following dermatoses: dermatophytosis, oral candidiasis, Kaposi's sarcoma, seborrheic dermatitis, and extensive xerosis cutis.

Conclusion

Mucocutaneous lesions occur throughout the course of HIV infection, and dermatologic findings in Mauritanian HIV-positive patients are similar to those of patients in other countries. Early detection of skin disorders in some patients may help establish the diagnosis of HIV and management of HIV-associated diseases, limiting the cost of care in low-resource countries.

http://ift.tt/2xAVEpi

Switching biologics in severe pediatric psoriasis: a retrospective analysis

http://ift.tt/2ysFoGb

The association of smoking with contact dermatitis and hand eczema – a review

Abstract

Given the high prevalence of allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), hand eczema (HE), and smoking, and the impact that smoking has on skin disease, the authors reviewed the existing literature to assess the association between smoking and contact dermatitis or hand eczema. Using the PubMed and SCOPUS databases, a literature search identified articles related to allergic contact dermatitis, irritant contact dermatitis, and hand eczema and a possible association with smoking. The search period included articles prior to and including April 2016. Seven of eight articles described a positive relationship between smoking and allergic or irritant contact dermatitis, while nine of nineteen articles found a positive association between smoking and hand eczema. Published studies document that smoking may be an important risk factor for both allergic and irritant contact dermatitis as well as hand eczema.

http://ift.tt/2xA5hER

Distinct clinical and sensitization patterns of cinnamon-induced contact stomatitis: a propos of two cases

http://ift.tt/2ysF6z5

Distinct epitope structures of defensin-like proteins linked to proline-rich regions give rise to differences in their allergenic activity

Abstract

Background

Art v 1, Amb a 4, and Par h 1 are allergenic defensin-polyproline–linked proteins present in mugwort, ragweed, and feverfew pollen, respectively. We aimed to investigate the physicochemical and immunological features underlying the different allergenic capacities of those allergens.

Methods

Recombinant defensin-polyproline–linked proteins were expressed in E. coli and physicochemically characterized in detail regarding identity, secondary structure, and aggregation status. Allergenic activity was assessed by mediator releases assay, serum IgE reactivity, and IgE inhibition ELISA using sera of patients from Austria, Canada, and Korea. Endolysosomal protein degradation and T-cell cross-reactivity were studied in vitro.

Results

Despite variations in the proline-rich region, similar secondary structure elements were observed in the defensin-like domains. Seventy-four percent and 52% of the Austrian and Canadian patients reacted to all three allergens, while Korean patients were almost exclusively sensitized to Art v 1. This was reflected by IgE inhibition assays demonstrating high cross-reactivity for Austrian, medium for Canadian, and low for Korean sera. In a subgroup of patients, IgE reactivity toward structurally altered Amb a 4 and Par h 1 was not changed suggesting involvement of linear epitopes. Immunologically relevant endolysosomal stability of the defensin-like domain was limited to Art v 1 and no T-cell cross-reactivity with Art v 1_25-36 was observed.

Conclusions

Despite structural similarity, different IgE-binding profiles and proteolytic processing impacted the allergenic capacity of defensin-polyproline–linked molecules. Based on the fact that Amb a 4 demonstrated distinct IgE-binding epitopes, we suggest inclusion in molecule-based allergy diagnosis.

http://ift.tt/2wW3AzI

Real-world experience with neuromuscular blockade reversal

Neuromuscular blocking agents are used in many surgical procedures and have enabled new surgical advances. The expanded landscape of neuromuscular blockade (NMB) reversal drugs allows for fast and complete NMB reversal and the reduction of postoperative complications from residual block. In the United States, neostigmine/glycopyrrolate and sugammadex are the primary agents for pharmacologic antagonism of neuromuscular blocking agents. Whereas neostigmine and an anticholinergic have been available for decades, sugammadex has only recently become available.

http://ift.tt/2wTyDB2

Neurofibromatosis type 1 and right mandibular hypoplasia: unusual diagnosis of occlusion of the left common carotid artery

Neurofibromatosis type 1 also known as Von Recklinghausen's disease is an autosomal dominant neurocutaneous disease, with a disturbance of the NF1 gene localized in the 17th chromosome. Its incidence is 1 of 2500–3300 newborns. It is characterized by the formation of tumours in ectoderm and mesoderm tissues; consequently, its clinical manifestations are widely varied. Most frequent clinical manifestations are café-au-lait spots, axillary and groin freckling, Lisch nodules and neurofibromas. Other manifestations include hyperpigmentation, tumours and skeletal, neurological and cardiovascular disturbances [1].

http://ift.tt/2yGcuDy

Airway management: Utilizing radiologist expertise and neuroimaging with head and neck masses

