Τετάρτη 23 Μαΐου 2018

Case 16-2018: A 45-Year-Old Man with Fever, Thrombocytopenia, and Elevated Aminotransferase Levels

Presentation of Case. Dr. Alyssa Sclafani (Medicine): A 45-year-old man presented to the emergency department of this hospital during the summer with fever, thrombocytopenia, and elevated aminotransferase levels. Three weeks before presentation, fever occurred (with temperatures as high as 40.0°C),…

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Chronic Urticaria: Comparisons of US, European, and Asian Guidelines

Abstract

Purpose of Review

Chronic urticaria is a common dermatological condition that has significant impact on quality of life. Multiple international societies have published guidelines, and although these guidelines generally agree on the definition of urticaria, as well as approach to diagnosis and management, there have been notable differences to date. These differences have been reconciled by the recent publication of the 2017 revision and update published by the EAACI/GA2LEN/EDF/WAO.

Recent Findings

The 2017 revision and update to the guidelines for chronic urticaria are the most comprehensive consensus document to date, and reconcile previously existing differences between the US, European, and Asian guidelines.

Summary

The purpose of our review is to present basic background on urticaria and discuss classification, diagnosis, and most importantly, management. We present differences from previous US, European, and Asian guidelines and reconcile the previous differences by summarizing the 2017 revision and update published by the EAACI/GA2LEN/EDF/WAO.



https://ift.tt/2IGR028

Chronic Urticaria: Comparisons of US, European, and Asian Guidelines

Abstract

Purpose of Review

Chronic urticaria is a common dermatological condition that has significant impact on quality of life. Multiple international societies have published guidelines, and although these guidelines generally agree on the definition of urticaria, as well as approach to diagnosis and management, there have been notable differences to date. These differences have been reconciled by the recent publication of the 2017 revision and update published by the EAACI/GA2LEN/EDF/WAO.

Recent Findings

The 2017 revision and update to the guidelines for chronic urticaria are the most comprehensive consensus document to date, and reconcile previously existing differences between the US, European, and Asian guidelines.

Summary

The purpose of our review is to present basic background on urticaria and discuss classification, diagnosis, and most importantly, management. We present differences from previous US, European, and Asian guidelines and reconcile the previous differences by summarizing the 2017 revision and update published by the EAACI/GA2LEN/EDF/WAO.



https://ift.tt/2IGR028

Effects of meta-tetrahydroxyphenylchlorin photodynamic therapy on isogenic colorectal cancer SW480 and SW620 cells with different metastatic potentials

Abstract

The aim of this study is to investigate the antitumor effects and possible mechanisms of meta-tetrahydroxyphenylchlorin-mediated photodynamic therapy (m-THPC-PDT) on human primary (SW480) and metastatic (SW620) colon cancer cell lines. SW480 and SW620 cells were incubated with various concentrations of m-THPC, followed by photodynamic irradiation. Subcellular localization of m-THPC in cells was observed with confocal laser scanning microscopy (CLSM). Photocytotoxicity of m-THPC in the two cells was investigated by using MTT assay. The flow cytometry was employed to detect the cell apoptosis. The migration and long-term recovery ability were determined by scratch test and colony formation assay respectively. CLSM showed that m-THPC was mainly distributed within the endoplasmic reticulum (ER) and lysosome of SW480 cells and within the lysosome and mitochondria of SW620 cells. m-THPC-PDT induced a dose-dependent and light energy-dependent cytotoxicity in SW480 and SW620 cells. Apoptosis rate was approximately 65 and 25% in SW480 and SW620 respectively when the concentration of m-THPC increased to 11.76 μM. However, the rate of necrotic cells had no significant changes in two cell lines. The colony formation and migration ability of the two cell lines were decreased with m-THPC-PDT treatment in a dose-dependent manner. PDT with m-THPC not only could effectively inhibit cell proliferation and decrease migration ability and colony formation ability, but also could effectively kill SW480 and SW620 cells in a dose-dependent manner in vitro. These results suggest that m-THPC is a promising sensitizer that warrants further development and extensive studies towards clinical use of colorectal cancer.



