Inciting Events Associated With Lumbar Facet Joint Pain.

BACKGROUND: Low back pain is the leading cause of years lost to disability with approximately 15%-25% of the chronic back pain population suffering from lumbar facet arthropathy. No large-scale study has sought to systematically identify inciting events for lumbar facet arthropathy. The aim of this study is to quantify the proportion of individuals with lumbar facetogenic pain who report a specific precipitating event(s) and to determine if there is a correlation between these events and treatment outcome. METHODS: Institutional electronic medical records were searched based on the current procedural terminology (CPT) codes representing lumbar facet joint radiofrequency ablation for procedures performed between January 2007 and December 2015. All patients had obtained >=50% pain relief based on 6-hour pain diaries after 1 or more diagnostic facet blocks. A positive outcome was defined as >=50% pain relief sustained for longer than 3-month after procedure, without additional procedural interventions. RESULTS: One thousand sixty-nine people were included in analysis. In the 52% of individuals who described an inciting event, the most commonly reported causes were falls (11%), motor vehicle collisions (11%), sports-related injuries (11%, of which weightlifting accounted for 62%), nonspine postsurgical injuries (2%), and "other" (17%). Six hundred seventeen (57.7%) individuals experienced >=50% pain relief sustained for >3 months. Patients whose pain was preceded by an inciting event were more likely to have a positive outcome than those who could not recall a specific precipitating factor (odds ratio, 1.5; confidence interval, 1.02-2.1, P = .01). Another factor associated with outcome was shorter duration of pain (8.1 +/- 9.2 vs 9.7 +/- 10.1 years, P = .02), with an observed modifier effect of age on outcomes. For a 1-year increase in age, there was a 10% increase in the odds of a positive response. CONCLUSIONS: Inciting events are common in patients diagnosed with lumbar facetogenic pain and may be associated with a positive outcome. (C) 2017 International Anesthesia Research Society

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The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-analysis.

BACKGROUND: The objective of this meta-analysis was to determine the efficacy of glycopyrrolate at reducing spinal hypotension during cesarean delivery. METHODS: A literature search was performed to identify randomized controlled trials investigating the effect of glycopyrrolate on spinal-induced hypotension during cesarean delivery. Primary outcomes were intraoperative hypotension and vasopressor requirement (phenylephrine equivalents). Secondary outcomes included heart rate (HR), nausea and vomiting, dry mouth, and Apgar scores. Risk ratios (RRs), and mean differences (MDs) were calculated using random-effects modeling with 95% confidence intervals for primary outcomes and 99% confidence intervals for secondary outcomes. RESULTS: Five randomized controlled trials met our inclusion criteria. A total of 311 patients were included: 153 received glycopyrrolate and 158 placebo. The incidence of spinal-induced hypotension was no different with prophylactic glycopyrrolate compared to control (RR, 0.93 [0.71 1.21]; P = .59), but the total phenylephrine dose required was significantly reduced with glycopyrrolate (MD, -62.64 [micro]g [-107.61 to .17.66 [micro]g]; P = .006). The maximal HR achieved in the glycopyrrolate group was significantly higher compared to controls (MD, 15.85 bpm [5.40- 26.31]; P

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Comparison of Registered and Reported Outcomes in Randomized Clinical Trials Published in Anesthesiology Journals.

BACKGROUND: Randomized clinical trials (RCTs) provide high-quality evidence for clinical decision-making. Trial registration is one of the many tools used to improve the reporting of RCTs by reducing publication bias and selective outcome reporting bias. The purpose of our study is to examine whether RCTs published in the top 6 general anesthesiology journals were adequately registered and whether the reported primary and secondary outcomes corresponded to the originally registered outcomes. METHODS: Following a prespecified protocol, an electronic database was used to systematically screen and extract data from RCTs published in the top 6 general anesthesiology journals by impact factor (Anaesthesia, Anesthesia & Analgesia, Anesthesiology, British Journal of Anaesthesia, Canadian Journal of Anesthesia, and European Journal of Anaesthesiology) during the years 2007, 2010, 2013, and 2015. A manual search of each journal's Table of Contents was performed (in duplicate) to identify eligible RCTs. An adequately registered trial was defined as being registered in a publicly available trials registry before the first patient being enrolled with an unambiguously defined primary outcome. For adequately registered trials, the outcomes registered in the trial registry were compared with the outcomes reported in the article, with outcome discrepancies documented and analyzed by the type of discrepancy. RESULTS: During the 4 years studied, there were 860 RCTs identified, with 102 RCTs determined to be adequately registered (12%). The proportion of adequately registered trials increased over time, with 38% of RCTs being adequately registered in 2015. The most common reason in 2015 for inadequate registration was registering the RCT after the first patient had already been enrolled. Among adequately registered trials, 92% had at least 1 primary or secondary outcome discrepancy. In 2015, 42% of RCTs had at least 1 primary outcome discrepancy, while 90% of RCTs had at least 1 secondary outcome discrepancy. CONCLUSIONS: : Despite trial registration being an accepted best practice, RCTs published in anesthesiology journals have a high rate of inadequate registration. While mandating trial registration has increased the proportion of adequately registered trials over time, there is still an unacceptably high proportion of inadequately registered RCTs. Among adequately registered trials, there are high rates of discrepancies between registered and reported outcomes, suggesting a need to compare a published RCT with its trial registry entry to be able to fully assess the quality of the study. If clinicians base their decisions on evidence distorted by primary outcome switching, patient care could be negatively affected. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. (C) 2017 International Anesthesia Research Society

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Low End-Tidal Carbon Dioxide at the Onset of Emergent Trauma Surgery Is Associated With Nonsurvival: A Case Series.

