Von Hippel-Lindau disease is a rare hereditary syndrome caused by germinal mutations in a von Hippel-Lindau tumor-suppressing gene. Retinal hemangioblastoma is the ocular hallmark lesion of von Hippel-Lindau d...
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Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Τετάρτη 5 Σεπτεμβρίου 2018
Effect of intravitreal dexamethasone on macular edema in von Hippel-Lindau disease assessed using swept-source optical coherence tomography: a case report
Sudden death after valve-in-valve procedure due to delayed coronary obstruction: a case report
Valve-in-valve transcatheter aortic valve implantation for degenerated aortic bioprostheses is an effective option for patients at high risk for redo surgery, even if it may be burdened by complications more c...
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An Unusual Presentation of Tapia Syndrome Mimicking a Partial Wallenberg Syndrome Following Anterior Cervical Spine Surgery
No abstract availablehttps://ift.tt/2ClfMBS
Perioperative Care for Pediatric Patients With Penetrating Brain Injury: A Review
Traumatic brain injury (TBI) continues to be the leading cause of death and acquired disability in young children and adolescents, due to blunt or penetrating trauma, the latter being less common but more lethal. Penetrating brain injury (PBI) has not been studied extensively, mainly reported as case reports or case series, due to the assumption that both types of brain injury have common pathophysiology and consequently common management. However, recommendations and guidelines for the management of PBI differ from those of blunt TBI in regards to neuroimaging, intracranial pressure (ICP) monitoring, and surgical management including those pertaining to vascular injury. PBI was one of the exclusion criteria in the second edition of guidelines for the acute medical management of severe TBI in infants, children, and adolescents that was published in 2012 (it is referred to as "pediatric guidelines" in this review). Many reviews of TBI do not differentiate between the mechanisms of injury. We present an overview of PBI, its presenting features, epidemiology, and causes as well as an analysis of case series and the conclusions that may be drawn from those and other studies. More clinical trials specific to penetrating head injuries in children, focusing mainly on pathophysiology and management, are needed. The term PBI is specific to penetrating injury only, whereas TBI, a more inclusive term, describes mainly, but not only, blunt injury.https://ift.tt/2wQF5qp
Anesthesia for Same Day Discharge After Craniotomy: Review of a Single Center Experience
Same day discharge or outpatient surgery for intracranial procedures has become possible with the advent of image-guided minimally invasive approaches to surgery and availability of short-acting anesthetic agents. In addition, patient satisfaction and the benefits of avoiding hospital stay have resulted in the evolution of neurosurgical day surgery. We reviewed our experience and the available literature to determine the perioperative factors involved which have promoted and will improve this concept in the future. Craniotomy and biopsy for supratentorial brain tumors and surgical clipping of intact cerebral aneurysms have been successfully performed as day surgeries. Patient perceptions and satisfaction surveys have helped in better understanding and delivery of care and successful outcomes. There are major differences in health care across the globe along with socioeconomic, medicolegal, and ethical disparities, which must be considered before widespread application of this approach. Nevertheless, collaborative effort by surgeons, anesthesiologists, and nurses can help in same day discharge of patients after cranial neurosurgery.https://ift.tt/2oHciQu
Ketamine Anesthesia Does Not Improve Depression Scores in Electroconvulsive Therapy: A Randomized Clinical Trial
Background: Although interest in ketamine use during electroconvulsive therapy (ECT) has increased, studies have been equivocal with regard to its efficacy. The aims of this clinical trial were to evaluate ketamine's antidepressive effects in ECT as a primary anesthetic, determine ketamine's tolerability when compared with standard anesthesia, and determine if plasma brain-derived neurotrophic factor (BDNF) is necessary for treatment response. Materials and Methods: Adults meeting criteria for treatment-resistant depression undergoing index course ECT received either methohexital (1 to 2 mg/kg) or ketamine (1 to 2 mg/kg) anesthesia in this dual-arm double-blinded randomized clinical trial (NCT02752724). The primary outcome of this study is change in depression questionnaire scores before and after ECT. Seizure data, depression severity using self-reported and clinician-assessed questionnaires, cognitive scoring, and plasma BDNF concentrations were obtained before and after completion of ECT. Results: There were no differences in seizure lengths, hemodynamics, or seizure stimuli between the ketamine (n=23;138 ECTs) and methohexital (n=27;159 ECTs) groups. Depression scores improved similarly after ECT in both groups. In the methohexital group, 15% of patients failed to achieve adequate seizures and were switched to ketamine and 26% were converted to bilateral ECT stimulus, whereas all ketamine patients achieved adequate seizures and only 4% required bilateral stimulus. Plasma BDNF increased after ECT only in the ketamine group. Conclusions: Our data show that ketamine does not significantly improve depression when compared with methohexital as a single induction agent for ECT, increases serum BDNF and does not increase rates of post-ECT agitation. Ketamine use in ECT may have some benefits for some patients that are not captured through standard depression assessment questionnaires alone.https://ift.tt/2oHchMq
