Electrophysiological Monitoring During Percutaneous Trigeminal Nerve Ganglion Block

No abstract available

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Successful Percutaneous Coronary Intervention for Atherosclerotic Coronary Lesion with Anomalous Origin of the Right Coronary Artery

Congenital coronary artery anomalies, including anomalous origin of a coronary artery, can manifest as life-threatening conditions, such as myocardial infarction or arrhythmia, and may even lead to sudden death associated with specific congenital anatomical features. Such arteries can also develop atherosclerotic lesions. This report describes the case of a 75-year-old man who was admitted to our hospital due to exertional dyspnea. The right coronary artery was found to originate from the left coronary sinus and exhibit tight stenosis due to atherosclerosis, causing effort angina pectoris. This case highlights the fact that coronary artery anomalies can cause angina pectoris via both atherosclerotic and nonatherosclerotic effects, and successful revascularization was achieved noninvasively via percutaneous coronary angioplasty.

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Blunt trauma to the antecubital fossa causing brachial artery injury and minor fractures around the elbow joint, an easily missed diagnosis with potential devastating consequences: a case report

Blunt trauma causing brachial artery injury in a young patient is very rare. Cases of brachial artery injury may be associated with closed elbow dislocation or instability. Elbow dislocation may not be evident...

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Venous air embolism in a patient with a massive upper gastrointestinal bleeding

Description 

Emergency medical responders (EMS) were called in for a subject who developed multiple generalised tonic-clonic seizures attributed to hydrocodone-acetaminophen overdose and possible upper gastrointestinal (GI) bleeding. His medical history was significant for peptic ulcer disease status post partial gastrectomy, chronic alcoholism, polysubstance abuse, factor V Leiden mutation with recurrent deep venous thrombosis and pulmonary embolism on warfarin treatment. On his way to the hospital, EMS had difficulty obtaining an intravenous access, and was only successful after three attempts, and the patient was started on intravenous fluids and naloxone. In the emergency room he had an episode of massive bleeding per rectum and was haemodynamically unstable. Fluid resuscitation was started, second intravenous access was obtained and nasogastric tube was placed. CT of the chest, abdomen and pelvis without contrast (figure 1) demonstrated a small amount of air in the right atrium, main pulmonary artery, and right lower lobe segmental and...

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Splenic torsion: a rare cause of abdominal pain

Splenic torsion is an exceedingly rare but clinically important disease process that should be recognised promptly by the treating physician. In this condition, there is twisting of the spleen along its vascular pedicle, subsequently leading to abdominal pain in the setting of organ ischaemia. Vascular thrombosis and splenic infarction may ensue. Torsion has been described in cases of a known wandering spleen. Abnormal development of the splenic suspensory ligaments may predispose a patient to a wandering spleen. Treatment of splenic torsion is typically surgical, with goals of preservation of the spleen if possible.

We present a case of a young woman who presented with left-sided chest and abdominal pain and was found to have splenic torsion with complete splenic infarction. Surgical intervention was required, and splenectomy was performed. In this case presentation, we outline the multidisciplinary approach needed to care for the patient with this rare condition.

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Aggressive myxoinflammatory fibroblastic sarcoma with multiple site metastases

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare soft tissue sarcoma which was initially observed in acral sites and characterised by spindle cells, pleomorphic bizarre cells and distinctive large Reed-Sternberg–like cells admixed with an intense inflammatory cell infiltrates. MIFS manifests as a slow growing often superficial lesion which can be mistaken as infectious or chronic inflammatory process or benign tumours such as nodular fasciitis, giant cell tumour of tendon sheath or synovial pseudocyst. We report a rare presentation of a MIFS in a 38-year-old man with extensive local spread from subcutaneous tissue to the ankle joint and bones as well as multiple synchronous metastases to lung, sixth rib and vertebra. Our case is peculiar for its aggressive clinical behaviour with short duration, fast growth and extensive metastases, a feature infrequent in MIFS.

