Treatment of hemorrhagic head and neck lesions by direct puncture and nBCA embolization

Life-threatening bleeding in the head and neck region requires urgent management. These hemorrhagic lesions, for example, a ruptured pseudoaneurysm, are often treated by transarterial embolization (TAE), but prior intervention or surgery, inflammation, anatomic variants, and vessel tortuosity may render an endovascular approach challenging, time-consuming, and sometimes impossible. We report two cases of severe head and neck hemorrhages successfully embolized with n-butyl cyanoacrylate via direct puncture, and propose this approach as a fast, safe, and effective alternative to TAE.

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Recurrent Metastatic Medullary Thyroid Carcinoma: A Case of Sustained Response to Prolonged Treatment with Somatostatin Analogues

Thyroid , Vol. 0, No. 0.


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Dexamethasone: The wonder drug in perioperative medicine

Anesthesiologist have a greater understanding of the role of the stress response and the development of inflammation following surgery on clinical outcomes [1,2]. Exacerbation of inflammation after surgery has been shown to be associated with multiple negative postsurgical outcomes (e.g., pain, cardiovascular events) [3]. The reduction of inflammation is, therefore, a common target used by anesthesiologists to minimize postoperative complications [4–7].

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What's up in the ALPS

Frédéric Rieux-Laucat

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The Influence of Collaboration: Ralph Waters' Friendship With John Lundy and the Spread of Regional Anesthesia.

Ralph Waters, the founder of the anesthesiology department and residency program at the University of Wisconsin-Madison, and John Lundy, the chair at the Mayo Clinic beginning in 1924, collaborated to expand regional anesthetic techniques and knowledge not only at their institutions, but also at institutions around the country through correspondence, meetings, and hosting of other anesthesiologists. The Ralph Waters Collection at the University of Wisconsin Archives was searched for information on Waters' and Lundy's involvement in regional anesthesia. This included publications by Waters and other anesthesiology department faculty, as well as personal correspondence with other leaders in anesthesia at that time. Correspondence between Waters and Lundy from this collection was reviewed in detail. This article underscores the importance of exchange of ideas by physicians through didactics, organizations, and research through the story of Ralph Waters and John Lundy's mutual exchange of ideas and even friendship beginning in the 1920s. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Pequena aspiração da pars flacida

Pequena aspiração da pars flacida

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Colesteatoma de meato

Colesteatoma de meato

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Colesteatoma aerado sem secreção

Colesteatoma aerado sem secreção

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CHRODIS criteria applied to the MASK (MACVIA-ARIA Sentinel NetworK) Good Practice in allergic rhinitis: a SUNFRAIL report

A Good Practice is a practice that works well, produces good results, and is recommended as a model. MACVIA-ARIA Sentinel Network (MASK), the new Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, i...

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An unusual complication of the traditional treatment of a closed fracture – generalized tetanus: a case report

Tetanus is a severe infectious disease that can lead to death. The clinical manifestations are due to an exotoxin secreted by Clostridium tetani, a spore-producing Gram-positive bacillus. The penetration of the g...

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Successful bridge to recovery in fulminant myocarditis using a biventricular assist device: a case report

Fulminant myocarditis is a life-threatening disease, and myocardial damage expands the right ventricle as well as the left ventricle in some cases. There is a mortality rate of over 40% in patients with fulmin...

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A CD3-bispecific molecule targeting P-cadherin demonstrates T cell-mediated regression of established solid tumors in mice

Abstract

Strong evidence exists supporting the important role T cells play in the immune response against tumors. Still, the ability to initiate tumor-specific immune responses remains a challenge. Recent clinical trials suggest that bispecific antibody-mediated retargeted T cells are a promising therapeutic approach to eliminate hematopoietic tumors. However, this approach has not been validated in solid tumors. PF-06671008 is a dual-affinity retargeting (DART^®)-bispecific protein engineered with enhanced pharmacokinetic properties to extend in vivo half-life, and designed to engage and activate endogenous polyclonal T cell populations via the CD3 complex in the presence of solid tumors expressing P-cadherin. This bispecific molecule elicited potent P-cadherin expression-dependent cytotoxic T cell activity across a range of tumor indications in vitro, and in vivo in tumor-bearing mice. Regression of established tumors in vivo was observed in both cell line and patient-derived xenograft models engrafted with circulating human T lymphocytes. Measurement of in vivo pharmacodynamic markers demonstrates PF-06671008-mediated T cell activation, infiltration and killing as the mechanism of tumor inhibition.

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Dipeptidyl Peptidase-4 Inhibitor Sitagliptin Prevented Weight Regain in Obese Women with Polycystic Ovary Syndrome Previously Treated with Liraglutide: A Pilot Randomized Study

Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.