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How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel

Otávio Bejzman Piltcher, Eduardo Macoto Kosugi, Eulalia Sakano, Olavo Mion, José Ricardo Gurgel Testa, Fabrizio Ricci Romano, Marco Cesar Jorge Santos, Renata Cantisani Di Francesco, Edson Ibrahim Mitre, Thiago Freire Pinto Bezerra, Renato Roithmann, Francini Greco Padua, Fabiana Cardoso Pereira Valera, José Faibes Lubianca Neto, Leonardo Conrado Barbosa Sá, Shirley Shizue Nagata Pignatari, Melissa Ameloti Gomes Avelino, Juliana Alves de Souza Caixeta, Wilma Terezinha Anselmo‐Lima, Edwin Tamashiro
Braz J Otorhinolaryngol.2018;84:265-79

Resume - Texto Completo - PDF

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Breaking paradigms in severe epistaxis: the importance of looking for the S‐point

Eduardo Macoto Kosugi, Leonardo Balsalobre, João Mangussi‐Gomes, Miguel Soares Tepedino, Daniel Marcus San‐da‐Silva, Erika Mucciolo Cabernite, Diego Hermann, Aldo Cassol Stamm
Braz J Otorhinolaryngol.2018;84:290-7

Resume - Texto Completo - PDF

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Peritonsillar and deep neck infections: a review of 330 cases

Paula Martínez Pascual, Paloma Pinacho Martinez, Eviatar Friedlander, Carlos Martin Oviedo, Bartolome Scola Yurrita
Braz J Otorhinolaryngol.2018;84:305-10

Resume - Texto Completo - PDF

https://ift.tt/2LpD6iG

Genomic profile of a squamous cell carcinoma ex pleomorphic adenoma compared to a head and neck squamous cell carcinoma

Fernanda Viviane Mariano, Luis Fernando Vidal Saccomani, Karina Giovanetti, André Del Negro, Luiz Paulo Kowalski, Ana Cristina Victorino Krepischi, Albina Altemani
Braz J Otorhinolaryngol.2018;84:393-7

Texto Completo - PDF

https://ift.tt/2IJlvEJ

In the first line of her book, Dr. Feemster writes, “vaccines represent one of the greatest public health...

In the first line of her book, Dr. Feemster writes, "vaccines represent one of the greatest public health advances of the past 100 years." Still, significant disparities continue to exist in widespread availability, adherence, and acceptance of vaccines, despite profound decreases and even eradication of preventable diseases since Jenner's renowned smallpox experiments in 1796.

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The Amish have Decreased Asthma and Allergic Diseases Compared to Old Order Mennonites

The prevalence of allergic diseases is increasing worldwide, particularly in Westernized regions. Epidemiologic studies from several continents have shown an association between infants born into farming environments and significantly decreased frequency of asthma and allergic diseases. The protective factors in farming environments remain poorly understood but may include animal exposure and farm (unprocessed) milk ingestion 1,2. The Amish, Old Order Mennonites (OOM), and Hutterites are distinct Anabaptist traditional agrarian cultures.

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Nonpharmacologic Considerations in the Management of Allergies and Asthma

A considerable amount of literature has been published on optimal management of patients who have allergy and/or asthma related diseases. While major progress has been reported with new and exciting pharmacological therapies which include biologically derived agents, this does not replace the need for an effective patient-provider interpersonal relationship [1]. Aside from our expertise derived from state-of-the art education (both in graduate medical education and continuing medical education) and clinical experience, there is more to optimal management of our patients' health besides the right prescription at the right time.

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Provider Practices in Screening for Mental Health Concerns in Caregivers of Patients with Primary Immunodeficiency

Primary immunodeficiency disorders (PID) are a diverse group of diseases that impact the immune system and require intensive treatment. The psychosocial impact of PID may be particularly pronounced among caregivers of children diagnosed with PID who often experience disruption to work and family responsibilities related to diagnosis and treatment, and face ongoing uncertainty regarding recurrent infections, hospitalizations, and life-threatening treatment. The psychological impact of chronic diseases may influence patient medical and psychosocial outcomes as well.

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A gland of diverse pathology and unpredictable behaviour: our experience of primary submandibular gland malignancies

Submandibular gland tumours are relatively uncommon tumours and demonstrate diverse histological types and a variable prognosis. The aim of this study was to analyze our experience with submandibular malignancies over a period of 6 years (January 2009 to December 2015). Patient data from the 6-year period were reviewed retrospectively and 51 patients with submandibular malignancies were identified. Demographic data, clinicopathological details, treatment received, complications, and follow-up were recorded.

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Comparative study of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars

Abstract

Aim

Aim of the study is to compare the primary and secondary healing after surgical removal of impacted mandibular third molars, in terms of swelling, severity of pain, trismus, and periodontal healing between two types of closure.