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Rare cause for a common presentation: isolated pulmonary valve endocarditis yet another mimicker

Isolated pulmonary valve endocarditis (PVE) is a rare condition. Known risk factors in previous case reports were intravenous drug abuse and congenital heart disease. Epidemiology of PVE has been changing. It is now being reported specially following invasive healthcare-related procedures even in patients with structurally normal heart. Vast majority of patients present with respiratory symptoms and diagnosis of endocarditis may be challenging unless there is high index of suspicion. Various microorganisms had been isolated as aetiological agents; however, Enterococcus faecalis is being increasingly isolated. PVE mostly managed conservatively with intravenous antibiotics with option for surgical intervention in specific situations. We present a patient with isolated PVE due to E. faecalis following colonoscopy and polypectomy with predisposing risk factor of alcohol excess, mimicking clinically as pneumonia and radiologically as a neoplastic lesion.

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Metastasis of malignant myoepithelial carcinoma to the brain

Myoepithelial tumours are a rare form of salivary gland neoplasm and intracranial metastases have rarely been described. The authors present the case of a 61-year-old patient with a history of primary myoepithelial carcinoma of the right foot. Metastases were found in the third ventricle, left temporal lobe and right frontal lobe. The third ventricular and left temporal lobe tumours were resected in a two-stage operation. Pathology of the third ventricular lesion was most consistent with metastasis. MRI of the spine 2 weeks after his operation revealed an intradural mass with several lesions in the lumbar thecal space suggesting further metastases. The patient succumbed to his disease 2 months after his two-stage operation and 5 years after his initial diagnosis. This appears to be the first case in the literature of multiple primary myoepithelial carcinoma metastases to the brain. Further information is needed to provide diagnostic and therapeutic recommendations.

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The successful treatment of a multidrug-resistant Achromobacter xylosoxidans corneal ulcer with topical meropenem

Microbial keratitis is a common corneal condition, with many known risk factors. We present a case of an 88-year-old female patient with a multidrug-resistant Achromobacter xylosoxidans corneal ulcer in a previously failed second penetrating keratoplasty, successfully managed with topical meropenem drops administered hourly around the clock, for five days preceding and then hourly day only, for five days following a repeat third penetrating keratoplasty. Topical meropenem 50 mg/mL was prepared by mixing a 500 mg vial of meropenem with 10 mL of sterile water with pharmacy advice that administration should be within an hour. To the best of our knowledge, this is the first report of the use of topical meropenem in the management of A.xylosoxidans keratitis. This case highlights the importance of the mean inhibitory concentrations for antibiotics when considering sensitivities. Topical meropenem may be a useful treatment option for multidrug-resistant bacterial corneal ulcers that are resistant to conventional therapy.

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Caseous calcification of the mitral valve annulus: a rare cause of bilateral cerebral and ocular embolisation

A 65-year-old woman presented with sudden bilateral visual loss of recent onset. She was recently diagnosed with multiple acute stroke syndrome for which she was commenced on antiplatelet therapy. Funduscopic examination revealed bilateral inferotemporal retinal artery occlusions. The recent history of multiple cerebral infarcts combined with the current ocular findings prompted a transoesophageal echocardiogram which successfully revealed caseous calcification of the mitral valve annulus as the source of the numerous sequential emboli, a finding which the conventional transthoracic echocardiogram had failed to disclose as a result of suboptimal image quality. Transoesophageal echocardiography should always be considered as part of the diagnostic workup of retinal arterial occlusive disease, particularly in bilateral lesions, due to its higher yield in identifying posteriorly located cardiac valvular and aortic lesions.