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Evidence for programmed odontoblast process retraction after dentine exposure in the rat incisor

Publication date: January 2018
Source:Archives of Oral Biology, Volume 85
Author(s): A. Mahdee, J. Eastham, J.M. Whitworth, J.I. Gillespie
ObjectiveTo re-examine the morphology and potential functions of odontoblasts in intact rat incisors and after cavity preparation into dentine.DesignIntact incisors were fixed, decalcified, snap frozen and sectioned (10μm), before staining with rhodamine phalloidin or antibodies for cyto-skeletal proteins: vimentin and actin, ion transporter: NaK-ATPase, and dendritic cell marker: OX6. Samples with cavity were processed similarly and stained for actin and vimentin before comparing the lengths of odontoblast processes (OP) at baseline, 3h and 24h (n=5 for each group).ResultsActin was expressed through the full length of OP, while vimentin immunoreactivity was not uniform, with 4 distinct regions. OP showed morphological complexity with fine branches emanating within different regions of dentine. Novel actin-positive tree-like OP were identified within predentine which reduced in intensity and length toward the incisal portion of the tooth. Specimens with cavities showed time-dependant pulpal retraction of OP.ConclusionsDifferences in structural antibody expression suggest functional variations in OP within different regions of dentine. The role of actin positive OP in predentine is not known, but could be related to dentine deposition, cellular stability or sensing mechanisms. Cavity preparation into dentine was followed by programmed retraction of OP which could be controlled either mechanically by the spatial limitation of the OP within dentinal tubules or structurally by the presence of vimentin, in addition to actin, in the mid-dentine.



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Dipeptidyl peptidase-4 inhibitor enhances restoration of salivary glands impaired by obese-insulin resistance

Publication date: January 2018
Source:Archives of Oral Biology, Volume 85
Author(s): Jitjiroj Ittichaicharoen, Nattayaporn Apaijai, Pongpan Tanajak, Piangkwan Sa-nguanmoo, Nipon Chattipakorn, Siriporn Chattipakorn
ObjectiveChronic high-fat diet consumption causes not only obese- insulin resistance, but also leads to pathological changes in salivary glands, including increased mitochondrial dysfunction, apoptosis, oxidative stress, and inflammation. Dipeptidyl peptidase-4 inhibitor (vildagliptin) is an oral anti-diabetic drug, using for treatment of type 2 diabetes. Vildagliptin has been shown to exert beneficial effects on several organs in cases of obese-insulin resistant condition. However, the effect of vildagliptin on salivary glands impaired by obese-insulin resistance has not been investigated. The hypothesis in this study is that vildagliptin confers beneficial effects on the salivary gland impaired by obese-insulin resistance via decreasing mitochondrial dysfunction, apoptosis, oxidative stress, and inflammation.DesignTwenty-four male Wistar rats were divided into two groups. Each group was fed with either a normal (ND; n=8) or a high fat diet (HFD; n=16) for 16 weeks. At week 13, the HFD-fed rats were subdivided into 2 subgroups to receive either a vehicle or vildagliptin (3mg/kg/day) for 28days via gavage feeding. ND-fed rats were treated with the vehicle. At the end of treatment, metabolic parameters were examined, and rats were killed. Submandibular glands were removed to appraise inflammatory markers, apoptosis and mitochondrial function.ResultsVehicle-treated HFD-fed rats developed obese-insulin resistance with an increase in oxidative stress, inflammation, apoptosis, and mitochondrial dysfunction in the salivary glands. Vildagliptin therapy reduced oxidative stress, inflammation, apoptosis and mitochondrial dysfunction in salivary gland of HFD-fed rats.ConclusionVildagliptin prevented salivary gland injury occurring due to obese-insulin resistance.



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Effect of chronic stress on capsaicin-induced dental nociception in a model of pulpitis in rats

Publication date: January 2018
Source:Archives of Oral Biology, Volume 85
Author(s): Maryam Raoof, Ehsan Ashrafganjoui, Razieh Kooshki, Mehdi Abbasnejad, Jahangir Haghani, Sara Amanpour, Mohammad-Reza Zarei
ObjectiveChronic stress can alter nociceptive sensitivity. However, the effect of stress exposure on dental nociception has been less addressed. Therefore, the present study investigated the effects of chronic exposures to some social and psychological stresses on pulpal nociceptive responses.DesignThe stress groups were constructed as follows: forced swimming (n=6), restraint (n=6), and mild (n=10) and severe (n=15) crowding stresses. Rats were subjected to stress for 1h per day for a week. At the end of the stress session, pulp irritation was induced by intradental application of capsaicin (100μg). There were another capsaicin or capsaicin plus stress training groups that received articaine 5min before the administration of capsaicin. Nociceptive responses were recorded for 40min. The time (ins) of continuous shaking of the lower jaw and excessive grooming and rubbing of the mouth near the procedure site was measured as nociceptive behaviors. Data was analyzed using one-way analysis of variance (ANOVA) followed by post hoc Tukey's test.ResultsSignificant nociceptive responses were evoked by the administration of capsaicin. Exposures to forced swimming (p<0.01), restraint (p<0.001), and both mild and severe crowding stresses (p<0.05) exaggerated capsaicin-induced nociceptive reaction. There was, however, no significant difference in nociceptive reaction time between the different stress groups. Articaine buccal infiltration attenuated nociceptive time in capsaicin and capsaicin plus stress training groups (p<0.001).ConclusionsThe current data support the association between chronic stress exposures and nociceptive behavior following intradental capsaicin administration.