Securing the airway in a patient with a head and neck mass is often challenging [1,2]. The location, size, and character of the mass can impede the anesthesiologist from safely extending the neck, opening the mouth, or placing airway devices such as an oral airway, LMA, or laryngoscope blade. Masses involving the larynx present an additional challenge of potential airway obstruction [2,3]. These cases can present with workup limited to labs and radiology imaging. In the absence of fiberoptic endoscopy or indirect laryngoscopy, imaging may be the only available map of the patient's airway.

http://ift.tt/2wTc2oa

Ultrasound guided continuous transmuscular quadratus lumborum analgesia for open renal surgery: A case series

Enhanced recovery following open renal surgery benefits from optimal dynamic analgesia allowing early mobilisation and patient comfort. Although, thoracic epidural analgesia (TEA) is considered as the gold standard, recent trends have revealed a move towards multimodal analgesia involving less invasive techniques that have a superior risk profile [1]. Wound infusion analgesia (WIA) has been described following open nephrectomy through a flank incision [2]. However, they fail to provide adequate pre-emptive and intraoperative analgesia.

http://ift.tt/2yH4kdU

Ventricular fibrillation caused by electrocautery for pericardium hemostasis during thoracotomy

Ventricular fibrillation (VF) is a serious perioperative cardiac event. Electrocautery devices are widely used in modern surgical procedures. Although these devices are safe and effective if used appropriately, there are also potential risks to the patients. This report presented a rare case of electrocautery-induced VF in a 52-year-old patient undergoing elective thoracotomy. The patient had no other underlying systemic diseases and no significant findings on physical examination. Upon entering the operating room, the monitors including ECG, pulse oximeter, and invasive arterial blood pressure monitor were applied.

http://ift.tt/2wTSkJ5

Laparoscopic guided continuous type 1 quadratus lumborum block — “Sindwani technique with case series”

Quadratus lumborum block (QLB) is a new abdominal wall block which has shown promising results in the post-operative pain management of patients undergoing abdominal surgeries [1]. Using ultrasound it can be given in four different ways [2]. QLB is a deep muscle plane block making it difficult even for an experienced anesthesiologist to perform it accurately using ultrasound. Presence of excess fat in obese patients adds to this challenge [3]. We would thus like to present a unique technique wherein, laparoscopic guided continuous type 1 QLB was successfully performed to manage the post-operative pain in a series of five patients undergoing laparoscopic nephrectomy.

http://ift.tt/2yH42Um

At most hospitals in the state of Iowa, most surgeons' daily lists of elective cases include only 1 or 2 cases: Individual surgeons' percentage operating room utilization is a consistently unreliable metric

Percentage utilization of operating room (OR) time is not an appropriate endpoint for planning additional OR time for surgeons with high caseloads, and cannot be measured accurately for surgeons with low caseloads. Nonetheless, many OR directors claim that their hospitals make decisions based on individual surgeons' OR utilizations. This incongruity could be explained by the OR managers considering the earlier mathematical studies, performed using data from a few large teaching hospitals, as irrelevant to their hospitals.

http://ift.tt/2wUdGpv

Argon embolus from argon beam coagulator

Argon beam coagulators (ABCs) have enhanced the ability of surgeons to perform procedures on highly vascular organs where bleeding is difficult to control with occlusion techniques alone. These coagulators work by using argon gas to create a path for electrical current to reach tissue. Although generally considered safe, there is the potential for argon gas embolism to occur with fatal or near fatal complications [1–9]. We recently cared for a patient that developed intra-operative symptoms consistent with argon embolism.

http://ift.tt/2yH3Xjw

A pragmatic trial to improve adherence with scheduled appointments in an inner-city pain clinic by human phone calls in the patient's preferred language

We investigated if human reminder phone calls in the patient's preferred language increase adherence with scheduled appointments in an inner-city chronic pain clinic. We hypothesized that language and cultural incongruence is the underlying mechanism to explain poor attendance at clinic appointments in underserved Hispanic populations.

http://ift.tt/2wTCWwe

Epidural labor analgesia: Whence come our patients' misconceptions?

The effect of epidural analgesia on labor outcomes has historically generated tremendous debate among obstetricians, anesthesiologists, midwives and labor nurses. Data from initial observational studies showed that women who chose epidural analgesia had an increased risk of prolonged labor and cesarean delivery compared with women who chose other types of analgesia or no analgesia. And women who received epidural analgesia early in labor, rather than later, had an increased risk of cesarean delivery.

http://ift.tt/2yG1yG9

Programmed intermittent peripheral nerve local anesthetic bolus compared with continuous infusions for postoperative analgesia: A systematic review and meta-analysis