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Cryptococcus neoformans empyema in a patient receiving ibrutinib for diffuse large B-cell lymphoma and a review of the literature

We report a case of Cryptococcus neoformans pulmonary infection complicated by empyema in a 79-year-old man with diffuse large B-cell lymphoma treated with R-CHOP and ibrutinib. A literature review identified 25 cases of cryptococcal pleural disease published since 1980. Most cases were caused by the C. neoformans species in immunocompromised hosts with an exudative pleural effusion and lymphocyte-predominant infiltrate. The cryptococcal antigen test was often positive when pleural fluid and serum were tested. The outcome was favourable in most cases with antifungal therapy and either thoracocentesis or surgical resection. We also identified 40 cases of opportunistic infections, most commonly aspergillosis, cryptococcosis and Pneumocystis jirovecii pneumonia, in patients treated with ibrutinib. In vitro studies indicate Bruton tyrosine kinase inhibition impairs phagocyte function and offer a mechanism for the apparent association between ibrutinib and invasive fungal infections.

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Transformation of jejunoileal follicular lymphoma into diffuse large B-cell lymphoma detected using double-balloon enteroscopy

Jejunoileal follicular lymphomas (FLs) are rare and have been reported to undergo histological transformation (HT). We report a case of jejunoileal FL transformation into diffuse large B-cell lymphoma (DLBCL). An 82-year-old woman presented with a 5.5 cm ulcerated jejunal mass, identified through double-balloon enteroscopy. The histopathology report revealed diffuse atypical lymphoid cells, which confirmed the presence of DLBCL. Neoplastic follicles confirmed the presence of FL. Genetic analysis revealed a match between the FL and DLBCL. Following a segmentectomy and chemotherapy, the patient is in remission. Based on this case, we should consider the possibility of jejunoileal FLs transforming into DLBCL.

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Aortocaval fistula: an unusual complication of ruptured abdominal aortic aneurysm

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm, which erodes into the wall of the inferior vena cava, resulting in the formation of a fistula. ACF presents with various inconsistent symptoms and signs. ACF can be a diagnostic dilemma if not suspected and it is lethal if left untreated.

A 60-year-old man presented with abdominal and lower back pain of sudden onset. Renal and liver functions were impaired, without signs of cardiac failure. CT angiography revealed an abdominal aneurysm rupture into the inferior vena cava. Patient underwent a successful open repair: ACF ligation from within the aneurysmal sac and an aorto-bi-iliac bypass using a Dacron graft. Renal and liver functions improved and the patient was discharged on the eighth postoperative day. A month later, the patient was fit and well with normal liver and renal functions.

Despite progress made in the endovascular treatment of ACF, complications still persist with a reported endoleak rate of 50%. Open repair is still a valid method for ACF repair in patients fit to undergo laparotomy and general anaesthesia. In this case, the patient was fit and along the lack of a suitable stent graft, the vascular team performed an open repair with good results.

Open repair of an ACF is a valid treatment method for patients who are fit enough to undergo laparotomy and general anaesthesia, and avoids complications related to endovascular repair, such as endoleaks.

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Acute infection-related glomerulonephritis with disseminated gonococcal infection in a 13-year-old girl

Infection-related glomerulonephritis results from glomerular immune complex deposition due to a variety of potential pathogens. Poststreptococcal glomerulonephritis is the best known example. We present a case of acute infection-related glomerulonephritis associated with disseminated gonococcal infection in a sexually active 13-year-old girl, the first report of such an association in the absence of endocarditis. The patient presented with features of acute disseminated gonococcal infection including fever, hypotension, tenosynovitis, polyarthralgias and petechiae. She developed hypocomplementemic glomerulonephritis synchronous with the acute infection. The renal biopsy revealed a diffuse endocapillary proliferative and exudative glomerulonephritis with subepithelial electron-dense humps and granular glomerular capillary wall staining for C3 and IgG, typical of acute postinfectious glomerulonephritis. After treatment and resolution of the gonococcal infection, the serum creatinine, complement levels and urine sediment normalised. The only residual renal damage 16 months later was low-grade proteinuria.

