Background: Milrinone has emerged as an option to treat delayed cerebral ischemia after subarachnoid hemorrhage. However, substantial variation exists in the administration of this drug. We retrospectively assessed the effectiveness of 2 protocols in patients with angiographically proven cerebral vasospasm. Methods: During 2 successive periods, milrinone was administered using either a combination of intra-arterial milrinone infusion followed by intravenous administration until day 14 after initial bleeding (IA+IV protocol), or a continuous intravenous milrinone infusion for at least 7 days (IV protocol). The primary endpoint was the reversion rate of vasospastic arterial segments following the first IA infusion of milrinone (IA+IV protocol) compared with the reversion rate during the first week of IV infusion (IV protocol). Results: There were 24 and 77 consecutive patients in IA+IV and IV protocols, respectively. The reversion rate was comparable between the 2 protocols: 71% (95% confidence interval [CI], 59%-83%) in the IA+IV protocol versus 64% (95% CI, 58%-71%) in the IV protocol (P=0.36). Rescue procedures for persistence or recurrence of vasospasm, that is, mechanical angioplasty and/or IA milrinone infusion, were similar between the 2 protocols. Patients with a good neurological outcome at 1 year, that is, modified Rankin Scale scores 0-2, were comparable between the 2 protocols. Side effects of milrinone were uncommon and equally distributed within the 2 protocols. Conclusions: These findings indicate that a continuous IV infusion of milrinone was as efficient as combined IA+IV infusion and suggest that this modality could be considered as a first easy-to-use option to treat patients with CVS. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Jean-François Payen, MD, PhD, Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France (e-mail: jfpayen@univ-grenoble-alpes.fr). Received April 11, 2018 Accepted June 7, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
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Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Κυριακή 15 Ιουλίου 2018
The Effect of Fluid Loading and Hypertonic Saline Solution on Cortical Cerebral Microcirculation and Glycocalyx Integrity
Background: Fluid loading and hyperosmolar solutions can modify the cortical brain microcirculation and the endothelial glycocalyx (EG). This study compared the short-term effects of liberal fluid loading with a restrictive fluid intake followed by osmotherapy with hypertonic saline (HTS) on cerebral cortical microcirculation and EG integrity in a rabbit craniotomy model. Methods: The experimental rabbits were allocated randomly to receive either
https://ift.tt/2NTgisx
https://ift.tt/2NTgisx
Impact of CPAP on Forehead Near-infrared Spectroscopy Measurements in Patients With Acute Respiratory Failure: Truth or Illusion
Background: Critically ill patients with acute respiratory failure admitted to an intensive care unit are at high risk for cerebral hypoxia. We investigated the impact of continuous positive airway pressure (CPAP) therapy on regional cerebral tissue oxygenation (rSO2). Materials and Methods: In total, 40 extubated surgical intensive care unit patients requiring classic oxygen therapy (COT) for acute respiratory failure were examined. Near-infrared spectroscopy (INVOS 5100C, Covidien) was used for 30 minutes to detect bilateral rSO2 during COT via facemask (6 L/min) and CPAP therapy (40% fraction of inspired oxygen, 8 cm H2O CPAP) using a randomized crossover study design. Patients served as their own control. Continuous hemodynamic routine monitoring and blood gas analysis were performed. The effect of CPAP therapy on rSO2 and influence of assessed covariables were investigated using a mixed linear model. Results: Median rSO2 increased from 57.9% (95% confidence interval [CI], 54.2-61.5) during COT to 62.8% (95% CI, 59.2-66.5) during CPAP therapy (P
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https://ift.tt/2Js4pqe
Multiple lesions of skull and cervical spine: a rare presentation of unicameral bone cysts
A 55-year-old man with a history of Benign Paroxysmal Positional Vertigo unalleviated by Epley manoeuvre presented to an otolaryngologist for dizziness, right ear fullness and headache. MRI of the brain showed numerous marrow-replacing lesions throughout the calvarium, skull base and upper cervical spine which were hypointense on T1-weighted images, hyperintense on T2-weighted images and avidly enhanced following contrast, concerning for a malignant process such as metastatic disease or multiple myeloma (figure 1). Systemic X-ray survey (spine, skull, chest, pelvis, all long bones) and nuclear medicine whole body bone scan were negative except for the lesions seen on MRI. β–2microglobin, immunoglobin and monoclonal protein electrophoresis were negative for myeloma or immunological process. Given the concern for metastatic disease, biopsy of a skull lesion was recommended. Pathological analysis of a calvarial lesion was consistent with unicameral bone cyst (figure 1). No ongoing therapy was offered; however, brain and spine surveillance imaging will continue.