BACKGROUND: End-tidal carbon dioxide (EtCO2) is a valuable marker of the return of adequate circulation following cardiac arrest due to medical causes. Previously, the prognostic value of capnography in trauma has been studied among limited populations in prehospital and emergency department settings. We aimed to investigate the relationship between early intraoperative EtCO2 and nonsurvival of patients undergoing emergency surgery at a level 1 academic trauma center as a case series. If there is a threshold below which survival was extremely unlikely, it might be useful in guiding decision-making in the early termination of futile resuscitative efforts. METHODS: Following institutional review board approval, a data set was created to investigate the relationship between EtCO2 values at the onset of emergent trauma surgery and nonsurvival. Patients who were admitted and transferred to the operating room (OR) directly from a resuscitation bay were identified using the Ryder Center trauma registry (October 1, 2013, to June 30, 2016). Electronic records from the hospital's anesthesia information management system were queried to identify the matching anesthesia records. The maximum EtCO2 values within 5 and 10 minutes of the onset of mechanical ventilation in the OR were determined for patients undergoing general anesthesia with mechanical ventilation. Patients were divided into 2 groups: those who were discharged from the hospital alive (survivors) and those who died in the hospital prior to discharge (nonsurvivors). The threshold EtCO2 giving a positive predictive value of 100% for in-hospital mortality was determined from a graphical analysis of the data. Association of determined threshold and mortality was analyzed using the 2-tailed Fisher exact test. RESULTS: There were 1135 patients who met the inclusion criteria. Within the first 5 minutes of the onset of mechanical ventilation in the OR, if the maximum EtCO2 value was

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Patient Survey of Referral From One Surgeon to Another to Reduce Maximum Waiting Time for Elective Surgery and Hours of Overutilized Operating Room Time.

BACKGROUND: Studies of shared (patient-provider) decision making for elective surgical care have examined both the decision whether to have surgery and patients' understanding of treatment options. We consider shared decision making applied to case scheduling, since implementation would reduce labor costs. METHODS: Study questions were presented in sequence of waiting times, starting with 4 workdays. "Assume the consultant surgeon (ie, the surgeon in charge) you met in clinic did not have time available to do your surgery within the next 4 workdays, but his/her colleague would have had time to do your surgery within the next 4 workdays. Would you have wanted to discuss with a member of the surgical team (eg, the scheduler or the surgeon) the availability of surgery with a different, equally qualified surgeon at Mayo Clinic who had time available within the next 4 workdays, on a date of your choosing?" There were 980 invited patients who underwent lung resection or cholecystectomy between 2011 and 2016; 135 respondents completed the study and 6 respondents dropped out after the study questions were displayed. RESULTS: The percentages of patients whose response to the study questions was "4 days" were 58.8% (40/68) among lung resection patients and 58.2% (39/67) among cholecystectomy patients. The 97.5% 2-sided confidence interval for the median maximum wait was 4 days to 4 days. Patients' choices for the waiting time sufficient to discuss having another surgeon perform the procedure did not differ between procedures (P = .91). Results were insensitive to patients' sex, age, travel time to hospital, or number of office visits before surgery (all P >= .20). CONCLUSIONS: Our results indicate that bringing up the option with the patient of changing surgeons when a colleague is available and has the operating room time to perform the procedure sooner is being respectful of most patients' individual preferences (ie, patient-centered). (C) 2017 International Anesthesia Research Society

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Abnormal Calcium Levels During Trauma Resuscitation Are Associated With Increased Mortality, Increased Blood Product Use, and Greater Hospital Resource Consumption: A Pilot Investigation.

BACKGROUND: Admission hypocalcemia predicts both massive transfusion and mortality in severely injured patients. However, the effect of calcium derangements during resuscitation remains unexplored. We hypothesize that any hypocalcemia or hypercalcemia (either primary or from overcorrection) in the first 24 hours after severe injury is associated with increased mortality. METHODS: All patients at our institution with massive transfusion protocol activation from January 2013 through December 2014 were identified. Patients transferred from another hospital, those not transfused, those with no ionized calcium (Ca2+) measured, and those who expired in the trauma bay were excluded. Hypocalcemia and hypercalcemia were defined as any level outside the normal range of Ca2+ at our institution (1-1.25 mmol/L). Receiver operator curve analysis was also used to further examine significant thresholds for both hypocalcemia and hypercalcemia. Hospital mortality was compared between groups. Secondary outcomes included advanced cardiovascular life support, damage control surgery, ventilator days, and intensive care unit days. RESULTS: The massive transfusion protocol was activated for 77 patients of whom 36 were excluded leaving 41 for analysis. Hypocalcemia occurred in 35 (85%) patients and hypercalcemia occurred in 9 (22%). Mortality was no different in hypocalcemia versus no hypocalcemia (29% vs 0%; P = .13) but was greater in hypercalcemia versus no hypercalcemia (78% vs 9%; P

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Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High-Stakes Environment, 3rd ed.

No abstract available

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Implementation of a Standardized Transfusion Protocol for Cardiac Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Decreased Blood Component Utilization and May Improve Clinical Outcome.

BACKGROUND: Extracorporeal membrane oxygenation supplies oxygenated blood to the body supporting the heart and lungs. Survival rates of 20% to 50% are reported among patients receiving ECMO for cardiac arrest, severe cardiogenic shock, or failure to wean from cardiopulmonary bypass following cardiac surgery. Bleeding is one of the most common complications in ECMO patients due to coagulopathy, systemic anticoagulation, and the presence of large bore cannulas at systemic pressure. Absence of a standardized transfusion protocol in this population leads to inconsistent transfusion practices. Here, we assess a newly developed dedicated transfusion protocol in this clinical setting. METHODS: Data were retrospectively reviewed for the first 30 consecutive cardiac ECMO patients prior and post implementation of the ECMO transfusion protocol. Diagnoses, laboratory results, blood component utilization, and outcomes were collected and analyzed. RESULTS: Comorbidities were similar between the 2 eras, as well as the pre-ECMO ejection fraction (P = .568) and duration on ECMO (P = .278). Transfusion utilization data revealed statistically significant decreases in almost all blood components and a savings in blood component acquisition costs of 51% ($175, 970). In addition, an almost 2-fold increase in survival rate was observed in the post-ECMO transfusion protocol era (63% vs 33%; relative risk = 1.82; 95% confidence interval, 1.07-3.10; P = .028). CONCLUSIONS: Our data indicate that implementation of a standardized transfusion protocol, using more restrictive transfusion indications in cardiac ECMO patients, was associated with reduced blood product utilization, decreased complications, and improved survival. This multidepartmental approach facilitates better communication and adherence to consensus clinical decision making between intensive care unit, surgery, and transfusion service and optimizes care of complicated and acutely ill patients. (C) 2017 International Anesthesia Research Society