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Laryngoceles with airway compromise complicating mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) encompasses a group of autoantibody-mediated, subepithelial blistering diseases, which primarily affect mucosal surfaces including oral, ocular, skin, genital, nasopharyngeal and oesophageal sites. We present a first description of laryngoceles as a manifestation of mucous membrane pemphigoid resulting in dynamic airway closure. Mucosal injury at other sites had previously resulted in pathergy and localised cicatrisation. We discuss successful combined medical and transcutaneous surgical intervention designed to avoid tracheostomy and minimise iatrogenic laryngeal cicatrisation.

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Primary bladder amyloidosis as a cause of haematuria

We report the case of a 46-year-old man who initially presented with macroscopic haematuria. Although initially concerning for a malignancy in the bladder, histology demonstrated a primary bladder amyloidosis that has remained stable for 6 years since the initial diagnosis. Primary bladder amyloidosis is an important clinical entity that can mimic bladder malignancy on clinical history, radiological investigation and cystoscopic evaluation. Although uncommon, it should not be neglected as a possible diagnosis in patients presenting with haematuria.

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Polypoidal lesions associated to choroidal naevus: spectrum of pachychoroid disease?

A 78-year-old woman was referred by an optician for an incidental finding of peripapillary naevus in the absence of visual symptoms. On examination, the right eye showed a choroidal naevus of around 1.5 disc diameter, adjacent to the optic disc. Optical coherence tomography detected the presence of pigment epithelium detachment and subretinal fluid within the context of the naevus. Fundus fluorescein angiography and indocyanine green showed multiple polypoidal lesions (Polypoidal Choroidal Vasculopathy, PCV) in the choroid within the spectrum of a pachychoroid, without any sign of malignancy related to neovascularisation. The patient underwent a follow-up of 6 months, showing stability of the lesions over this timeframe. No treatment has been required since the polypoidal lesions were outside the fovea and visual acuity remained stable. The association between choroidal naevi and polypoidal lesions is rare¹; however, this seems to confirm that these findings are part of the spectrum of pachychoroid disease.

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Two for the price of one: emerging carbapenemases in a returning traveller to New York City

We report a case of a complex orthopaedic infection in a patient returning to New York City from Bangladesh where he was involved in a serious motor vehicle accident. He developed extensive osteomyelitis with a carbapenem-resistant Klebsiella pneumoniae. The isolate was unique due to the coexistence of New Delhi metallo-β-lactamase-1 and Oxacillinase type-181 carbapenemases, which are relatively uncommon in North America and were presumably acquired in Bangladesh. Herein, we explore challenges associated with management of carbapenem-resistant Enterobacteriaceae infections, including limited available data on effective antimicrobial therapy. We also highlight the added value of rapid diagnostic technology in guiding clinical management. Ultimately, the patient required both aggressive surgical management and combination therapy with aztreonam and ceftazidime-avibactam for true source control and favourable clinical outcome.

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Efficacy of 4-year treatment of icon infiltration resin on postorthodontic white spot lesions

White spot lesions are defined as enamel surface and sub surface demineralisation, although these lesions can be reversed and do not form cavities. Infiltration using fluid resin proved to be a valid micro-invasive alternative compared with traditional conservative therapy. This has allowed treatment without any trauma (no use of local anaesthesia and cavity preparation) of numerous lesions in only one session with stable clinical (mechanical stability, enamel hardness, conservation of sound tissue) and aesthetic results (disappearance of lesions) over the time. The present report evaluates the effectiveness of Icon infiltration resin on postorthodontic white spots at 6 months, 1 and 4 years.

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Unruptured giant left ventricular pseudoaneurysm after silent myocardial infarction

Description 

An 88-year-old woman presented with complaints of class 2 dyspnoea for the last 6 months with episodes of paroxysmal nocturnal dyspnoea. Except for her age, she had no other risk factor for coronary artery disease. On cardiovascular examination, she had double apical impulse with a pan-systolic murmur at the apex and her ECG showed Q waves in inferior leads. She had one episode of resting typical chest pain 2 years back for which she did not seek medical consultation; afterwards, she never experienced angina pain.