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Cell-free nucleic acids in body fluids as biomarkers for the prediction and early detection of recurrent head and neck cancer: A systematic review of the literature

Publication date: December 2017
Source:Oral Oncology, Volume 75
Author(s): Joost H. van Ginkel, Fons J.B. Slieker, Remco de Bree, Robert J.J. van Es, Stefan M. Willems
Liquid biopsy is a minimally invasive detection method for molecular biomarkers in body fluids which may serve as a novel tool in management of head and neck cancer. The purpose of this systematic review is to outline the current status of liquid biopsy in head and neck squamous cell carcinoma (HNSCC) patients by systematically identifying and qualifying all published studies on the diagnostic or prognostic value of cell-free nucleic acids detection for posttreatment disease monitoring and/or disease outcome. A search was performed in PubMed, EMBASE, and Cochrane Library. Thirty articles met the inclusion criteria for further analysis. Study and patient characteristics, molecular analysis method and treatment or prognostic outcomes were extracted. Seventeen studies investigated circulating miRNAs in blood. Of these studies, 16 found statistically significant results for a total of 24 different candidate miRNAs for prognostication or treatment monitoring. The remaining studies investigated circulating tumor DNA by targeting somatic mutations, allelic imbalances, hypermethylation, or HPV-DNA. Of these studies, 2 found a statistically significant association between nucleic acid levels (tumor DNA targeted by allelic imbalances and HPV-DNA) in blood and/or saliva and prognostic outcome. One study found significantly different pre- and posttreatment levels of mitochondrial DNA in serum. Despite large differences among these studies in both design and results, individual results are promising and provide ground for more large-scale studies with standardized serial assessment of patient samples in the future.



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Childhood Thyroid Function Reference Ranges and Determinants: A Literature Overview and a Prospective Cohort Study

Thyroid , Vol. 0, No. 0.


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Subtotal Parathyroidectomy and Relocation of the Parathyroid Remnant for Renal Hyperparathyroidism: modification of a traditional operation

We describe a modification of the conventional subtotal parathyroidectomy operation where the parathyroid gland(s) remnant is repositioned with intact vascular supply to a plane superficial to the infrahyoid s...

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Table of contents

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Masthead

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Mechanisms and Factors That Drive Extensive Human Immunodeficiency Virus Type-1 Hypervariability: An Overview

Viral Immunology , Vol. 0, No. 0.


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PSMA-PET Imaging for Advanced ACC/SDC

Conditions:   Salivary Gland Cancer;   Adenoid Cystic Carcinoma;   Salivary Duct Carcinoma
Intervention:   Diagnostic Test: PSMA-PET/CT scan
Sponsors:   Radboud University;   Adenoid Cystic Carcinoma Research Foundation
Not yet recruiting

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FATE-NK100 as Monotherapy and in Combination With Monoclonal Antibody in Subjects With Advanced Solid Tumors

Conditions:   HER2 Positive Gastric Cancer;   Colorectal Cancer;   Head and Neck Squamous Cell Carcinoma;   EGFR Positive Solid Tumor;   Advanced Solid Tumors;   HER2-positive Breast Cancer;   Hepatocellular Carcinoma;   Small Cell Lung Cancer;   Renal Cell Carcinoma;   Pancreas Cancer
Interventions:   Drug: FATE-NK100;   Drug: Cetuximab;   Drug: Trastuzumab
Sponsor:   Fate Therapeutics
Not yet recruiting

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First-in-Human Study of XMT-1536 in Cancers Likely to Express NaPi2b

Conditions:   Platinum Resistant Ovarian Cancer;   Non-Small Cell Lung Cancer, Non-squamous;   Papillary Renal Cell Carcinoma;   Papillary Thyroid Cancer;   Salivary Gland Cancer
Intervention:   Drug: XMT-1536
Sponsors:   Mersana Therapeutics;   Novella Clinical
Not yet recruiting

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A Study of RO7198457 (Personalized Cancer Vaccine [PCV]) as a Single Agent and in Combination With Atezolizumab in Participants With Locally Advanced or Metastatic Tumors

Conditions:   Melanoma;   Non-Small Cell Lung Cancer;   Bladder Cancer;   Colorectal Cancer;   Triple Negative Breast Cancer;   Renal Cancer;   Head and Neck Cancer;   Other Solid Cancers
Interventions:   Drug: RO7198457;   Drug: Atezolizumab
Sponsors:   Genentech, Inc.;   Biontech RNA Pharmaceuticals GmbH
Recruiting

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An 85-Year-Old Woman With a Red, Painful Rash

An 85-year-old woman with type 2 diabetes mellitus is admitted to the hospital because of a progressive, red, painful rash on her right leg. What's the next step in her treatment?
Osmosis

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Histamine and T helper cytokine driven epithelial barrier dysfunction in allergic rhinitis