Cerebral Oxygen Saturation During Electroconvulsive Therapy: A Secondary Analysis of a Randomized Crossover Trial
Background: Electroconvulsive therapy (ECT) causes acute changes in cerebral perfusion and oxygenation. Near-infrared spectroscopy is a novel, noninvasive technique to assess cerebral oxygen saturation (cSO2). We hypothesized that cSO2 increases during ECT and more so with atropine premedication and decreases when systemic desaturation (peripheral oxygen saturation 60% at any measured time point, even in those with systemic desaturation. Conclusions: ECT increased cSO2 irrespective of atropine premedication. cSO2 was lower when systemic desaturation occurred. Future studies should explore the effect of cerebral oxygenation changes during ECT on outcome of psychiatric conditions.https://ift.tt/2oHbJWS
Red Cell Distribution Width After Subarachnoid Hemorrhage
Background: High red cell distribution width (RDW) values have been associated with increased hospital mortality in critically ill patients, but few data are available for subarachnoid hemorrhage (SAH). Methods: We analyzed an institutional database of adult (>18 y) patients admitted to the Department of Intensive Care after nontraumatic SAH between January 2011 and May 2016. RDW (normal value, 10.9% to 13.4%) was obtained daily from admission for a maximum of 7 days, from routine blood analysis. We recorded the occurrence of delayed cerebral ischemia (DCI), and neurological outcome (assessed using the Glasgow Outcome Scale [GOS]) at 3 months. Results: A total of 270 patients were included (median age 54 y—121/270 male [45%]), of whom 96 (36%) developed DCI and 109 (40%) had an unfavorable neurological outcome (GOS, 1 to 3). The median RDW on admission was 13.8 [13.3 to 14.5]% and the highest value during the intensive care unit (ICU) stay 14.2 [13.6 to 14.8]%. The RDW was high (>13.4%) in 177 patients (66%) on admission and in 217 (80%) at any time during the ICU stay. Patients with a high RDW on admission were more likely to have an unfavorable neurological outcome. In multivariable regression analysis, older age, a high WFNS grade on admission, presence of DCI or intracranial hypertension, previous neurological disease, vasopressor therapy and a high RDW (OR, 1.1618 [95% CI, 1.213-2.158]; P=0.001) during the ICU stay were independent predictors of unfavorable neurological outcome. Conclusions: High RDW values were more likely to result in an unfavorable outcome after SAH. This information could help in the stratification of SAH patients already on ICU admission.https://ift.tt/2wOWsb5
Safety Outcomes Following Spine and Cranial Neurosurgery: Evidence From the National Surgical Quality Improvement Program
Background: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to establish predictors for 30-day postoperative complications following spine and cranial neurosurgery. Materials and Methods: The ACS-NSQIP participant use files were queried for neurosurgical cases between 2005 and 2015. Prevalence of postoperative complications following neurosurgery was determined. Nested multivariable logistic regression analysis was used to identify demographic, comorbidity, and perioperative characteristics associated with any complication and mortality for spine and cranial surgery. Results: There were 175,313 neurosurgical cases (137,029 spine, 38,284 cranial) identified. A total of 23,723 (13.5%) patients developed a complication and 2588 (1.5%) patients died. Compared with spine surgery, cranial surgery had higher likelihood of any complication (22.2% vs. 11.1%; Phttps://ift.tt/2oHbCuq
Effects of Transcutaneous Electrical Acupoint Stimulation on the Stress Response During Extubation After General Anesthesia in Elderly Patients Undergoing Elective Supratentorial Craniotomy: A Prospective Randomized Controlled Trial
Background: Elderly patients have an increased risk of a stress response during extubation after general anesthesia. In this study, we aimed to investigate whether transcutaneous electrical acupoint stimulation (TEAS) might decrease the stress response and improve the quality of recovery in elderly patients after elective supratentorial craniotomy. Materials and Methods: In this prospective randomized controlled study, patients were randomly assigned to either a TEAS group (n=37) or a control group (n=38). The primary outcomes were the hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol. The secondary outcome included the consumption of remifentanil and propofol, time to extubation and reorientation, extubation quality score, postoperative quality of recovery, and postoperative complications. Results: Compared with the control group, hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol during extubation were decreased in the TEAS group. TEAS reduced the consumption of remifentanil (Phttps://ift.tt/2oLe4QR
Simultaneous Surgical Decompression of Bilateral Subdural Hematoma and an Administration of Epidural Blood Patch for Spontaneous Intracranial Hypotension
No abstract availablehttps://ift.tt/2wKYW9M
Hemodynamic Instability and Cardiovascular Events After Traumatic Brain Injury Predict Outcome After Artifact Removal With Deep Belief Network Analysis