Materials and methods

A total of 60 patients, divided into two groups randomly: group A, with 30 patients in which primary closure was done; group B, with 30 patients in which secondary closure was done. A comparison between two groups was done in terms of postoperative pain, swelling, trismus at first, third, and seventh postoperative days, and periodontal healing near adjacent second molar after 6 months.

Results

The swelling and pain in group A were greater than that in group B, with a statistically significant difference (p < 0.05). Mouth opening is greater in group B compared to group A. There is no significant difference in periodontal healing in between two groups after 6 months. Complication like alveolar osteitis was noted in 1 patient (3.3%) in group B.

Conclusion

We conclude that secondary closure was better than primary closure in terms of postoperative pain, swelling, and trismus. Irrespective of any closure technique, there is no difference in terms of periodontal healing.



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Pyramidal Artery: An Artery to Pyramidal Lobe—A New Nomenclature

Abstract

Thyroid lobes are supplied by superior and inferior thyroid arteries. We dissected out a specific arterial pattern always present along with a well developed pyramidal lobe. Authors named this as "Pyramidal Artery". This may be a common unnoticed bleeding site during surgery. Thyroid anomalies are commonly observed as incidental finding during surgery. Presence of pyramidal lobe is the most common finding among other thyroid anomalies due to persistence of thyroglossal duct. Present study reported incidence of pyramidal lobe in 41.46% cases and pyramidal lobe branches off more frequently from left lobe than right. Special attention has to be paid during total thyroidectomy in order not to leave the thyroid tissue. Few such anatomical variations and surgical importance of vascular pattern in such cases is discussed in paper.



https://ift.tt/2J4t8EM

Pyramidal Artery: An Artery to Pyramidal Lobe—A New Nomenclature

Abstract

Thyroid lobes are supplied by superior and inferior thyroid arteries. We dissected out a specific arterial pattern always present along with a well developed pyramidal lobe. Authors named this as "Pyramidal Artery". This may be a common unnoticed bleeding site during surgery. Thyroid anomalies are commonly observed as incidental finding during surgery. Presence of pyramidal lobe is the most common finding among other thyroid anomalies due to persistence of thyroglossal duct. Present study reported incidence of pyramidal lobe in 41.46% cases and pyramidal lobe branches off more frequently from left lobe than right. Special attention has to be paid during total thyroidectomy in order not to leave the thyroid tissue. Few such anatomical variations and surgical importance of vascular pattern in such cases is discussed in paper.



https://ift.tt/2J4t8EM

Histone modifications and their role in epigenetics of atopy and allergic diseases

This review covers basic aspects of histone modification and the role of posttranslational histone modifications in the development of allergic diseases, including the immune mechanisms underlying this develop...

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Association between fractional exhaled nitric oxide, sputum induction and peripheral blood eosinophil in uncontrolled asthma

The fractional exhaled nitric oxide (FeNO) and blood eosinophils are biomarkers of eosinophilic airway inflammation used in the diagnosis and management of asthma, although induced sputum is the gold standard ...

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Ketamine and electroconvulsive therapy: so happy together?

Purpose of review Anesthetics, such as thiopental, methohexital, propofol and ketamine have been used to induce unconsciousness for electroconvulsive therapy (ECT), each with its advantages and disadvantages. Only until recently was it discovered that ketamine may have inherent antidepressant effects. We reviewed the side effect profile of ketamine and examined the literature for whether or not ketamine augments the antidepressant effects of ECT. Recent findings Systematic reviews and meta-analyses of randomized controlled trials of the potential benefits of adding ketamine to ECT treatment have generated varied conclusions. Currently there is a lack of clear evidence that ketamine with ECT is more efficacious than ECT alone. Summary Large, multicenter randomized controlled trials are needed to further investigate the potential advantages of adding ketamine to ECT for patients with severe or refractory depression. The addition of ketamine to ECT treatment may have some early beneficial effect in patients with acute depressive disorders. Most likely, ECT itself is responsible for lasting remission from severe depression. Ketamine's side effect profile may be undesirable in certain patient populations, and so the risks and benefits of the addition of this drug to ECT treatment must be weighed. Correspondence to Kathryn Cobb, MD, N2198 UNC Hospitals, CB# 7010, Chapel Hill, NC 27599-7010, USA. Tel: +1 919 966 5136; e-mail: kathryn_cobb@med.unc.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Treatment of ventriculoperitoneal shunt infection and ventriculitis caused by Acinetobacter baumannii: a case report

Acinetobacter baumannii (A. baumannii) infections are a recognized problem in healthcare, causing ventriculoperitoneal shunt infection and ventriculitis. Such infections are serious intracranial infection that ca...