Publication date: Available online 23 October 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Brecht Steelant, Sven F. Seys, Laura Van Gerven, Matthias Van Woensel, Ricard Farré, Paulina Wawrzyniak, Inge Kortekaas Krohn, Dominique M. Bullens, Karel Talavera, Ulrike Raap, Louis Boon, Cezmi A. Akdis, Guy Boeckxstaens, Jan L. Ceuppens, Peter W. Hellings
BackgroundAllergic rhinitis (AR) is characterized by mucosal inflammation, driven by activated immune cells. Mast cells and TH2 cells might decrease epithelial barrier integrity in AR maintaining a leaky epithelial barrier.ObjectiveWe sought to investigate the role of histamine and TH2 cells in driving epithelial barrier dysfunction in AR.MethodsAir-liquid interface (ALI) cultures of primary nasal epithelial cells (pNECs) were used to measure trans-epithelial electrical resistance, paracellular flux of FITC-dextran 4kDa and mRNA expression of tight junctions. Nasal secretions were collected from healthy controls, AR patients and idiopathic rhinitis (IR) patients and were tested in vitro. In addition, the effect of activated TH1 and TH2 cells, mast cells and neurons was tested in vitro. The effect of IL-4, IL-13, IFN-γ and TNFα on mucosal permeability was tested in vivo.ResultsHistamine as well as nasal secretions of AR but not IR patients rapidly decreased epithelial barrier integrity in vitro. Pretreatment with histamine receptor-1 antagonist, azelastine prevented the early effect of nasal secretions of AR patients on epithelial integrity. Supernatant of activated TH1 and TH2 cells impaired epithelial integrity, while treatment with anti-TNFα or anti-IL-4Rα monoclonal antibodies restored the TH1 and TH2 induced epithelial barrier dysfunction respectively. IL-4, IFN-γ and TNFα enhanced mucosal permeability in mice. Antagonizing IL-4 prevented mucosal barrier disruption and tight junction downregulation in a mouse model of house dust mite allergic airway inflammation.ConclusionOur data indicate a key role for allergic inflammatory mediators in modulating nasal epithelial barrier integrity in the pathophysiology in AR.

Graphical abstract

Teaser

Capsule summary: A defective epithelial barrier is demonstrated in allergic rhinitis, and we here show that histamine, released during the early allergic immune reaction, together with T cell cytokines, released during chronic inflammation, contribute to this defect.


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A novel recycling mechanism of native IgE-antigen complexes in human B cells facilitates transfer of antigen to dendritic cells for antigen presentation

Publication date: Available online 23 October 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): P. Engeroff, M. Fellmann, D. Yerly, M.F. Bachmann, M. Vogel
BackgroundIgE-immune complexes have been shown to enhance antibody and T cell responses in mice by targeting CD23 (FcεRII), the low-affinity receptor for IgE on B cells. In humans, the mechanism by which CD23-expressing cells take up IgE-immune complexes (IgE-IC) and process them is not well understood.ObjectiveTo investigate this question, we compared the fate of IgE-IC in human B cells and in CD23 expressing monocyte-derived dendritic cells (moDCs) that represent classical APCs and we aimed at studying IgE-dependent antigen presentation in both cell types.MethodsB cells and monocytes were isolated from peripheral blood and monocytes were differentiated into moDCs. Both cell types were stimulated with IgE-immune complexes consisting of NIP-specific IgE JW8 and NIP-BSA to assess binding, uptake and degradation dynamics. To assess CD23-dependent T cell proliferation, B cells and moDCs were pulsed with IgE-NIP-Tetanus Toxoid (TT) complexes and cocultured with autologous T cells.ResultsIgE-IC binding was CD23-dependent in B cells and moDCs and CD23 aggregation, as well as IgE-IC internalization, occurred in both cell types. While IgE-IC was degraded in moDCs, B cells did not degrade the complexes but recycled them in native form to the cell surface enabling IgE-IC uptake by moDCs in cocultures. The resulting proliferation of specific T cells was dependent on cell-cell contact between B cells and moDC which was explained by increased upregulation of co-stimulatory molecules CD86 and MHC class II on moDCs induced by B cells.ConclusionOur findings argue for a novel model in which human B cells promote specific T cell proliferation upon IgE-IC encounter. On one hand, B cells act as carriers transferring antigen to more efficient APCs such as dendritic cells, on the other hand, B cells can directly promote DC maturation and thereby enhance T cell stimulation.

Teaser

The here described IgE/CD23-dependent antigen recycling and presentation pathway in B cells may be targeted to regulate T cell responses in IgE-mediated diseases.


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Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: the 2-4-6 Study

Publication date: Available online 23 October 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Javier Molina-Infante, Ángel Arias, Javier Alcedo, Ruth Garcia-Romero, Sergio Casabona-Frances, Alicia Prieto-Garcia, Ines Modolell, Pedro L. Gonzalez-Cordero, Isabel Perez-Martinez, Jose Luis Martin-Lorente, Carlos Guarner-Argente, Maria L. Masiques, Victor Vila-Miravet, Roger Garcia-Puig, Edoardo Savarino, Carlos Teruel Sanchez-Vegazo, Cecilio Santander, Alfredo J. Lucendo
BackgroundNumerous dietary restrictions and endoscopies limit the implementation of empiric elimination diets in eosinophilic esophagitis (EoE). Milk and wheat/gluten are the most common food triggers.ObjectiveTo assess the effectiveness of a step-up dietary strategy for EoE.MethodsProspective study conducted in 14 centers. Patients underwent a 6-week two-food group elimination diet (TFGED) (milk and gluten-containing cereals). Remission was defined by symptom improvement and <15 eos/HPF. Non-responders were gradually offered a four-food group elimination diet (FFGED: TFGED + egg and legumes) and a six-food group elimination diet (SFGED: FFGED + nuts and fish/seafood). In responders, eliminated food groups were individually reintroduced, followed by endoscopy.Results130 patients (25 pediatric) were enrolled with 97 completing all phases of the study. A TFGED achieved EoE remission in 56 patients (43%), with no differences between ages. Food triggers in TFGED responders were milk (52%), gluten-containing grains (16%) and both (28%). EoE induced only by milk was present in 18% and 33% of adults and children, respectively. Remission rates with FFGED and SFGED were 60% and 79%, with increasing food triggers, especially after SFGED. Overall, 55/60 (91.6%) of responders to TFGED/FFGED had one or two food triggers. Compared to initial SFGED, a step-up strategy reduced endoscopic procedures and diagnostic process time by 20%.ConclusionsA TFGED diet achieves EoE remission in 43% of children and adults. A step-up approach identifies early a majority of responders to empiric diet with few food triggers, avoiding unnecessary dietary restrictions, saving endoscopies and shortening the diagnostic process.