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Acute facial nerve paralysis in children,............................................................................................................................................ Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature by Latha M Sneha via CHRISMED Journal of Health and Research : 2014 - 1(4) Latha M Sneha, Raichel Priyanka, Shanthini Thanga Tamilselvan, Julius Xavier Scott CHRISMED Journal of Health and Research 2017 4(3):209-211 Infections, inflammatory, and autoimmune conditions are the well-recognized etiologies of acute facial nerve paralysis in children. Bell's palsy is idiopathic peripheral facial nerve palsy. Cranial neuropathies do occur in children due to the central nervous system involvement by malignancies but uncommon in pediatric acute lymphoblastic leukemias and even rarer in acute myeloid leukemias (AMLs). We report a case of a 13-year-old girl who presented with acute facial nerve palsy, wa

The common etiology associated with acute facial nerve paralysis in children are otitis media, mastoiditis, viral infections such as herpes, varicella, mumps, HIV, meningitis, encephalitis, mycoplasma, Lyme disease, and inflammatory conditions such as vasculitis, Henoch–Schonlein purpura, Kawasaki syndrome, Gullain–Barre syndrome, and hypertension.[3]

Seventy percent of the children with acute lower motor neuron facial paralysis have a favorable prognosis and it resolves spontaneously within 3 months without any sequela. In 40%–75% of children, cause of unilateral facial paralysis is idiopathic, described as Bell's palsy and most of them have a positive history of viral illness 2–3 weeks preceding the neurological manifestations. The use of steroids to reduce the duration of paralysis and reduce the risk of long-term impairment was based on adult studies though the benefits of steroids in children is yet to be proven.[4] Due to the self-resolving nature of the idiopathic variety of the facial palsy seen in children, the neurological manifestations of leukemia as an etiology is never thought of. Steroids, when commonly prescribed in such cases causes a partial recovery thereby masking the primary pathology and adds to the diagnostic dilemma.

The frequency of symptomatic facial palsy has been found to be higher in the younger age group when compared to the idiopathic variety.[5]

AML accounts for 15% of all leukemia and presents with symptoms of prolonged fever, hepatosplenomegaly, and skin or mucocutaneous bleeds. When focal masses of immature myeloid cells from the granulocytic lineage infiltrate the soft tissues and bones, they are called granulocytic sarcomas or chloromas and occur in 5% of cases of AML. It is postulated that the granulocytic sarcomas traverse through the haversian canals from the bone marrow and gets deposited in the subperiosteum to form soft tissue masses.[6]

Granulocytic sarcomas may manifest concurrently with the disease or during remission or relapse. However, when sarcomas precede the disease in peripheral blood or marrow, it often poses a diagnostic challenge, more so, if cranial neuropathies are caused by unidentifiable chloromas as in our case. Facial paralysis resulting from leukemic infiltration, though rare, occurs during the relapse of the disease or as a complication primary disease, but it is not a well-recognized presenting symptom of childhood leukemia. Diagnostic delays of 1 month have been reported when facial nerve palsy was the isolated manifestation of AML in children.[7] Otomastoiditis due to the leukemic infiltration of the temporal bone has been attributed to the facial nerve paralysis. MRI with contrast of the facial nerve canal helps in identifying the facial nerve enhancement. However, the clinical findings of facial nerve paralysis were not always associated with radiological findings in most of the cases.[7]

Baek et al. have reported 11 children who had facial nerve paralysis as isolated feature of AML. Brain imaging studies showed mastoiditis in four of them and chloroma was identified in five of them. Six of them did not have blast in the CSF. Facial nerve palsy improved within a mean period of 1–6 months of chemotherapy.[7] Rohit et al. have reported a case of 13-year-old girl-AML with t(8:21) positivity who presented with bilateral proptosis and facial nerve palsy.[8]

When leukemic children presented with cranial neuropathies, the treatment included systemic and intrathecal chemotherapy with whole brain irradiation. However, Baek et al. recommend allogenic bone marrow transplant, avoiding whole brain irradiation in children to reduce the development of secondary malignancies and to prevent the long-term sequelae on cognitive and endocrine function.

Due to the self-resolving nature of the idiopathic variety of facial nerve palsy, when these children present to general physicians or neurologists, the diagnosis of leukemia is overlooked. Gradual progression of the paralysis beyond 3 weeks should warrant additional investigations to rule out the etiology.

CASE REPORT

Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 209-211

Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature

Latha M Sneha¹, Raichel Priyanka², Shanthini Thanga Tamilselvan², Julius Xavier Scott^3
1 Department of Pediatrics, Division of Pediatric Hemato Oncology, Sri Ramachandra University, Chennai, Tamil Nadu, India
² Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu, India
³ Division of Pediatric Hemato Oncology, Sri Ramachandra University, Chennai, Tamil Nadu, India

Date of Web Publication

13-Jul-2017

Correspondence Address:
Latha M Sneha
Division of Pediatric Hemato Oncology, Sri Ramachandra University, No. 1, Ramachandra Nagar, Porur, Chennai - 600 116, Tamil Nadu 
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/cjhr.cjhr_123_16

Abstract

Infections, inflammatory, and autoimmune conditions are the well-recognized etiologies of acute facial nerve paralysis in children. Bell's palsy is idiopathic peripheral facial nerve palsy. Cranial neuropathies do occur in children due to the central nervous system involvement by malignancies but uncommon in pediatric acute lymphoblastic leukemias and even rarer in acute myeloid leukemias (AMLs). We report a case of a 13-year-old girl who presented with acute facial nerve palsy, was being treated as Bell's palsy elsewhere and was later diagnosed to have AML.