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Orbitocerebral mucormycosis and intracranial haemorrhage: a role for caution with steroids in suspected giant cell arteritis
A 75-year-old man with type 2 diabetes mellitus presented with complete loss of vision in his right eye and severe headaches for the past 24 hours. He had been treated for suspected giant cell arteritis (GCA) with high-dose corticosteroids which were being tapered to stop after an inconclusive right temporal artery biopsy and an erythrocyte sedimentation rate (ESR) value of 8. His current acute presentation, however, raised further concern for partially treated GCA and precipitated treatment with pulsed methylprednisolone. The patient, taking metformin, developed diabetic ketoacidosis and was transferred to the intensive care unit where a swollen, painful right eye with chemosis and complete ophthalmoplegia was subsequently revealed to be secondary to cavernous sinus thrombosis. Rhino-orbital skin necrosis with positive samples for the organism Rhizopus on eventual orbital exenteration revealed angioinvasive fungal infection, mucormycosis, to be the cause. We discuss here the lessons learnt, and how best to treat a susceptible cohort within our ageing western population.
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Spontaneous migration into the stomach and out of the intestine, as late complication of a gastric band
Description
A 45-year-old woman with morbid obesity (body mass index 44 kg/m²) presented to the emergency department with severe abdominal pain, nausea, vomiting and no defaecation. She had a laparoscopic adjustable gastric banding (LAGB) inserted elsewhere in 2006. No data or follow-up was performed postoperatively. A CT scan demonstrated a perforated LAGB through the gastric antrum (figure 1). Furthermore the connecting tube perforated the small intestine at the level of the proximal part of the jejunum with a partially intraluminally positioned banding (figure 2), causing prestenotic dilatation of the jejunum (figure 3). An upper gastrointestinal endoscopy confirmed an intact port site with a connected tube and migration and perforation of the band into the jejunum with an erosion of the gastric (figure 4) and duodenal wall. At closer inspection of the port site and connecting tube, we observed a high level...
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Emphysematous Osteomyelitis
Description
A 56-year-old man with a known history of type 2 diabetes mellitus, hypertension, nephrolithiasis and gout presented with fatigue and flank pain for 3 days. The above symptoms were associated with fevers and chills. On admission, the patient's vitals were remarkable for fever with maximum temperature (T max) 39.1°C, hypotension requiring pressor support and tachycardia. On auscultation, he had reduced air entry at lung bases, distended abdomen, bipedal oedema and petechial rash over the upper extremities and the trunks. In addition, there was purplish discolouration over the left medial sacral area. Laboratory work-up was remarkable for elevated white cell count 21.4x109/L (4.0–12.0x109/L), creatinine 7.98 mg/dL (0.60–1.40 mg/dL), anion gap of 25, erythrocyte sedimentation rate of 70 mm/hour (0–20 mm/hour), total bilirubin of 4.9 mg/dL (0.2–1.2 mg/dL) and lipase 422 U/L (0–140 U/L). Platelet count was 31x103/µL (150–400 103/µL), aspartate aminotransferase of 71 U/L (10–40 U/L) and alanine aminotransferase of 37 U/L (3–45 U/L). Septic shock was suspected, and the patient was...
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Campylobacter fetus spondylodiscitis in a patient with HIV infection and restored CD4 count
Campylobacter fetus (C. fetus) is a rare condition and mostly seen in elderly or immunocompromised patients. We present the first case of C. fetus spondylodiscitis in a virologically suppressed HIV seropositive patient with low back pain. MRI was performed and showed spondylodiscitis of the L4–L5 region. Empirical antibiotic therapy with flucloxacillin was started after blood cultures were drawn and an image-guided disc biopsy was performed. Blood cultures remained negative. The anaerobic culture of the puncture biopsy of the disc revealed presence of C. fetus after which the antibiotic treatment was switched to ceftriaxone. Guided by the susceptibility results, the therapy was switched to ciprofloxacin orally for 6 weeks after which the patient made full clinical, biochemical and radiographic recovery. Since no other immune-deficient conditions were noted, it is important to highlight that patients with HIV infection with restored CD4 counts and complete virological suppression can still be susceptible for infections caused by rare pathogens. Low back pain should raise suspicion for these conditions and should be examined properly.