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Comparative study of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars

Abstract

Aim

Aim of the study is to compare the primary and secondary healing after surgical removal of impacted mandibular third molars, in terms of swelling, severity of pain, trismus, and periodontal healing between two types of closure.

Materials and methods

A total of 60 patients, divided into two groups randomly: group A, with 30 patients in which primary closure was done; group B, with 30 patients in which secondary closure was done. A comparison between two groups was done in terms of postoperative pain, swelling, trismus at first, third, and seventh postoperative days, and periodontal healing near adjacent second molar after 6 months.

Results

The swelling and pain in group A were greater than that in group B, with a statistically significant difference (p < 0.05). Mouth opening is greater in group B compared to group A. There is no significant difference in periodontal healing in between two groups after 6 months. Complication like alveolar osteitis was noted in 1 patient (3.3%) in group B.

Conclusion

We conclude that secondary closure was better than primary closure in terms of postoperative pain, swelling, and trismus. Irrespective of any closure technique, there is no difference in terms of periodontal healing.



https://ift.tt/2s5zxoM

Topical Sirolimus to Treat Tuberous Sclerosis Complex

Tuberous sclerosis complex (TSC) causes the formation of hamartomatous tumors in multiple organs. Facial angiofibromas frequently arise during childhood and can be a source of patient distress owing to bleeding and effects on appearance. The standard treatment is surgical, delivered by multiple modalities, including lasers, shave excision, dermabrasion, electrosurgery, or cryosurgery. These approaches are effective but can create concerns about the potential for scarring, pain, anesthesia risk, postoperative recovery, and the need for repeated procedures delivered in the office or operating room. Consequently, there has been interest in the development of a topical therapy for home use that is painless and nonscarring. In this issue, Koenig and collaborators show that topical 0.1% or 1.0% sirolimus (rapamycin) applied once daily is safe and effective for treating facial angiofibromas. This is welcome news for many with TSC. Furthermore, these results are expected to fuel investigations into other uses for sirolimus in dermatology. The story of how topical sirolimus became a treatment option for TSC is based in scientific discoveries of its molecular target and that target's role in relevant diseases.

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Prevalence of Crohn Disease Among Patients With Hidradenitis Suppurativa

This cross-sectional cohort analysis of electronic health records from a large US database evaluates overall and subgroup prevalence of Crohn disease among patients with hidradenitis suppurativa.

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Mogamilizumab Prior to Allogeneic Hematopoietic Stem Cell Transplantation

This case series describes characteristics of 8 patients with mycosis fungoides or Sézary syndrome who received mogamulizumab before allogeneic hematopoietic stem cell transplantation and any resulting graft-vs-host disease–related complications.

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Topical Rapamycin in Patients With Facial Angiofibromas

This randomized clinical trial examines the efficacy and safety of topical rapamycin therapy for treatment of patients with tuberous sclerosis complex–related facial angiofibromas.

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Immunotherapy-Related Eruption Limited to Sites of Melanoma Metastases

This case report describes 2 patients with cutaneous eruptions secondary to immunotherapy for metastatic melanoma limited to sites of locoregional melanoma metastases.

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Perioperative Hyperchloremia and its Association With Postoperative Acute Kidney Injury After Craniotomy for Primary Brain Tumor Resection: A Retrospective, Observational Study

Background: Hyperchloremia is known to influence postoperative outcomes and may result in postoperative acute kidney injury (AKI). This study sought to investigate whether hyperchloremia was associated with postoperative AKI in patients who underwent surgery for primary brain tumor resection. Materials and Methods: This is a retrospective, observational study of patients who underwent craniotomy for primary brain tumor resection at a single tertiary care hospital between January 2005 and October 2017. Maximum levels of serum chloride (mmol/L) measured on postoperative days (PODs) 0 to 3 and increase in serum chloride (mmol/L), (maximum serum chloride−baseline serum chloride before surgery) were measured. We examined whether perioperative hyperchloremia was associated with postoperative AKI during PODs 0 to 3. Univariate and multivariate logistic regression analyses were used in this study. Results: A total of 726 patients were included in the analysis; of these, 39 (5.4%) were diagnosed with postoperative AKI during PODs 0 to 3. The risk of postoperative AKI was associated with maximum chloride levels (odds ratio, 1.10; 95% confidence interval, 1.02-1.19; P=0.015) and with an increase in serum chloride levels during PODs 0 to 3 (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P=0.004). Conclusions: Our study shows that perioperative hyperchloremia during PODs 0 to 3 was associated with an increased risk of postoperative AKI during this period after craniotomy for primary brain tumor resection. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Sang-Hwan Do, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, South Korea (e-mail: shdo@snu.ac.kr). Received January 31, 2018 Accepted April 19, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Ultrasound-guided single injection versus continuous sciatic nerve blockade on pain management and mobilisation after total knee arthroplasty (CoSinUS trial): A randomised, triple-blinded controlled trial