The role of the programmed intermittent bolus (PIB) technique for infusion of local anesthetics in continuous peripheral nerve blockade (CPNB) remains to be elucidated. Randomized controlled trials (RCTs) on PIB versus continuous infusion for CPNB have demonstrated conflicting results and no systematic review or meta-analysis currently exists. We aimed to delineate via systematic review with meta-analysis if there is any analgesic benefit to performing PIB versus continuous infusion for CPNB.

http://ift.tt/2wTCWfI

Validity of using a work habits scale for the daily evaluation of nurse anesthetists' clinical performance while controlling for the leniencies of the rating anesthesiologists

Anesthesiologists can provide psychometrically reliable daily evaluations of certified registered nurse anesthetist (CRNA) work habits for purposes of the mandatory ongoing professional practice evaluation (OPPE). Our goal was to evaluate the validity of assessing CRNA work habits.

http://ift.tt/2yH3U7k

Paravertebral block restore diaphragmatic motility measured by ultrasonography in patients with multiple rib fractures

Multiple rib fractures are associated with severe pain, leading to alteration of pulmonary function. Paravertebral block (PVB) rather than systemic opioids have been recommended for prevention of critical pneumonia due to sufficient pain relief to facilitate coughing up [1]. Sonographic evaluation of the diaphragm is an accepted qualitative method of assessing the diaphragmatic motion in normal and pathological situations [2]. The norm of mean diaphragmatic excursion is 18±3mm during quiet breathing and 66±13mm during deep breathing [2].

http://ift.tt/2wTVw7u

With directed study before a 4-day operating room management course, trust in the content did not change progressively during the classroom time

A 4-day course in operating room (OR) management is sufficient to provide anesthesiologists with the knowledge and problem solving skills needed to participate in projects of the systems-based-practice competency. Anesthesiologists may need to learn fewer topics when the objective is, instead, limited to comprehension of decision-making on the day of surgery, We tested the hypothesis that trust in course content would not increase further after completion of topics related to OR decision-making on the day of surgery.

http://ift.tt/2yH3RbE

The Murphy eye as guidance for topical airway anesthesia during awake tracheal intubation with a channeled blade videolaryngoscope

Several publications have been published proposing awake videolaryngoscope-assisted intubation with a channeled videolaryngoscope [1,2]. We absolutely agree with this approach of awake videolaryngoscope-assisted tracheal intubation with maintained spontaneous respiration. We think that this approach is still significantly underused and could prevent a relevant part of airway problems in anesthesia. To become a more common and widespread approach, it should be as simple and efficient as possible.

http://ift.tt/2wTSjoz

Should we withhold angiotensin converting enzyme inhibitors before anaesthesia? An updated debate on the pros and cons

We read with interest the article by Vaquero Roncero et al. [1]. Indeed, over the last three decades, several investigators have endeavoured to identify risk factors associated to systemic hypotension following the assumption of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). In the 90s, administration of general anaesthetics in patients on chronic ACEi/ARBs was believed to be invariably associated to catastrophic hypotension occurring soon after induction, as described in some reports [2].

http://ift.tt/2yFZf5K

Selection of anesthesia technique: Not always the right reasons or the right outcomes…

Anesthesiologists often strive to achieve the perfect anesthetic technique for a given surgical procedure. Unfortunately, the reality is that we do not have a perfect anesthetic even for common and simple surgeries (e.g., laparoscopic cholecystectomy) [1,2]. General anesthesia, even for minor surgeries, often results in significant discomfort to patients due to postoperative nausea, vomiting and sore throat [3–5]. Neuraxial anesthesia frequently causes hypotension, pruritus and urinary retention [6–8].

http://ift.tt/2wU5tBJ

Sildenafil related cerebral venous thrombosis following spinal anesthesia

Various factors have been demonstrated in the etiology of cerebral venous thrombosis (CVT), including hypotension, dehydration, hormonal states (pregnancy, obesity), systemic diseases, malignancy and drugs. We report the case of a man who developed CVT following spinal anesthesia that was related to a long-term usage of sildenafil. Written informed consent was obtained from the patient to publish this report.

http://ift.tt/2yFQVmy

Influence of depth of neuromuscular blockade on surgical conditions during low-pressure pneumoperitoneum laparoscopic cholecystectomy: A randomized blinded study

To evaluate the influence of neuromuscular blockade (NMB) on surgical conditions during low-pressure pneumoperitoneum (8mmHg) laparoscopic cholecystectomy (LC), while comparing moderate and deep NMB. Secondary objective was to evaluate if surgical conditions during low-pressure pneumoperitoneum LC performed with deep NMB could be comparable to those provided during standard-pressure pneumoperitoneum (12mmHg) LC.

http://ift.tt/2wU5dCL

Ultrasound-guided pectoral nerves (PECS) block: Complications observed in 498 consecutive cases

To the Editor

http://ift.tt/2yGfPlR

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Τετάρτη 27 Σεπτεμβρίου 2017

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