Teaser

A two-food group elimination diet achieves EoE remission in 43% of patients, identifying early 2/3 of potential responders to a SFGED.A step-up strategy saves endoscopic procedures, shortens the diagnostic process, and avoids unnecessary dietary restrictions.


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MicroRNA

Publication date: Available online 23 October 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Thomas X. Lu, Marc E. Rothenberg
MicroRNAs (miRNAs) are small endogenous RNAs that regulate gene-expression post-transcriptionally. MiRNA research in allergy is expanding because miRNAs are crucial regulators of gene expression and promising candidates for biomarker development. MiRNA mimics and miRNA inhibitors currently in preclinical development have shown promise as novel therapeutic agents. Multiple technological platforms have been developed for miRNA isolation, miRNA quantitation, miRNA profiling, miRNA target detection and for modulating miRNA levels in vitro and in vivo. Here we will review the major technological platforms with consideration given for the advantages and disadvantages of each platform.



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Recurrence of immature ovarian teratoma as malignant follicular carcinoma with liver and peritoneal metastasis 22 years after completion of initial treatment

Growing tumour syndrome (GTS) is a rare event in which germ cell tumours treated with chemotherapy undergo maturation, acquire resistance to chemotherapy and regrow. The optimum treatment strategy is complete surgical excision. We report on a case of GTS with malignant metastases to the liver presenting 22 years after completion of treatment for immature teratoma, successfully managed with surgical resection alone.

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Buttock wounds: beware what lies beneath

A 25-year-old man presented to a major trauma centre with multiple stab wounds, most significantly to the right buttock. Triple-phase CT revealed no acute bleeding and his wounds were closed. In the month following injury, he re-presented seven times to the emergency department (ED) complaining of bleeding and wound breakdown. After his seventh ED attendance, he was examined under general anaesthesia. Intraoperatively, profuse arterial bleeding was encountered and the local major haemorrhage protocol was activated. The on-call consultant vascular surgeon attended and definitive control was achieved. A large haematoma had acted to tamponade ongoing arterial bleeding and an underlying pseudoaneurysm: a finding not reported, but present, on the initial CT angiogram. Following 24 hours in the intensive care unit, he was transferred to the surgical ward and discharged 4 days later. Regular review in the outpatient department over the following 9 weeks monitored successful wound healing.

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Vascular consideration in repair of total scalp avulsion

Successful total scalp replantation was performed in our case. Based on the angiosome concept and anatomical study, the avulsed scalp survived with unilateral anastomosis of the superficial temporal artery and superficial temporal vein, largely due to the presence of rich arterial and venous arcades in the scalp. The patient currently has no problems with activities of daily living, although total hypoaesthesia and dysfunction of the left frontal muscle of the forehead are present. In addition, the combined findings of hair growth pattern indicated the vascular territories of the scalp skin.

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Urothelial carcinoma in an orthotopic neobladder: an unusual pattern of recurrence and metastasis

We report a case of a 65-year-old patient with muscle invasive bladder cancer that was treated with neoadjuvant chemotherapy, followed by radical cystoprostatectomy with pelvic lymph node dissection and orthotopic neobladder according to Hautmann. Nine years later, routine follow-up showed local recurrence in the neobladder and metastatic disease of the urothelial carcinoma in the related mesenteric lymph nodes. The entire neobladder specimen was removed including the mesentery of the neobladder. Based on the anatomical lymph drainage of the ileal neobladder, we considered the metastatic disease in the mesentery lymph node as locoregional disease spread. This case shows that such locoregional lymph node metastasis may be amenable to treatment by induction chemotherapy and radical surgery.

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Subarachnoidal fat droplet deposition and fat embolism syndrome

Description

A 68-year-old woman presenting with multiple rib, spine fractures, femur and ankle fractures after a fall from height was admitted. Although she responded to verbal orders appropriately at the time of admission, her consciousness drastically deteriorated after 4.5 hours of the accident. She presented a decerebrate posture and acute respiratory failure with bilateral diffuse infiltration consistent with non-cardiogenic pulmonary oedema, requiring mechanical ventilation. She was also complicated with decreased platelet count, suggesting fat embolism syndrome (FES). At the time of the acute deterioration, brain CT demonstrated no gross abnormality, except for fat droplet in the subarachnoidal space (figure 1). On the third day, MRI showed numerous pinpoint hyperintense foci in the grey and white matter of the cerebral and cerebellar hemispheres on diffusion-weighted images (figure 2), consistent with the 'starfield appearance'. Right to left shunt, including patent foramen ovale, was not evident by transthoracic...