Keywords: Acute myeloid leukemia, Bell's palsy, child

How to cite this article: Sneha LM, Priyanka R, Tamilselvan ST, Scott JX. Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature. CHRISMED J Health Res 2017;4:209-11

How to cite this URL: Sneha LM, Priyanka R, Tamilselvan ST, Scott JX. Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature. CHRISMED J Health Res [serial online] 2017 [cited 2017 Jul 14];4:209-11. Available from: http://www.cjhr.org/text.asp?2017/4/3/209/210478

Introduction

Acute, peripheral facial palsy can be presenting feature of infections, inflammatory, and autoimmune conditions and has a good prognosis in children. The incidence of facial paralysis in children <10 years of age is reported to be 2.7/100,000.^[1] Majority of them are unilateral, idiopathic, and termed Bell's palsy. A diagnosis of exclusion, Bell's palsy accounts for 42%–85% of cases in children with facial nerve paralysis.^[2] Although association of facial palsies in malignancies is well reported, facial paralysis is not a well-recognized presenting feature of leukemias in children, especially in acute myeloid leukemia (AML). The presence of Bell's palsy in children warrants a complete evaluation to rule out leptomeningeal diseases. We report a case of an adolescent girl who presented with acute facial nerve palsy, treated as Bell's palsy elsewhere and was later diagnosed to have AML.

Case Report

A 13-year-old girl presented with acute onset of right-sided facial nerve palsy of 2 weeks duration. She was diagnosed to have idiopathic Bell's palsy elsewhere and was being treated symptomatically with physiotherapy and oral steroids with no improvement in symptoms. She had no constitutional symptoms of fever, anorexia or fatigue, bone pain, mucocutaneous, or skin bleeds. In view of persistent symptoms, she was referred to a higher center for further evaluation. Examination revealed a right-sided lower motor neuron facial nerve palsy [Figure 1], without hepatosplenomegaly or lymphadenopathy. Central nervous system examination and rest of the systemic examination were normal. Investigations revealed hemoglobin 5.9 g/dl, total leukocyte count 14,900/μL (polymorphs: 64.1%, lymphocytes 30.3%), and platelet count 83,000/μL. Peripheral smear revealed leukocytosis with increase in blasts (50%) with  Auer rods ^{More Details} along with thrombocytopenia [Figure 2].

Figure 1: Right-sided lower motor neuron palsy Click here to view

Figure 2: Peripheral smear showing blasts with Auer rods Click here to view

Bone marrow aspiration showed hypercellular marrow with 58% blasts, promyelocytes - nil, myelocytes - 9, metamyelocytes - 9, neutrophil - 3, eosinophil - 2, band - 4, lymphocytes - 9, monocytes - nil, and plasma cells - 1 [Figure 3]. Cerebrospinal fluid (CSF) analysis was negative for malignant cells. Flow cytometry revealed blasts positive for CD33, cytoplasmic myeloperoxidase, and Human leukocyte antigen –D related (HLA-DR). Magnetic resonance imaging (MRI) brain, MRI angiogram, and venogram were normal. Cytogenetics was negative for t(8:21), inversion 16, t(9:11), and t(15:17). The girl was diagnosed as AML M0. She was started on chemotherapy and after the first cycle of chemotherapy, the bone marrow is in remission and she had partial resolution of facial nerve palsy.

Figure 3: Bone marrow aspirate showing hypercellular marrow with increased blasts 58% Click here to view

Discussion

The common etiology associated with acute facial nerve paralysis in children are otitis media, mastoiditis, viral infections such as herpes, varicella, mumps, HIV, meningitis, encephalitis, mycoplasma, Lyme disease, and inflammatory conditions such as vasculitis, Henoch–Schonlein purpura, Kawasaki syndrome, Gullain–Barre syndrome, and hypertension.^[3]

Seventy percent of the children with acute lower motor neuron facial paralysis have a favorable prognosis and it resolves spontaneously within 3 months without any sequela. In 40%–75% of children, cause of unilateral facial paralysis is idiopathic, described as Bell's palsy and most of them have a positive history of viral illness 2–3 weeks preceding the neurological manifestations. The use of steroids to reduce the duration of paralysis and reduce the risk of long-term impairment was based on adult studies though the benefits of steroids in children is yet to be proven.^[4] Due to the self-resolving nature of the idiopathic variety of the facial palsy seen in children, the neurological manifestations of leukemia as an etiology is never thought of. Steroids, when commonly prescribed in such cases causes a partial recovery thereby masking the primary pathology and adds to the diagnostic dilemma.

