High-flow oxygen via tracheostomy facilitates weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction: two case reports

Weaning from prolonged mechanical ventilation is extremely difficult in tracheostomized patients with restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy supplies heated and humidified oxygen ...

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A successful microsurgical approach to treating penile amputation following genital self mutilation

Abstract

We present the case of a 33-year-old male who presented to the Emergency Department having amputated his penis as a result of auditory hallucinations triggered by cannabis use. A successful microsurgical technique involving anastomosing the individual structures of the penile shaft enabled a successful cosmetic and functional outcome including restoration of erectile function.

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Complete unilateral ureteral duplication encountered during intersphincteric resection for low rectal cancer

Abstract

Complete duplication of ureters is a very rare clinical entity that may either be asymptomatic or present with a variety of clinical findings. In the presented case a 51-year-old Caucasian female underwent an intersphincteric resection for low rectal cancer. Intraoperatively, during the standard bilateral recognition and mobilization of the ureters, complete unilateral duplication of the left ureter was incidentally detected, deriving from a single renal parenchyma. Such a congenital abnormality though constitutes a major risk-factor of accidental ureteral injury during operations including pelvis. Conclusively, meticulous exposure of both ureters combined with surgeons' unceasing awareness constitute the cornerstone of a safe operation.

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High-grade angiosarcoma presenting with cytology-negative hemorrhagic ascites

Abstract

Angiosarcomas are a rare subtype of soft-tissue sarcomas originating from the vascular endothelium. Both retroperitoneal and omental angiosarcomas tend to be aggressive and rapidly fatal if not amenable to early intervention. In this report, we describe an unusual case of high-grade angiosarcoma with cytology-negative hemorrhagic ascites and diffuse omental invasion. Multiple investigations into the origin of the hemorrhagic ascites, including cytological analysis, tumor marker measurements, serum-ascites albumin gradient calculation and frozen section pathological examination, failed to reveal a diagnosis. We conclude that malignancy should be considered in the differential diagnosis in the presence of suspicious cytology-negative hemorrhagic ascites and concomitant retroperitoneal and abdominal findings.

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Distraction osteogenesis for brachymetatarsia using initial circular fixator and early trans-fixation metatarsal K—wires—a series of three cases†

Abstract

Brachymetatarsia is a rare forefoot deformity predominantly affecting the fourth metatarsal. Current treatment include gradual lengthening by distraction osteogenesis using an external fixator or single-stage lengthening with bone grafting or a combination of the above two procedures. Our aim was to assess outcomes and complications of a novel technique for gradual metatarsal lengthening using a circular fixator. The procedure was performed on three female patients with unilateral congenital shortening of the fourth ray. All participants reported aesthetic dissatisfaction as well as pressure related complications of the deformity and opted for lengthening and distraction osteogenesis using a frame. Mean duration of the treatment was 122 days and average length gained was 12 mm. The desired metatarsal length was achieved in all three patients with no significant complications. This method of treatment of brachymetatarsia is effective and reproducible. This a promising technique, owing to its low complication rates and efficacy in lengthening.

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Development of a Donor Tissue Holding Technique for Descemet’s Membrane Endothelial Keratoplasty Using a 25-Gauge Graft Manipulator

Purpose: To report a modified surgical technique called the "donor tissue holding technique for Descemet's membrane endothelial keratoplasty (DMEK)" using a newly developed 25-gauge graft manipulator. Methods: Six consecutive patients exhibiting endothelial dysfunction were enrolled and treated by DMEK. In brief, after insertion of a DMEK donor into the anterior chamber, the edge of the roll was grasped using a graft manipulator and this grasp was maintained throughout the centering and opening of the roll (holding technique). The following parameters were evaluated in comparison to the previous 10 consecutive DMEK cases in which the no touch technique was used: time of graft unfolding, incidence of intra-/postoperative complications, and best spectacle-corrected visual acuity (BCVA) and endothelial cell density (ECD) 6 months after the procedure. Results: In both technique groups, neither intra- nor postoperative complications were noted in any case. No differences were observed between the two groups in postoperative BCVA (p = 0.88). Also, no differences were observed between the two groups in postoperative ECD (holding technique group: 2,108.3 cells/mm², no touch technique group: 1,491.7 cells/mm²) (p = 0.08) Most notably, the time of graft unfolding prior to filling with air was significantly reduced in the holding technique group (305.5 s) compared to that of the no touch technique group (1,310.0 s; p = 0.01). Conclusions: This donor tissue holding technique enabled rapid and safe DMEK in a reproducible manner, even in Asian eyes with shallow anterior chambers with high vitreous pressure.
Case Rep Ophthalmol 2018;9:431–438

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Bilateral suprazygomatic maxillary nerve blocks vs. infraorbital and palatine nerve blocks in cleft lip and palate repair: A double-blind prospective, randomised study