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Case of fatal familial insomnia caused by a d178n mutation with phenotypic similarity to Hashimotos encephalopathy
Fatal familial insomnia (FFI) is a rare prion disease commonly inherited in an autosomal dominant pattern from a mutation in the PRioN Protein (PRNP) gene. Hashimoto's encephalopathy (HE) is characterised by encephalopathy associated with antithyroid peroxidase (TPO) or antithyroglobulin (Tg) antibodies. These two conditions characteristically have differing clinical presentations with dramatically different clinical course and outcomes. Here, we present a case of FFI mimicking HE. A woman in her 50s presented with worsening confusion, hallucinations, tremor and leg jerks. Several maternal relatives had been diagnosed with FFI, but the patient had had negative genetic testing for PRNP. MRI of brain, cervical and thoracic spine were unremarkable except for evidence of prior cervical transverse myelitis. Cerebrospinal fluid analysis was normal. Anti-TPO and anti-Tg antibodies were elevated. She was started on steroids for possible HE and showed improvement in symptoms. Following discharge, the results of her PRNP gene test returned positive for variant p.Asp178Asn.
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The treatment of trismus with Ativan: a 3-year-old with difficulty opening her mouth
Description
A 3-year-old healthy girl presented with intermittent spells of difficulty opening her mouth, talking and swallowing.
Episodes began 3 weeks prior without any inciting incident. Initially occurring weekly, episodes were brief and self-resolving, but had begun increasing in frequency. Symptoms were typically worse later in the day. The presenting episode started 36 hours earlier. The child was eating when her jaw unexpectedly clenched tightly, preventing her from chewing, swallowing or opening her mouth. She had no other neurological symptoms. Family denied any new exposures or trauma. She had no other systemic symptoms. Her father had severe blepharospasms in youth that resolved without treatment.
Her mouth was pursed and jaw tightly clenched (figures 1 and 2). She was drooling and appeared unable to swallow secretions or speak, though was whining and appeared frustrated. Temporomandibular joint (TMJ) was non-tender with symmetrical jaw musculature. She had fasciculations over...
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Rare cause of voiding dysfunction in an adult man: urethral diverticulum compressing the anterior urethra
Description
A 46-year-old man presented to us with lower urinary tract symptoms that include severe voiding symptoms. He had a history of injury to the perineum 3 years back. A smooth cystic swelling was palpable in the perineum in midline. Uroflowmetry was done and was suggestive of poor urinary flow (Qavg: 2 mL/s and Qmax: 6 mL/s), with significant postvoid residual urine (PVR). A micturating cystourethrogram (MCU) with retrograde urethrography (RUG) was done and was suggestive of an anterior urethral diverticulum, which was compressing the urethra, along with significant PVR (figure 1). The patient was planned for open excision of the urethral diverticulum. A cystourethroscopy was done preoperatively and clearly showed a normal anterior urethra and the opening of the diverticulum on the ventral aspect of the urethra (figure 2). The patient was operated in lithotomy position and a midline perineal incision was done. The diverticulum was dissected free and then excised,...
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Urea cycle disorder presenting as bilateral mesial temporal sclerosis – an unusual cause of seizures: a case report and review of the literature
Urea cycle disorders are secondary to defects in the system converting ammonia into urea, causing accumulation of ammonia and other byproducts which are neurotoxic. Ornithine transcarbamylase deficiency is the...
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A Rare Case of Vascular Leiomyosarcoma Originating from a Branch Vessel of the External Iliac Vein
Leiomyosarcoma arising from the external iliac vein is uncommon. This is a report of a 51-year-old Japanese man with venous leiomyosarcoma originating from a branch vessel of the left external iliac vein. The tumor was found during a medical examination, and the patient had no symptoms. Computed tomography showed a 72 × 49 mm mass adjacent to the left external iliac vein. The tumor was resected en-block along with ligation of the external iliac vein due to strong adhesion with the tumor. Histological examination showed venous leiomyosarcoma, and its origin was thought to be a branch vessel of the left external iliac vein. The patient has remained free from recurrence at 30 months after surgery.
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