The frequency of symptomatic facial palsy has been found to be higher in the younger age group when compared to the idiopathic variety.^[5]

AML accounts for 15% of all leukemia and presents with symptoms of prolonged fever, hepatosplenomegaly, and skin or mucocutaneous bleeds. When focal masses of immature myeloid cells from the granulocytic lineage infiltrate the soft tissues and bones, they are called granulocytic sarcomas or chloromas and occur in 5% of cases of AML. It is postulated that the granulocytic sarcomas traverse through the haversian canals from the bone marrow and gets deposited in the subperiosteum to form soft tissue masses.^[6]

Granulocytic sarcomas may manifest concurrently with the disease or during remission or relapse. However, when sarcomas precede the disease in peripheral blood or marrow, it often poses a diagnostic challenge, more so, if cranial neuropathies are caused by unidentifiable chloromas as in our case. Facial paralysis resulting from leukemic infiltration, though rare, occurs during the relapse of the disease or as a complication primary disease, but it is not a well-recognized presenting symptom of childhood leukemia. Diagnostic delays of 1 month have been reported when facial nerve palsy was the isolated manifestation of AML in children.^[7] Otomastoiditis due to the leukemic infiltration of the temporal bone has been attributed to the facial nerve paralysis. MRI with contrast of the facial nerve canal helps in identifying the facial nerve enhancement. However, the clinical findings of facial nerve paralysis were not always associated with radiological findings in most of the cases.^[7]

Baek et al. have reported 11 children who had facial nerve paralysis as isolated feature of AML. Brain imaging studies showed mastoiditis in four of them and chloroma was identified in five of them. Six of them did not have blast in the CSF. Facial nerve palsy improved within a mean period of 1–6 months of chemotherapy.^[7] Rohit et al. have reported a case of 13-year-old girl-AML with t(8:21) positivity who presented with bilateral proptosis and facial nerve palsy.^[8]

When leukemic children presented with cranial neuropathies, the treatment included systemic and intrathecal chemotherapy with whole brain irradiation. However, Baek et al. recommend allogenic bone marrow transplant, avoiding whole brain irradiation in children to reduce the development of secondary malignancies and to prevent the long-term sequelae on cognitive and endocrine function.

Due to the self-resolving nature of the idiopathic variety of facial nerve palsy, when these children present to general physicians or neurologists, the diagnosis of leukemia is overlooked. Gradual progression of the paralysis beyond 3 weeks should warrant additional investigations to rule out the etiology.

Conclusion

While managing young children with acute lower motor neuron facial nerve palsy, neurologists and general physicians should have an index of suspicion for the neurological manifestations of acute leukemia and hence complete blood counts, peripheral smear and a bone marrow study if needed should be a part of the work up for etiology in such cases. The routine use of steroids may result in partial remission and can cause diagnostic delays.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

References

1.	Singhi P, Jain V. Bell's palsy in children. Semin Pediatr Neurol 2003;10:289-97.   [PUBMED]
2.	May M, Fria TJ, Blumenthal F, Curtin H. Facial paralysis in children: Differential diagnosis. Otolaryngol Head Neck Surg 1981;89:841-8.
3.	Ciorba A, Corazzi V, Conz V, Bianchini C, Aimoni C. Facial nerve paralysis in children. World J Clin Cases 2015;3:973-9.
4.	Unüvar E, Oguz F, Sidal M, Kiliç A. Corticosteroid treatment of childhood Bell's palsy. Pediatr Neurol 1999;21:814-6.
5.	Krishnamurthy S, Weinstock AL, Smith SH, Duffner PK. Facial palsy, an unusual presenting feature of childhood leukemia. Pediatr Neurol 2002;27:68-70.
6.	Stein-Wexler R, Wootton-Gorges SL, West DC. Orbital granulocytic sarcoma: An unusual presentation of acute myelocytic leukemia. Pediatr Radiol 2003;33:136-9.
7.	Baek HJ, Han DK, Kim YO, Choi IS, Hwang TJ, Kook H. Facial palsy as the presenting symptom of acute myeloid leukemia in children: Three cases with stem cell transplantations. Korean J Pediatr 2009;52:713-6.
8.	Rohit K, Jitender MK, Atul S, Soumya S. The paradox of recurrent with rare: A rare case of bilateral proptosis and facial palsy in acute myeloid leukemia with recurrent cytogenetic translocation t(8:21). Int J Appl Basic Med Res 2015;5:76-8.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cyclical Cushing's: how best to catch the ups and downs

A 68-year-old man with a background of hypertension and type 2 diabetes presented with fluctuating symptoms of muscle aches and pains and tiredness. His initial work-up for the possibility of hypercortisolaemia showed a completely variable pattern, with 24-hour cortisol excretion and serum cortisol post 1 mg dexamethasone suppression test ranging from normal to significantly elevated. A series of salivary cortisol with symptom diary confirmed the cyclical nature of hypercortisolaemia, and his concomitant adrenocorticotropic hormone (ACTH) levels were elevated. An inferior petrosal sinus sampling, performed during hypercortisolaemic phase of his cycle,suggested a central source of ACTH secretion. He had unsuccessful exploration of his pituitary and was eventually treated with bilateral adrenalectomy followed by lifelong steroid replacement. His symptoms improved immediately, and he came off his oral hypoglycaemic and antihypertensive agents within 6 months following his surgery.

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A mass obstructing mechanical prosthetic heart valve: thrombus or pannus?

Description

Mechanical prosthetic valve obstruction carries a significant morbidity and mortality, if not treated urgently. Most notable causes of an acquired obstruction include thrombosis and pannus formation.1 It is critically important to exclude isolated pannus, since thrombolysis is an effective and rapid treatment option in case of a thrombus, while it is contraindicated in pannus. Published guidelines provide no diagnostic strategy to differentiate them.2 Transesophageal echocardiogram (TEE) is indispensable for assessing the leaflet motion and the nature and extent of the obstructing mass. However, in resource-poor settings, where TEE is not always available, therapy is based on transthoracic echocardiography and fluoroscopic findings.

A 50-year-old woman presented with complaints of worsening dyspnoea associated with orthopnoea for 3 days. She had undergone a mitral valve replacement with a mechanical bi-leaflet prosthesis 6 months prior for severe rheumatic mitral regurgitation, following which she was asymptomatic. Examination revealed blood...