BACKGROUND Cleft defects are common craniofacial malformations which require early surgical repair. These patients are at high risk of postoperative airway obstruction and respiratory failure. Cleft surgery may require high doses of opioids which may contribute to these complications. OBJECTIVES To compare the effectiveness of proximal and distal approaches to blocking the maxillary nerve in patients undergoing cleft lip or cleft palate surgery. DESIGN Randomised, controlled and double-blind study. SETTING The current study was carried out in Guwahati (Assam, India) between April 2014 and June 2014. PATIENTS A total of 114 patients older than 6 months who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included coagulation disorders, peripheral neuropathy or chronic pain syndrome, infection in the puncture site, allergy to local anaesthetics, lack of consent and language problems or other barriers that could impede the assessment of postoperative pain. INTERVENTIONS Patients were randomly assigned to one of two groups: proximal group (bilateral suprazygomatic maxillary nerve blocks) and distal group (bilateral infraorbital nerve blocks for cleft lip repair and bilateral greater and lesser palatine nerve blocks and nasopalatine nerve block for cleft palate surgery). MAIN OUTCOME MEASURE The primary endpoint was the percentage of patients requiring extra doses of opioids. Secondary endpoints included pain scores, respiratory and nerve block-related complications during the first 24 h. RESULTS In the intra-operative period, there was a significant reduction of nalbuphine consumption in the proximal group (9.1 vs. 25.4%, P = 0.02). The percentage of patients requiring intra-operative fentanyl was lower in the proximal group (16.4 vs. 30.5%, P = 0.07). There were no differences in either postoperative pain scores or in postoperative complications. No technical failure or block-related complications were reported. CONCLUSION Bilateral suprazygomatic maxillary nerve block is an effective and safe alternative to the traditional peripheral nerve blocks for cleft lip and cleft palate surgery, in a mixed paediatric and adult population. Correspondence to Gaston Echaniz, Department of Anesthesiology, Vall d'Hebron Hospital, Department of Surgery, Universitat Autònoma de Barcelona, Passeig de Vall d'Hebron, 119-129, Barcelona 08035, Spain. E-mail: grcechaniz@vhebron.net 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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Measurement of forces applied using a Macintosh direct laryngoscope compared with a Glidescope video laryngoscope in patients with predictors of difficult laryngoscopy: A randomised controlled trial

BACKGROUND In patients with predictive features associated with easy direct laryngoscopy, videolaryngoscoy with the GlideScope has been shown to require less force when compared with Macintosh direct laryngoscopy. OBJECTIVE The aim of this study was to compare forces applied with Glidescope vs. Macintosh laryngoscopes in patients with predictive features associated with difficult direct laryngoscopy. DESIGN A prospective randomised study. SETTING Toronto General Hospital, a university tertiary centre in Canada. PATIENTS Forty-four patients aged over 18 years, with one or more features of difficult intubation, undergoing elective surgery requiring single-lumen tracheal intubation. INTERVENTION We measured the force applied to oropharyngeal tissues by attaching three FlexiForce Sensors (A201-25) to the concave surface of Macintosh and GlideScope laryngoscope blades. Anaesthetists or experienced anaesthesia residents performed laryngoscopies with both devices in a randomised sequence. MAIN OUTCOME MEASURES The primary outcome was peak force. The secondary outcomes were average force and impulse force. The latter is the integral of the force over the time during which the force acted. RESULTS Complete data were available for 40 individuals. Peak and average forces decreased with GlideScope (17 vs. 21 N, P = 0.03, and 6 vs. 11 N, P 

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Modified ROTEM for the detection of rivaroxaban and apixaban anticoagulant activity in whole blood

BACKGROUND Rapid detection of the anticoagulant effect of oral factor Xa (FXa) inhibitors may be essential in several emergency clinical situations. Specific assays quantifying the drugs are performed in plasma and require a turnaround time that is too long to be useful in emergency situations. Rotational thromboelastometry (ROTEM) is a whole blood coagulation assay of blood viscoelasticity and could be of interest for FXa inhibitor detection in emergency. However, conventional ROTEM reagents only detect high amounts of inhibitors. OBJECTIVE The aim of this study was first to assess the effect of whole blood components on the viscoelastic measurement of the effects of FXa inhibitors, an second to evaluate whether a modified ROTEM, triggered with a low amount of tissue factor and a saturating amount of phospholipid vesicles, can reliably detect low levels of FXa inhibitor activity in whole blood. DESIGN Diagnostic test study. SETTINGS A university research laboratory. From November 2014 to April 2016. PATIENTS Sixty-six patients: 30 treated with rivaroxaban, 17 with apixaban and 19 without treatment. INTERVENTION ROTEM was triggered with 2.5 pmol l−1 of tissue factor and 10 μmol l−1 of phospholipid vesicles. MAIN OUTCOME MEASURES Modified ROTEM parameters were measured in different experimental conditions: platelet-poor plasma (PPP), platelet-rich plasma, PPP supplemented with fibrinogen and reconstituted whole blood with various haematocrit levels adjusted between 30 and 60%. Modified ROTEM was further validated using whole blood from patients who were either treated or not treated with FXa inhibitors. RESULTS Modified ROTEM allowed detection of as little as 25 ng ml−1 FXa inhibitors in PPP, with at least a 1.4-fold increase of the clotting time (P ≤ 0.02). Neither changes of fibrinogen concentration nor variations of platelet count or haematocrit precluded FXa inhibitor detection. A lengthened modified ROTEM clotting time of more than 197 s allowed detection of FXa inhibitor concentrations above 30 ng ml−1 in whole blood with 90% sensitivity and 85% specificity. CONCLUSION Modified ROTEM may be applicable in emergency situations for the detection of FXa inhibitors in whole blood. Correspondence to Charles M. Samama, MD, PhD, FCCP, Department of Anaesthesia and Intensive Care Medicine, Cochin University Hospital, 27 rue du Faubourg St Jacques, 75014 Paris, France Tel: +33 1 42 34 85 51/+33 6 62 14 86 64; fax: +33 1 58 41 14 15; e-mail: marc.samama@aphp.fr 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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Advanced colorectal carcinoma with testicular metastasis in an adolescent: a case report

Colorectal carcinoma in the pediatric age group is rare and tends to be very aggressive and present late, due to which it has a very poor prognosis. It may present with distant metastasis; however, metastasis ...

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