BACKGROUND Combining continuous femoral nerve blockade with single injection sciatic nerve blockade is standard peripheral nerve block practice for total knee arthroplasty (TKA) during the first 24 postoperative hours. OBJECTIVES To assess the analgesic benefits and mobilisation capability of continuous sciatic blockade in conjunction with continuous femoral nerve blockade for 72 h after arthroplasty. DESIGN Randomised, triple-blinded controlled trial. SETTING Single-Centre, German University Hospital. PATIENTS In total, 50 patients receiving continuous femoral nerve blockade (5 ml h−1 ropivacaine 0.2%) for TKA under general anaesthesia. INTERVENTIONS Patients were randomised to receive a sciatic nerve catheter with an initial dose of 10 ml ropivacaine 0.2% followed by either continuous double-blinded application of 5 ml h−1 ropivacaine 0.2% (CO) or 5 ml h−1 saline infusion (SIN). MAIN OUTCOME Measures primary endpoint: cumulative morphine consumption until 48 h postoperatively. Further endpoints included morphine consumption, pain scores, mobilisation, dynamometry until postoperative day 3. RESULTS Median [25th to 75th percentiles] cumulative morphine consumption at postoperative day 2 differed significantly between groups (CO 15 mg [11 to 25] versus SIN, 43 mg [27 to 67.5, P 

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Activating PIK3CD mutations impair human cytotoxic lymphocyte differentiation, function and EBV immunity

Publication date: Available online 22 May 2018
Source:Journal of Allergy and Clinical Immunology
Author(s): Emily S.J. Edwards, Julia Bier, Theresa S. Cole, Melanie Wong, Peter Hsu, Lucinda J. Berglund, Kaan Boztug, Anthony Lau, Emma Gostick, David A. Price, Michael O'Sullivan, Isabelle Meyts, Sharon Choo, Paul Gray, Steven M. Holland, Elissa K. Deenick, Gulbu Uzel, Stuart G. Tangye
BackgroundGermline gain-of function (GOF) mutations in PIK3CD, encoding the catalytic p110δ subunit of phosphatidylinositol-3 kinase, result in hyperactivation of the PI3K-AKT-mTOR pathway and underlie a novel inborn error of immunity. Affected individuals exhibit perturbed humoral and cellular immunity, manifesting as recurrent infections, autoimmunity, hepatosplenomegaly, uncontrolled EBV and/or CMV infection, and an increased incidence of B-cell lymphoproliferation and/or lymphoma. Mechanisms underlying disease pathogenesis remain unknown.ObjectiveUnderstanding the cellular and molecular mechanisms underpinning inefficient surveillance of EBV-infected B cells is required to understand disease in individuals with PIK3CD GOF mutations, identify key molecules required for cell mediated immunity against EBV, and develop immunotherapeutic interventions for the treatment of this as well as other EBV-opathies.MethodsWe studied the consequences of PIK3CD GOF mutations on the generation, differentiation and function of CD8+ T cells and NK cells, which are implicated in host defense against infection with herpesviruses including EBV.ResultsPIK3CD GOF total and EBV-specific CD8+ T cells were skewed towards an effector phenotype, with exaggerated expression of markers associated with premature immunosenescence/exhaustion, and increased susceptibility to re-activation induced cell death. These findings were recapitulated in a novel mouse model of PI3K GOF. NK cells in PIK3CD GOF individuals also exhibited perturbed expression of differentiation-associated molecules. Both CD8+ T cells and NK cells had reduced capacity to kill EBV-infected B cells. PIK3CD GOF B cells had increased expression of CD48, PDL-1/2 and CD70.ConclusionsPIK3CD GOF mutations aberrantly induce exhaustion and/or senescence and impair cytotoxicity of CD8+ T and NK cells. These defects may contribute to clinical features of affected individuals, such as impaired immunity to herpesviruses and tumor surveillance.