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Rapid developing empyema by group F beta Streptococcus anginosus group

A 43-year-old male had progressive pleuritic left-sided chest tightness with shortness of breath. He had dental caries and tenderness on palpation of the left lateral chest. Complete blood count showed leucocytosis. CT scan of the chest with pulmonary emboli protocol showed multiple pulmonary nodules and nodular pleural thickening at left posterior lateral pleura. Forty-eight hours post CTPE scan, CT scan of the chest, abdomen and pelvis displayed right lower lobe consolidation and left-sided pleural effusion with superimposed compressive atelectasis. Ceftaroline intravenous was initiated, with CT-guided pigtail chest tube insertion. Pleural fluid later grew group F beta-haemolytic Streptococcus anginosus. Patient improved significantly and was discharged 11 days later with intravenous ertapenem. Patients with group F beta-haemolytic streptococci should be managed aggressively with early and accurate diagnosis, antibiotics, drainage and possible surgery.

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Congenital kinking of aorta

Pseudocoarctation is an unusual anomaly mirroring true coarctation. Congenital kinking or pseudocoarctation of aorta was never a benign condition. Although surgical repair should be suggested for all symptomatic individuals. Regular follow-up is obligatory for all asymptomatic patients deprived of linked anomalies. We suggest CT-aortogram as a non-invasive imaging modality for the definitive diagnosis of pseudocoarctation.

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A case report on a rare anatomic variant of cystic duct insertion

Abstract

We report a case a 70-year-old female presenting with abdominal pain who has a cystic duct coursing medial to the common bile duct before anastomosing just proximal to the ampulla. Low medial insertion of the cystic duct is a rare anatomic variant that is easily misidentified on imaging studies and may complicate surgical and percutaneous intervention. It can be identified by pre-operative imaging modalities such as magnetic resonance cholangiopancreatography.

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Giant spontaneous herniation of the post-pneumonectomy cavity

Abstract

Following a pneumonectomy, excessive mediastinal shift can cause rare complications involving the post-pneumonectomy cavity, which can become the seat of herniation of the residual lung and of the heart. We herein report an even more rare event, entailing an impressive herniation of the actual entire post-pneumonectomy cavity through an intercostal space, which developed spontaneously nearly 3 years after surgery. Surgical excision of the hernia sac and repair of the defect with polypropylene mesh provided adequate treatment and good cosmetic results. Postoperative recovery was uneventful and no signs of recurrence have been observed.

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Successful laparoscopic repair of gastro-gastric fistula following Roux-en-Y gastric bypass at Harlem Community Hospital

Abstract

Gastro-gastric fistula is a communication between the gastric remnant and gastric pouch. It is a rare complication of Roux-en-Y gastric bypass. It is caused by anastomotic leak, marginal ulcers, distal obstruction or erosion from foreign body. In this case report, we are presenting a successful laparoscopic repair of gastro-gastric fistula in a patient who presented with weight gain after initial loss.

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The response to Trendelenburg position is minimally affected by underlying hemodynamic conditions in patients with aortic stenosis

Abstract

Purpose

Trendelenburg positioning is commonly used to temporarily treat intraoperative hypotension. The Trendelenburg position improves cardiac output in normovolemic or anesthetized patients, but not hypovolemic or non-anesthetized patients. Therefore, the response to Trendelenburg positioning may vary depending on patient population or hemodynamic conditions. We thus tested the hypothesis that the effectiveness of the Trendelenburg position, as indicated by an increase in cardiac output, improves after replacement of a stenotic aortic valve. Secondarily, we evaluated whether measurements of left ventricular preload, systolic function, or afterload were associated with the response to Trendelenburg positioning.

Methods

This study is a secondary analysis of a clinical trial which included patients having aortic valve replacement (AVR) who were monitored with pulmonary artery catheters (NCT01187329). We examined changes in thermodilution cardiac output with Trendelenburg positioning before and after AVR. We also examined whether echocardiographic and hemodynamic measurements of preload, afterload, and systolic function were associated with changes in cardiac output during Trendelenburg positioning.

Results

Thirty-seven patients were included. The median [IQR] cardiac output change with Trendelenburg positioning was −3% [−10%, 5%] before AVR versus +4% [−4%, 15%] after AVR. Estimated median difference in cardiac output with Trendelenburg was 5% (95% CI 1, 15%, P = 0.04) greater after AVR. The response to Trendelenburg positioning was largely independent of hemodynamic conditions.

Conclusion

The response to Trendelenburg positioning improved following AVR, but by a clinically unimportant amount. The response to Trendelenburg positioning was independent of hemodynamic conditions.

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Correction of High Astigmatism after Penetrating Keratoplasty with Toric Multifocal Intraocular Lens Implantation

After penetrating keratoplasty (PK), high astigmatism is often induced, being frequently about 4–6 dpt. According to the entity and typology of astigmatism, different methods of correction can be used. Selective suture removal, relaxing incisions, wedge resections, compression sutures, photorefractive keratectomy, and laser-assisted in situ keratomileusis can reduce corneal astigmatism and ametropia, but meanwhile they can cause a reduction in the corneal integrity and cause an over- or undercorrection. In case of moderate-to-high regular astigmatisms, the authors propose a toric multifocal intraocular lens (IOL) implantation to preserve the corneal integrity (especially in PK after herpetic corneal leukoma keratitis). We evaluated a 45-year-old patient who at the age of 30 was subjected to PK in his left eye due to corneal leukoma herpetic keratitis, which led to high astigmatism (7.50 dpt cyl. 5°). The patient was subjected to phacoemulsification and customized toric multifocal IOL implantation in his left eye. The correction of PK-induced residual astigmatism with a toric IOL implantation is an excellent choice but has to be evaluated in relation to patient age, corneal integrity, longevity graft, and surgical risk. It seems to be a well-tolerated therapeutic choice and with good results.
Case Rep Ophthalmol 2017;8:385–388

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Sturge-Weber Syndrome Associated with Monolateral Ocular Melanocytosis, Iris Mammillations, and Diffuse Choroidal Haemangioma