Background: Hemodynamic instability and cardiovascular events heavily affect the prognosis of traumatic brain injury. Physiological signals are monitored to detect these events. However, the signals are often riddled with faulty readings, which jeopardize the reliability of the clinical parameters obtained from the signals. A machine-learning model for the elimination of artifactual events shows promising results for improving signal quality. However, the actual impact of the improvements on the performance of the clinical parameters after the elimination of the artifacts is not well studied. Materials and Methods: The arterial blood pressure of 99 subjects with traumatic brain injury was continuously measured for 5 consecutive days, beginning on the day of admission. The machine-learning deep belief network was constructed to automatically identify and remove false incidences of hypotension, hypertension, bradycardia, tachycardia, and alterations in cerebral perfusion pressure (CPP). Results: The prevalences of hypotension and tachycardia were significantly reduced by 47.5% and 13.1%, respectively, after suppressing false incidents (P=0.01). Hypotension was particularly effective at predicting outcome favorability and mortality after artifact elimination (P=0.015 and 0.027, respectively). In addition, increased CPP was also statistically significant in predicting outcomes (P=0.02). Conclusions: The prevalence of false incidents due to signal artifacts can be significantly reduced using machine-learning. Some clinical events, such as hypotension and alterations in CPP, gain particularly high predictive capacity for patient outcomes after artifacts are eliminated from physiological signals.https://ift.tt/2wNG1vL
Scalp Block: Tool for Diagnosis in Postoperative Headache of Unknown Origin
No abstract availablehttps://ift.tt/2CpLWwp
Deep vs. moderate neuromuscular blockade during laparoscopic surgery: A systematic review and meta-analysis
BACKGROUND Previous studies have reported that deep neuromuscular block (posttetanic-count 1 to 2 twitches) improves surgical conditions during laparoscopy compared with moderate block (train-of-four count: 1 to 2 twitches). However, comparisons of surgical conditions were made using different scales and assessment intervals with variable results. OBJECTIVE To explore the heterogeneity of previous comparisons between deep and moderate neuromuscular block. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Medline, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to October 2017. ELIGIBILITY CRITERIA Our meta-analysis included RCTs comparing the effects of deep with moderate neuromuscular block on surgical field conditions during laparoscopic surgery. The frequency of excellent or good operating conditions on a surgical rating scale was compared. Heterogeneity was assessed by subgroup analyses. RESULTS Eleven RCTs involving 844 patients were included. On the surgical rating scale, the frequency of excellent or good operating conditions was higher with deep block compared with a moderate block (odds ratio 2.83, 95% confidence interval 1.34 to 5.99, P = 0.007, I2 = 59%). We analysed surgical rating according to the number of assessments made. There was a significant difference in surgical rating with multiple assessments, but no difference when the assessment was made on only one occasion. A significant difference in rating was noted with variable abdominal pressures; there was no significant difference with the same fixed abdominal pressure. Trial sequential analysis demonstrated that the cumulative z-curve crossed the O′Brien–Fleming significance boundary. However, required information size was not achieved. CONCLUSION Deep block was associated with excellent or good surgical rating more frequently than moderate block. However, this finding was not consistent on subgroup analyses based on frequencies of assessment of surgical conditions and abdominal pressure. Further studies are required to address the heterogeneity and power shortage demonstrated by the trial sequential analysis. Correspondence to Won Ho Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Institute of the Research of the Perioperative Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea Tel: +82 2 2072 2462; fax: +82 2 747 5639; e-mail: wonhokim.ane@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology
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Pulmonary artery sarcoma mimicking pulmonary embolism
Description
A 62-year-old woman with diabetes presented with progressive exertional dyspnoea, chest pain and palpitation for several months. She had no history of leg oedema, fever, bodyweight change and general weakness. Therefore, she received associated exams at cardiovascular outpatient department. Transthoracic echocardiogram showed right atrium and ventricle dilatation with severe pulmonary hypertension. Besides, a thrombus-like mobile mass was noted at right ventricle and pulmonary artery (figure 1, video 1). Pulmonary embolism, as one of the life-threatening conditions, was our tentative diagnosis, and she was transferred to the emergency department. Chest CT showed multifocal filling defects at right ventricle, main pulmonary artery trunk and bilateral pulmonary arteries with several lung nodules (figure 2). Primary tumour or metastasis was our final impression by image study. Finally, the patient underwent surgery, which confirmed the mass to be pulmonary artery intimal sarcoma, not a large thrombus (
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Improvement in lung function following medialisation thyroplasty in a postbilateral lung transplant patient
A 59-year-old man underwent external medialisation thyroplasty for his left unilateral vocal cord paralysis (UVCP) secondary to recent thoracic surgery. The patient had undergone bilateral lung transplant for idiopathic pulmonary fibrosis and was referred to the ear, nose and throat surgical team with new-onset voice hoarseness. Examination confirmed left UVCP, and after failing conservative management a decision was made to perform external medialisation thyroplasty. Following an uneventful procedure, the patient's phonation returned to normal, and remarkably on spirometry there was evidence of significant improvement in lung function. Despite case series demonstrating subjective improvement in respiration, this is the first documented case, to our knowledge, of significant improvement in spirometry following this procedure.