Transthoracic echocardiography revealed giant aneurysm involving the lateral wall of the left ventricle (figure 1, videos 1 and 2). The ratio of the maximum diameter of the orifice to the maximum internal dimensions of the aneurysmal cavity was less than 0.5 (figure 2). There was large clot in the aneurysm involving the posterior wall of the left ventricle (

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Hypophosphataemia: an important cause of collapse

We present a case of a 44-year-old man, civil servant, who presented to the emergency department (ED) following an episode of collapse. He was usually fit and well and while at work he had developed a headache with pins and needles over his face and subsequently collapsed. On arrival to ED, he had a Glasgow Coma Scale (GCS) of 4/15. There was no history of note apart from being prescribed citalopram for depression. Laboratory investigations revealed severe hypophosphataemia (phosphate 0.19 mmol/L) and no other electrolyte abnormality. He was commenced on intravenous phosphate and his GCS improved to 15 within 4 hours. Further investigations revealed no cause for his severe hypophosphataemia and repeat bloods in clinic follow-up showed a normal phosphate level.

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Extravasation of contrast beneath the preputial skin due to improper technique of retrograde urethrogram

Description 

A 22-year-old uncircumcised male patient had a thin stream of urine and had to exert pressure while voiding. He had a history of some instrumentation in his penis during childhood, but no records were available. He was first seen by a primary care physician, who made a provisional diagnosis of stricture urethra and advised for a retrograde urethrogram (RUG). His RUG had a contrast shadow, which was thought to be possible dilated distal urethra due to proximal obstruction (stricture), and the patient was referred to us for further management (figure 1). When we examined the patient, he was found to have phimosis. A dorsal slit was done and the meatus was examined, which was normal. A gentle calibration was done with a 14F Foley catheter that was normal. He voided with a good stream after surgery. The radio-opaque shadow that was seen on the RUG...

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Purple urinary bag syndrome: what every primary healthcare provider should know

Description 

A 70-year-old man with bladder outlet obstruction due to benign prostatic hyperplasia who was on urethral (Foley) catheter presented to us with complaint of purple discoloration of his urine collection bag (figure 1). He had history of multiple failed trials of voiding without catheter. Along with this he had constipation for which he was already taking laxatives. He was on Foley catheter for 6 months (which was changed every 3 weeks) and now was planned for transurethral resection of prostate (TURP). He was alarmed by this discolouration. His urine was clear but the urine collection bag had a purple discolouration. On microscopic examination, his urine had plenty of leucocytes and his urinary pH was 8. His urine culture was positive for Escherichia coli (>10⁵ colony forming units/mL). His serum creatinine was 0.9 mg/dL. A diagnosis of purple urinary bag syndrome (PUBS) was made. His catheter was replaced...

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Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file

BACKGROUND Residual neuromuscular block (rNMB) after surgery is not difficult to identify if proper neuromuscular monitoring is used, but many clinicians do not use quantitative neuromuscular monitoring. OBJECTIVE The aim of this study was to develop a REsidual neuromuscular block Prediction Score (REPS) to predict postoperative rNMB and compare the predictive accuracy of the prediction score with train-of-four count (TOFC) measurement at the end of a surgical case. DESIGN Retrospective cohort study of data on file. DATA SOURCE Electronic patient data and peri-operative data on vital signs, administered medications, and train-of-four ratio (TOFR) obtained in the postoperative recovery rooms [postanaesthesia care unit (PACU)] at Massachusetts General Hospital in Boston, Massachusetts, USA. PATIENTS Quantitative TOFR measurements obtained on admission to the PACU were available from 2144 adult noncardiac surgical patients. MAIN OUTCOME MEASURE Presence of rNMB at PACU admission, defined as a TOFR of less than 0.9. RESULTS In the score development cohort (n=2144), rNMB occurred in 432 cases (20.2%). Ten independent predictors for residual paralysis were identified and used for the score development. The final model included: hepatic failure, neurological disease, high-neostigmine dose, metastatic tumour, female sex, short time between neuromuscular blocking agent administration and extubation, aminosteroidal neuromuscular blocking agent, BMI more than 35, absence of nurse anaesthetist and having an experienced surgeon. The model discrimination by C statistics was 0.63, 95% confidence interval (0.60 to 0.66), and risk categories derived from the REPS had a higher accuracy than the last documented intra-operative TOFC for predicting rNMB (net reclassification improvement score 0.26, standard error 0.03, P 