We present the case of a 12-year-old boy with Sturge-Weber syndrome and ocular melanocytosis who presented with bilateral naevus flammeus of the face and hyperpigmentation of the right iris associated with ipsilateral iris mammillations. The patient had glaucoma and a diffuse choroidal haemangioma of the right eye. Optical coherence tomography of the anterior segment confirmed iris hyper-pigmentation and did not show abnormalities of the chamber angle structures. B-scan ultrasonography and enhanced depth imaging optical coherence tomography were performed and showed a marked difference in thickness and reflectance between the right and left choroid. Visual field examinations with perimetry showed early defects in the right eye. Peripapillary optical coherence imaging showed borderline values of retinal nerve fibre layer thickness reduction in the right eye. Sturge-Weber syndrome associated with ocular melanocytosis and iris mammillations is an extremely rare condition. This paper highlights the role of multi-imaging methods in the enhanced evaluation of rare diseases towards choosing the most appropriate management strategies and improving the follow-up of patients over time.
Case Rep Ophthalmol 2017;8:375–384

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Spironolactone for Secondary Central Serous Chorioretinopathy: A Challenge-Rechallenge Case

Central serous chorioretinopathy (CSCR) is potentially sight-threatening and has been associated with corticosteroid use. CSCR secondary to steroid use can sometimes be challenging to treat, especially if continuing steroid use is medically necessary. In this case report we demonstrate the efficacy of spironolactone as an effective agent in countering CSCR secondary to steroid use. This challenge-rechallenge case may be helpful to clinicians in delineating a treatment paradigm for these patients.
Case Rep Ophthalmol 2017;8:370–374

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Optical Coherence Tomography Angiography: Employing a Novel Technique for Investigation in Vogt-Koyanagi-Harada Disease

Purpose: To report a case of Vogt-Koyanagi-Harada (VKH) disease and describe the imaging findings by means of optical coherence tomography angiography (OCTA). Methods: Medical and ophthalmological history, ophthalmological examination, laboratory evaluation, B-scan ultrasonography, fluorescein and indocyanine angiography, and optical coherence tomography (OCT) were performed at baseline, as well as OCTA. Results: A 50-year-old healthy female presented with decreased vision in both eyes. A Topcon DRI OCT Triton Plus swept source OCT system was used to visualize and evaluate the retinal and choroidal vascular plexus. Patchy and confluent dark areas in the superficial and deep retinal capillary plexus and choriocapillaris corresponded to areas of hypoperfusion, analyzed as areas of ischemia. Conclusions and Importance: VKH disease is characterized by ocular, neurological, and integumentary findings in its complete form. We present a case of incomplete disease in a 50-year-old female evaluated by means of OCTA which is a novel technique that provides depth-resolved images of the retina and choroidal microvasculature without dye injection that allows better visualization and detailed evaluation of the retinal and choroidal vascular plexus.
Case Rep Ophthalmol 2017;8:362–369

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Case 21-2017: A 28-Year-Old Pregnant Woman with Endocervical Carcinoma

Presentation of Case. Dr. Mariam Naqvi (Obstetrics and Gynecology): A 28-year-old pregnant woman with Rh isoimmunization and endocervical carcinoma was seen in the maternal–fetal outpatient clinic of this hospital at 34.1 weeks of gestation. The patient was gravida 3, para 2001 (the first delivery…

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A novel case of Raoultella planticola osteomyelitis and epidural abscess

A spinal epidural abscess is the collection of pus in the epidural space, and is a potentially life-threatening condition that requires early detection and prompt management. Almost two-thirds of cases are caused by Staphylococcus aureus, followed by Gram-negative bacilli which account for approximately 16% of cases. Raoultella planticola is an emerging pathogen, and is an extremely rare cause of invasive infection in humans. It has been reported to cause urinary tract infections, pneumonia, bacteraemia, cholangitis, cholecystitis, conjunctivitis and soft tissue infections. We report the first case, to our knowledge, of R. planticola osteomyelitis and spinal epidural abscess.

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Fatal case of descending necrotising mediastinitis

Description

A 56-year-old man presented with a 4-day history of fever and sore throat followed by 1 day of wheezing. On examination, he appeared in acute distress. The blood pressure was 129/76 mm Hg, the pulse was 88 per min, the respiratory rate was 22 per min and the temperature was 38.2°C. Auscultation over the upper airway area noted stridor. Chest radiograph showed tracheal stenosis and air along the aorta (figure 1). At the emergency department, he developed respiratory arrest, and the trachea was incubated. CT scan with intravenous contrast showed a space-occupying lesion behind the pharynx and mediastinum emphysema (figure 2). A diagnosis of retropharyngeal abscess with descending necrotising mediastinitis was made. Despite antimicrobial therapy in intensive care, he developed septic shock and died on day 4 after the admission. Patients with retropharyngeal abscess usually have fever, sore throat, odynophagia, drooling and fatigue with dyspnoea and stridor mimicking wheezing in...

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Primary cardiac leiomyosarcoma presenting as haemoptysis in a 22-year-old patient: an unusual presentation of a rare condition

Primary cardiac sarcomas are rare malignant tumours and among them, leiomyosarcoma is extremely rare. They are especially rare in a young age group. We present a case of a 22-year-old male patient with primary leiomyosarcoma of the left atrium involving the pulmonary veins who presented with haemoptysis and shortness of breath. He underwent surgical excision of the tumour along with mitral valve replacement followed by adjuvant chemotherapy. No recurrence was reported on his second 6 monthly follow-ups.

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Malar rash with pulmonary hypertension and chronic obstructive pulmonary disease

Description

Malar rash is a fixed erythema involving the facial cheeks and nasal bridge with sparing of the nasolabial folds. It has a classic butterfly appearance (figure 1). Its causes include local and systemic diseases, including rosacea, erysipelas and systemic lupus erythematosus (SLE).1 Rarely it occurs due to mitral stenosis with reduced cardiac output and pulmonary hypertension.2 Its association with severe pulmonary hypertension from chronic obstructive pulmonary disease (COPD) is not commonly described.