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Autism and trichotillomania in an adolescent boy
An adolescent with autism spectrum disorder and improperly treated attention deficit hyperactivity disorder presented with recurrent hair pulling. Treatment with selective serotonin reuptake inhibitor and stimulant improved these conditions.
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Staring at the stars: a case of gastrointestinal basidiobolomycosis from the Indian subcontinent
Description
A 24-year-old male patient from the hot and arid state of Rajasthan, India, presented with low-grade fever, dull aching lower abdominal pain, loss of weight and loss of appetite for 2 years. In addition, he had frequent episodes of colicky abdominal pain and vomiting. He was evaluated elsewhere prior to presenting at our hospital. A contrast-enhanced computed axial tomography of the abdomen revealed diffuse circumferential thickening of the ileocecal region (figure 1). A fine -needle aspiration cytology revealed features suggestive of non-specific inflammation. He did not respond to multiple courses of antibiotics and was taken up for laparotomy, in which the affected segment of intestine was resected. On gross examination, the resected segment of bowel showed multiple areas of necrosis and small perforations. Histopathological examination (HPE) revealed panmural inflammation of the intestine with eosinophilic microabscesses. Broad aseptate hyphae were noted and reported as mucormycosis. Postoperatively, he...
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Unusual ocular manifestations following viper bite
We report a case of a 70-year-old farmer admitted for viper bite who presented with bilateral hyphema and angle closure attack. He was managed conservatively with topical steroids and cycloplegics. He responded well and was discharged after 2 weeks.
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Effect of topiramate on sweat chloride level while screening for cystic fibrosis
Cystic fibrosis is the most common life-limiting genetic condition in Caucasians caused by Cystic Fibrosis Transmembrane conductance Regulator (CFTR) gene mutations. Sweat chloride is the current gold standard for diagnosis where values >60 mmol/L are diagnostic and values >30 mmol/L are indeterminate. There is limited literature on the effect of medications on the sweat chloride values. We report a case of topiramate being responsible for false-positive testing which resulted in overutilisation of medical resources and psychosocial stress on the family. Topiramate should be considered during the interpretation of the gold standard testing as one of the cause of false-positive sweat tests.
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Electrical impedance tomography effectively used in a case of paediatric pulmonary Langerhans cell histiocytosis
A 2-year-old boy with severe pulmonary Langerhans cell histiocytosis presented in extreme respiratory failure. He was intubated and ventilated. Despite maximal support, he deteriorated and needed extremely high ventilator pressures. An electrical impedance tomography monitor was used to inform management. This is a monitoring technique which is not used in children due to the lack of suitable interface devices and a lack of randomised clinical evidence. Despite technical difficulties, a good signal was achieved. This informed management and enabled the selection of a suitable ventilator strategy, facilitating weaning. Electrical impedance tomography is a viable technology for use in paediatric critical respiratory failure. This is a non-invasive and safe technology which adds individual patient information which is not available through any other modalities. We urge equipment manufacturers to develop belts which will allow routine application of this life-saving technology in children.
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Cervical aortic arch: an unusual cause of a pulsatile neck mass
A 72-year-old man presented with epistaxis on two occasions requiring admission. Prior to performing a bilateral sphenopalatine artery ligation diathermy, anaesthetic concern was raised regarding what the patient described as a 'congenital aortic aneurysm', with an overlying scar secondary to explorative surgery as a child. The abnormality was a cervical aortic arch (CAA). CAA is a rare vascular anomaly, which most commonly manifests as a pulsatile neck mass. In this case, we discuss the differential diagnosis for a pulsatile neck mass and considerations to be made in the workup. We also highlight the importance of cardiovascular risk factor management in patients with CAA.
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