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Near-infrared spectroscopy in vegetables and humans: An observational study

BACKGROUND Cerebral near-infrared spectroscopy (NIRS) of tissue oxygen saturation is claimed to be a surrogate marker for global cerebral perfusion. Increasingly, NIRS target-based therapy has been used during cardiac surgery in the hope of decreasing the incidence of adverse neurological outcome. OBJECTIVES We report NIRS values for some common vegetables and faculty at a world-class medical institution. DESIGN Observational nonblinded study. SETTING Single tertiary care institution and local urban vegetable market. PARTICIPANTS Five yams (Dioscorea cayenensis), five courgettes (Cucurbita pepo) and five butternut squashes (Cucurbita moschata) were studied. Five cardiothoracic surgeons and anaesthesiologists were the control group. INTERVENTIONS None. MAIN OUTCOME MEASURES NIRS value of each species. RESULTS Mean NIRS value for the control group was 71% [95% confidence interval (CI) 68 to 74] and was similar to that of the yellow squashes [75% (95% CI 74 to 76)]. These values were significantly greater than the NIRS measurements of both the butternut squash and yam [63% (95% CI 62 to 64) and 64% (95% CI 63 to 65), respectively, P 

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Superior sealing effect of a three-dimensional printed modified supraglottic airway compared with the i-gel in a three-dimensional printed airway model

Abstract

Purpose

The aim of this study was to compare the force exerted by a three-dimensional (3D) printed modified supraglottic airway (mSGA) vs. that exerted by the i-gel on a 3D printed airway model.

Methods

After a preliminary experiment in Thiel embalmed cadavers, we created a 3D printed mSGA and five 3D printed airway models based on computed tomography data from five female Japanese patients. We compared the force exerted by the i-gel and mSGA on the larynx of the 3D printed airway models. In addition, tidal volumes with insertion of the airway devices into the 3D printed airway model and administration of different levels of pressure-controlled ventilation (PCV) were compared.

Results

The values below indicate mean values ± SD (p value, 95% confidence interval) for the mSGA and i-gel, respectively. The forces exerted by the cuff parts were as follows: ventral: 12.5 ± 5.4 vs. 20.7 ± 3.7 N (p = 0.0001, − 10.0 to − 6.5), proximal: 1.9 ± 1.4 vs. 1.7 ± 1.3 N (p = 0.322, − 0.26 to 0.74), and dorsal parts: 6.9 ± 2.2 vs. 12.5 ± 4.8 N (p = 0.0001, − 7.9 to − 3.4), respectively. We also found significantly higher tidal volumes with the mSGA under PCV of 10, 15, and 20 cmH₂O.

Conclusions

The method of creating the mSGA that we proposed in this study can be applied to development of novel SGAs that is anatomically more suitable for pharyngolaryngeal structure.

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Successful Treatment of Methampyrone-Induced Toxic Epidermal Necrolysis with Therapeutic Plasma Exchange

The toxic epidermal necrolysis (TEN) is a severe cutaneous adverse reaction frequently caused by drug exposure. A 58-year-old male was admitted to the hospital after administration of methampyrone. He developed sloughing of the total epidermis which rapidly extended over the trunk and limbs. The presumptive diagnosis was drug-induced TEN. Despite the treatment with pulsed glucocorticoid and cyclosporine, the skin lesions extended over the entire body. Strikingly, the progression of blistering was stopped by therapeutic plasma exchange (TPE). TPE was discontinued after the signs of skin inflammation had been overcome. He recovered in 8 days of hospitalization. We present here a case of a methampyrone-induced TEN which was successfully treated with TPE.

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