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Rescuing the host Descemets membrane in full-thickness traumatic wound dehiscence in deep anterior lamellar keratoplasty: intraoperative optical coherence tomography (iOCT)-guided technique

Optimal visual recovery following full-thickness traumatic wound dehiscence in a case of operated deep anterior lamellar keratoplasty (DALK) is rarely seen. Here we report a case of 22-year-old male patient presented to our casualty department with complaint of sudden-onset diminution of vision in his right eye following blunt trauma of 1 day duration. DALK had been performed 11 months ago for advanced keratoconus in the same eye. Best-corrected visual acuity (BCVA) in the right eye was hand movement close to face with accurate projection of rays and in the left eye was 20/20. Slit-lamp examination showed the presence of inferior 180° graft dehiscence with broken sutures and shallow anterior chamber with corneal oedema. Repair of the dehiscence with descemetopexy was done under the guidance of intraoperative optical coherence tomography with the successful rescuing of the host Descemet's membrane. BCVA at 6 months follow-up was 20/40.

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Mucoepidermoid carcinoma of the posterior-lateral border of tongue: a rare presentation

Mucoepidermoid carcinoma (MEC) is the most common malignant tumour of the major and minor salivary glands. Minor salivary glands are scattered in different areas of the oral cavity such as palate, retromolar area, floor of the mouth, buccal mucosa, lips and tongue, but so far, only a few lingual MEC cases have been documented in the literature and most of the studies have shown a predilection for base and dorsum of the tongue. We report a rare case of MEC involving the posterior-lateral border of the tongue.

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Use of i-gel for laser ablation of a bronchial lesion

The use of laser for airway lesions requires airway management. Usual options include special laser-resistant endotracheal tubes. The use of supraglottic devices have been described in the literature. Laryngeal mask airway carries the risk of cuff damage during the use of laser. i-gel is made of thermoplastic material and does not require air inflation and thus potentially reduce the risk of cuff rupture. i-gel use in laser surgeries has not been described in the literature. We present successful airway management in laser surgery for bronchial tumour using i-gel.

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A newer technique of suture placement in scalpel and laser-assisted vestibular deepening

Surgical vestibular deepening procedures are well established and are being routinely performed.

In spite of being an old technique, postoperative results in most of the instances are disappointing. Usually eventual loss of the clinically gained vestibular depth obtained through the surgical procedures occurs. This happens mainly due to rapid epithelialisation of the surgical wound and healing by scarring. Therefore, in the present case, after the initial incision, the labial free end of flap was sutured by a new technique so as to prevent rapid epithelialisation. Finally, the incision was completed and vestibular deepening was achieved with the help of diode laser as they are reported to produce remarkably less scarring at the surgical site.

http://ift.tt/2zz8jsY

Acute hepatitis B virus infection and severe non-immune haemolytic anaemia: a rare relationship

The clinical presentation of acute hepatitis B virus (HBV) infection is usually related to the onset of liver failure and damage. Anaemia may occur, but it is only rarely attributed to haemolysis. The authors report about the case of a 41-year-old woman with the diagnosis of acute HBV infection and coagulopathy (without encephalopathy) who developed non-immune haemolytic anaemia. Total recovery of the analytical liver profile, coagulopathy and anaemia was achieved through treatment targeting HBV.This case shows that, although rare, non-immune haemolytic anaemia may occur in association with acute HBV infection and that HBV suppression seems to lead to progressive anaemia resolution.

http://ift.tt/2h4bQbO

Successful management of caesarean scar live ectopic pregnancies with local KCL and systemic methotrexate

Two cases of live caesarean scar ectopic pregnancies are presented. Beta human chorionic gonadotropin (b-hCG) values in both patients at presentation were 50 099 mIU and 297 969 mIU, respectively. Both were managed with intrasac potassium chloride injection to induce fetal demise and multiple dose methotrexate therapy. The time for b-hCG to become negative in both patients was 91 days and 119 days, respectively. Successful management of live caesarean scar pregnancies even with very high b-hCG is possible with minimally invasive approach.

http://ift.tt/2zyH5mh

Case of undiagnosed pneumocystis pneumonia (PCP)

Pneumocystis pneumonia (PCP) is an opportunistic fungal infection that is usually seen in immunocompromised patients, especially those with HIV, malignancies, organ transplants and on drug therapies like chemotherapy and steroids. PCP has subacute presentation in patients with AIDS which if left untreated gets worse and is a significant cause of morbidity and mortality. Here we present a case of PCP went undiagnosed, partially due to the patient being unaware of his HIV positive status and partially because no organism could be found under the microscope.

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Successful maternal and perinatal outcomes in a term pregnancy with giant abdominopelvic leiomyomatosis

A 30-year-old second gravida with history of laparoscopic myomectomy and one previous caesarean section was admitted at 31 weeks and 2 days period of gestation (POG) with a diagnosis of diffuse abdominopelvic leiomyomatosis and moderate anaemia. After correction of anaemia with intravenous iron and erythropoietin, laparotomy was performed at 37 weeks POG. A healthy female baby weighing 2.9 kg was delivered by classical caesarean section followed by hysterectomy in view of multiple fibroid uterus with uncontrolled bleeding. Debulking surgery was performed, and multiple large intraperitoneal leiomyomata with encasing blood vessels were removed. There was another 15x15 cm leiomyoma arising from the diaphragm which was excised. She received 4 units of packed red blood cells and fresh frozen plasma intraoperatively. The postoperative course was uneventful, both mother and baby were healthy and discharged 7 days after surgery.