Graphical abstract

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Prognostic Significance of Lymph Node Yield and Lymph Node Ratio Prospective Observational Study

Condition:   Head and Neck Cancer
Intervention:   Diagnostic Test: Lymph Node Yield (LNY) and Lymph Node Ratio (LNR)
Sponsor:   Oreste Iocca, M.D., D.D.S.
Not yet recruiting

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Spontaneous acalculous gallbladder perforation post-cardiac transplantation

Spontaneous acalculous gallbladder perforation is a rare radiological and clinical phenomenon with life-threatening consequences. In the setting of recent cardiac transplantation, the condition is increasingly uncommon and difficult to diagnose preoperatively. We describe a case of spontaneous acalculous gallbladder perforation in an intensive care unit (ICU) patient, most likely due to a combination of cardiac transplantation and immunosuppression. There are no such documented cases in the literature with an established preoperative diagnosis, to the best of our knowledge. Abdominal CT and targeted ultrasound proved complimentary in establishing the diagnosis, facilitating successful and timely treatment with urgent cholecystectomy.



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Stuck guidewire due to soft tissue imposition: a rare complication of central line catheter placement

Central venous catheter (CVC) placement is a commonly done procedure but is associated with a few complications, and guidewire-related complications are one of them. In our case after induction of general anaesthesia, we planned to insert a CVC in the right internal jugular vein under ultrasound guidance. After the insertion of the introducer needle, when we tried to insert the guidewire, it got stuck and was neither moving forward nor in a backward direction. Too much force was not applied to remove the guidewire as it might have caused shearing of the guidewire and further complicated the picture. This problem was solved by simultaneous withdrawal of guidewire along with the needle, and on examination we found soft tissue debris lodged within the lumen which was preventing the guidewire movement in both directions. So, it is suggested that guidewire should be removed along with needle as a single unit if it is required.



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Neuromyelitis optica spectrum disorder presenting as rhomboencephalitis

Rhomboencephalitis, at least in its acute phase, is often a severely disabling syndrome, and can be life threatening. A range of underlying conditions can lead to this clinical syndrome. Rapid diagnosis to initiate treatment early is key to a beneficial outcome. We report the case of a 22 year old Afro-Caribbean woman, who presented with a two -week history of walking difficulties, upper limb incoordination and slurred speech. Her brainstem function deteriorated at pace, and she developed hypersomnia. A broad diagnostic approach led to prophylactic treatment for the most common infectious causes. This did not improve her symptoms. Non-infectious inflammatory causes were therefore considered and plasma exchange treatment was initiated leading to marked improvement within days. Screening for autoimmune conditions confirmed aquaporin-4 positive neuromyelitis optica spectrum disorder (NMOSD) as the underlying cause. Immunotherapy with rituximab was started. So far, no relapse has been observed. While the definition of NMOSD continues to be refined, aquaporin-4 testing should be considered early in patients presenting with rhomboencephalitis who do not respond to antibiotic and antiviral treatment. Vigilance and early intervention are key to limit morbidity and mortality from NMOSD.



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Motor Cortex Stimulation for Deafferentation Pain

Abstract

Purpose of Review

Since the early 1990s, motor cortex stimulation (MCS) has been a unique treatment modality for patients with drug-resistant deafferentation pain. While underpowered studies and case reports have limited definitive, data-driven analysis of MCS in the past, recent research has brought new clarity to the MCS literature and has helped identify appropriate indications for MCS and its long-term efficacy.

Recent Findings

In this review, new research in MCS, repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) are analyzed and compared with historical landmark papers. Currently, MCS is effective in providing relief to 40–64% of patients, with decreasing analgesic effect over time addressed by altering stimulation settings. rTMS and tDCS, two historic, non-invasive stimulation techniques, are providing new alternatives for the treatment of deafferentation pain, with rTMS finding utility in identifying MCS responders. Future advances in electrode arrays, neuro-navigation, and high-definition tDCS hold promise in providing pain relief to growing numbers of patients.

Summary

Deafferentation pain is severe, disabling, and remains a challenge for patients and providers alike. Over the last several years, the MCS literature has been revitalized with studies and meta-analyses demonstrating MCS effectiveness and providing guidance in identifying responders. At the same time, rTMS and tDCS, two time-honored non-invasive stimulation techniques, are finding new utility in managing deafferentation pain and identifying good MCS candidates. As the number of potential therapies grow, the clinician's role is shifting to personalizing treatment to the unique pain of each patient. With new treatment modalities, this form of personalized medicine is more possible than ever before.



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