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Sterile subdural empyema: an unusual presentation

Description

A 66-year-old man presented to the emergency department with a 6-week history of progressively worsening generalised weakness and gait instability. Physical examinations revealed a low-grade fever of 37.7°C. In addition, the patient was found to have very poor dentition and bilateral sensorineural hearing reduction with no other focal neurological deficit. Laboratory investigations showed a white cell count of 25.8 10⁹/L (Ref: 4–10.8 10⁹/L), predominately neutrophils at 84% (Ref: 36%–75%). A CT of the head was negative for any acute processes and a subsequent MRI of the head with and without contrast was consistent with bilateral frontal subdural empyema (SDE) and ventriculitis (figure 1). He was started initially on vancomycin, ceftriaxone and metronidazole and he underwent bilateral burr hole biopsy and drainage of a thick, creamy white fluid within 2 days of starting the antibiotics. Pathological findings were consistent with an abscess; however, the microbiological culture failed to...

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Spontaneous right coronary artery dissection

Description

A 41-year-old gravida 1 para 1 female with a medical history of hypertension and panic attacks presented to the emergency room with crushing chest pain radiating to her back for 2–3 hours. There was associated shortness of breath and anxiety but no other complaints. Initial evaluation confirmed normal vital signs as well as unremarkable physical examination, ECG, chest X-ray, CT chest and echocardiogram. Troponin was elevated (0.89 ng/mL) and she was admitted for cardiac monitoring, and was started on aspirin and metoprolol. She continued to have ongoing chest discomfort and rising cardiac enzymes along with new inferior lead T-wave inversion on ECG. Nitroglycerin, clopidogrel and fondaparinux were administered and ultimately the decision was made to perform cardiac catheterisation. Coronary angiography revealed 80% mid-right coronary artery stenosis secondary to spontaneous coronary artery dissection (Figure 1A, B) and a bare-metal stent was deployed with restoration of normal blood flow (Figure 2)....

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Exercise-induced anaphylaxis in an elderly patient

A 75-year-old Japanese woman presented with acute flushing pruritus and a feeling of diffuse warmth followed by collapse while dancing. After resting for 30 min and receiving a rapid infusion of 0.9% sodium chloride, her condition stabilised. She admitted that she had a similar experience 2 years earlier while dancing. Based on her history, her symptoms were attributed to exercise-induced anaphylaxis. None of the episodes was associated with any other suspicious cotriggers of anaphylaxis. She was successfully discharged from the clinic without any complications after receiving careful guidance on how to prevent this condition.

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Dysphagia management in bilateral frontal opercular syndrome (Foix-Chavany-Marie syndrome)

An 80-year-old woman was admitted to hospital with acute anarthria and severe dysphagia, characterised by loss of voluntary control of the muscles of facial expression, mastication, bolus manipulation (tongue) and pharyngeal constriction, with relative preservation of involuntary movements. Brain imaging revealed an acute infarct in the left frontal operculum and an area of gliosis consistent with an old infarct in the right frontal operculum. A clinical and radiological diagnosis of bilateral anterior frontal opercular syndrome (Foix-Chavany-Marie-syndrome) was made.

Deglutition consists of a voluntary oral stage and an involuntary pharyngeal and oesophageal phase. As involuntary movements were relatively preserved and no sensory loss was suspected, it was hypothesised that, once initiated or triggered, pharyngeal swallowing could be adequate. This was trialled at the bedside without adverse effects and subsequently videofluoroscopy demonstrated timely laryngeal elevation and closure, adequate opening of the upper oesophageal sphincter and smooth transit of the bolus from mouth to oesophagus. Oral intake was restored within days of admission and a percutaneous endoscopic gastrostomy was avoided. This is the first time to the authors' knowledge that this management approach has been described for this condition.

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Spontaneous painful subungual thumb haematoma

We present the case of a 56-year-old man who presented to our accident and emergency department 15 years after a work-based injury to his left thumb.

In January 2017, the patient was woken up acutely with excruciating pain in his left thumb with no preceding trauma. On clinical examination, only a subungual haematoma was noted. Radiographs of the effected thumb demonstrated a round, lytic lesion with an accompanying hairline fracture on the distal phalanx of the left thumb. The radiologist suggested a differential diagnosis of enchondroma should be considered.

The patient was referred for a routine plastic surgery outpatient appointment. Curettage sampling of the lesion was performed and a cement filler was used to prevent further pathological fractures.

The biopsy report stated that the sample contained normal bone tissue with no evidence of enchondroma or other malignancy and the patient was discharged without any further complications.

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Sentinel lymph node biopsy status is not the most powerful predictor of prognosis in cutaneous melanoma

Abstract

Sentinel lymph node (SLN) status has been advocated in several recently published articles as the single most valuable prognostic marker for melanoma, and of greater prognostic importance than more established parameters such as Breslow thickness. A careful examination of the evidence for these claims, however, indicates that they are not substantiated by the available data, are somewhat misleading and suggest misinterpretation of the statistical analysis of the papers to which they refer. We will examine the basis for these claims and show why they are invalid.

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Chemical peels: A review of current practice

Abstract

Chemical peels belong to a group of cutaneous resurfacing procedures that are used in the treatment of photoageing, inflammatory dermatoses, epidermal proliferations, pigmentary disorders and scarring. This review describes best current practice, highlights recent advances in chemical peel technology and discusses the recommended uses for different peel types. It also presents the results of a survey of the chemical peeling practices of 30 Australian dermatologists.

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High-risk squamous cell carcinoma masquerading as dense inflammation on Mohs frozen sections

Abstract

High-risk squamous cell carcinoma (SCC) can present a unique challenge in Mohs surgery. This case report describes how high-risk SCC may masquerade as only a dense inflammation on frozen sections. This feature should raise the index of suspicion for hidden SCC and be a routine indication for further processing by paraffin sections and immunohistochemistry.

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UK multicentre audit of the management of eczema in children

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Maxillary Sinus Kaposi Sarcoma: Case Report in an HIV-Negative Patient with Thymoma

Introduction. Kaposi sarcoma is an angioproliferative disorder that requires infection with human herpesvirus 8 (HHV-8) for its development. The majority of cases are associated with HIV infection or other immunocompromising conditions. Thymomas are occasionally associated to cytopenia, which may alter the patients' immune responses. Methods. Case report using clinical records. Results. Case report of a 46-year-old male patient diagnosed with thymoma and myasthenia gravis. The patient was referred to an otolaryngology consultation with complaints of facial pain in the right malar region, interpreted as an acute sinusitis. Following examination, an expansive maxillary sinus mass was found, and endoscopic surgery was undertaken. After careful investigation, it was diagnosed as a Kaposi sarcoma. Conclusions. It is thought to be the first described case of a maxillary sinus Kaposi sarcoma in an HIV-negative patient. Thus, this entity has to be considered in the differential diagnosis of sinus masses, even in non-HIV patients.

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Invasive squamous cell carcinoma: comparison of differentiation grade and tumour depth by anatomical site in 1666 tumours

Summary

Background

Invasive squamous cell carcinomas (SCCs) presents with different grades of differentiation and depths of invasion.

Aim

To compare the grade of differentiation, tumour diameter and tumour depth by anatomical site in invasive SCC.

Methods

Retrospective clinical and histopathological data on consecutive cases of SCC came from a clinic in Sydney, Australia were assessed. A multinomial logistic regression model was applied to compare grades of differentiation by age, sex, anatomical sites, and histological tumour maximum diameter and depth.

Results

In total, 1666 SCCs were identified, including 82.1% (n = 1367) well-differentiated, 13.3% (n = 222), moderately differentiated and 4.6% (n = 77) poorly differentiated SCCs. Patients with poorly differentiated tumours were more likely to be older and male (both P < 0.001). The most common site for poor differentiation was the scalp in men (n = 12; 15.6%) and the cheek or chin in women (n = 7; 9.1%). In the multivariate model, compared with well-differentiated SCC, older age was significantly associated with poorly and moderately differentiated SCC (P < 0.01 and P = 0.02, respectively). Larger tumour diameters were related to poor differentiation (P = 0.03). Ear, forehead and chest sites had increased tumour depth and poor differentiation.

Conclusions

This study found increased rates of poorly differentiated SCC on the forehead and cheek for both sexes, while men displayed increased rates of poorly differentiated SCC on the bald scalp and the ears. Tumour diameter and depth increased as tumours varied from well-differentiated to moderately differentiated and from moderately differentiated to poorly differentiated. An increase in depth and increased prevalence of poorly differentiated tumours were found on the ears for men and on various facial sites for both sexes.

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In chronic spontaneous urticaria, high numbers of dermal endothelial cells, but not mast cells, are linked to recurrent angio-oedema

Summary

Background

Chronic spontaneous urticaria (CSU) is an inflammatory skin disorder characterized by recurrent weals, angio-oedema or both. Recent studies have shown that the number of endothelial cells is increased in the skin of patients with CSU, but the underlying mechanisms and clinical implications of this are unclear.

Aim

To evaluate whether mast cell (MC) or endothelial cell (EC) numbers correlate with CSU and whether they are relevant for disease duration, disease activity or the presence of clinical features.

Methods

We determined the numbers of CD31+ ECs and MCs in nonlesional skin of 30 patients with CSU using quantitative histomorphometry, and assessed their correlation with each other and with clinical features such as disease duration, disease activity and occurrence of angio-oedema.

Results

The numbers of MCs and ECs were high in the nonlesional skin of patients with CSU, but did not correlate with each other. Neither MC number nor EC number correlated with disease duration or disease activity. Interestingly, patients with high numbers of cutaneous CD31+ ECs had higher rates of recurrent angio-oedema and vice versa.

Conclusions

Based on these findings, we speculate that vascular remodelling and MC hyperplasia in patients with CSU occurs independently and via different mechanisms. Targeting of the mechanisms that drive neoangiogenesis in CSU may result in novel therapeutic strategies for the management of patients with angio-oedema.

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