We recently admitted a 76-year-old woman to our intensive care unit with dyspnoea and cough on a background of COPD. On examination she had a malar rash (figure 1) in association with a respiratory rate of 24 breaths/min, raised jugular venous pressure, peripheral oedema and signs of peripheral venous congestion including leg ulcers and hyperpigmentation of her extremities. Admitting arterial blood gas showed pO₂ of 9 kPa on 80% oxygen,...

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Facial palsy and atrial fibrillation: a special case of Ramsay Hunt syndrome

Ramsay Hunt syndrome (herpes zoster oticus) is a rare complication of latent Varicella Zoster virus infection. It can be complicated by permanent hearing loss, loss of taste and postherpetic neuralgia. Although Ramsay Hunt syndrome most prominently involves the facial nerve, a number of other cranial nerves can be involved such as the vestibulocochlear, glossopharyngeal and the vagus nerve. We report on a case of Ramsay Hunt syndrome with cranial polyneuritis complicated by atrial fibrillation. Vagal involvement as evidenced by physical examination and MRI findings was present in our patient. We hypothesise that viral vagal neuritis likely contributed to the development of atrial fibrillation in our patient through involvement of the autonomic components of the vagus nerve.

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Urodynamic findings in Susac syndrome: first reported filling cystometrogram

Susac syndrome is a rare neurological disease, with only 300 cases reported in the literature. Lower urinary symptoms are not an uncommon feature of the disease, yet there is no information on specific dysfunction typical urodynamic findings associated with the disease. We present what we believe to be the first reported filling cystometrogram study of Susac syndrome for the evaluation of voiding dysfunction.

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Headache, TIA and subarachnoid haemorrhage: dissecting an unusual cause for stroke-like symptoms

We present a case of supraclinoid internal carotid artery dissection. Eleven months prior, the patient developed isolated periorbital pain and was diagnosed with giant-cell arteritis with iritis. The patient experienced recurrent spells concerning for transient ischaemic attacks and was transferred to our institution for endovascular intervention after head CT revealed an embolic infarct with a 'dense middle cerebral artery sign.' Digital subtraction angiography was negative for occlusion, instead demonstrating luminal stenosis and poststenotic dilatation. He subsequently experienced acute neurological decline secondary to massive subarachnoid haemorrhage. Non-invasive vascular imaging revealed an intimal flap and a pseudoaneurysm at the site of luminal stenosis, confirming our suspicion for intracranial carotid artery dissection. Given the moribund clinical state, the family opted to withdraw care, and he quickly expired.

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A rare case of Hodgkins lymphoma presenting with papulonecrotic tuberculid

Description

A 78-year-old man complained of pruritic skin lesions over the trunk and all limbs and occasional fever for 3 months. He had papulonodular skin lesions with erythematous base involving anterior as well as posterior aspects of the trunk and all limbs with predilection for extensor surface (figure 1). Mantoux test was negative. Skin biopsy showed features of papulonecrotic tuberculid (figure 2) with a negative Mycobacterium tuberculosis PCR and acid-fast bacilli stain. CT scan of the chest and abdomen showed multiple, enlarged mediastinal and retroperitoneal lymph nodes (largest 2.4 cm). Trucut biopsy and immunohistochemistry from retroperitoneal node revealed features of classical Hodgkin's lymphoma, nodular sclerosis variety with CD15 and CD30 positivity. In the absence of conclusive evidence of tuberculosis, he was treated with chemotherapy alone (oral prednisolone, etoposide, procarbazine and cyclophosphamide). Two months later, he is asymptomatic with partial resolution of skin lesions.

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Ventricular fibrillation induced by high-output ICD shock: report of cases and review of literature

This report highlights the importance of realising that even the modern-day implantable cardioverter defibrillators (ICDs) with R wave synchronised appropriate shocks have a potential proarrhythmic effect. We present two cases of ventricular fibrillation induction resulting from an appropriate ICD shock observed in two different patients at our institution. Such cases have not been reported before. We discuss the possible reasons for our observations and are also submitting a pertinent literature review with our reports.

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Anaplastic carcinoma of thyroid gland with widespread soft tissue metastasis: an unusual presentation

Anaplastic thyroid cancer is the rarest tumour of the thyroid gland, representing only 2% of clinically recognised thyroid cancers. The most common metastatic sites are lungs, followed by the intrathoracic and neck lymph nodes. We report the case of a 62-year-old woman who presented to our setting with multiple soft tissue nodules, thyroid mass, head swelling and weight loss. Radiological investigation showed a large thyroid mass with widespread metastasis in subcutaneous tissues of both upper limbs, chest and abdomen. Metastasis was also found in lungs, skull and adrenal glands after which the patient was diagnosed with stage IVc anaplastic thyroid carcinoma (ATC). After careful consideration of patient's clinical condition with multiple poor prognostic factors, medical therapy was withheld and she was discharged on hospice care. The patient expired after 1 month. In ATC, metastasis to subcutaneous tissue is an extremely rare occurrence of which there is hardly any evidence in literature.

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An unconventional valvuloplasty: severe pulmonary stenosis with 'candy cane' inferior vena cava

Femoral vein is the usual approach to balloon pulmonary valvuloplasty (BPV). However, alternative access may be mandated in some peculiar situations. We hereby report a 10-year-old patient with symptomatic severe valvular pulmonary stenosis with interrupted inferior vena cava which was successfully treated with transjugular BPV. Technical considerations for this approach as well as other possible options for such patients are discussed.

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Central retinal artery occlusion in a 30-year-old woman taking tranexamic acid

We present a case of a 30-year-old woman who suffered a central retinal artery occlusion while taking tranexamic acid. She had no vascular risk factors and was placed on the drug for treatment of menorrhagia. After 1 month of taking the drug, she suffered a central retinal artery occlusion in her left eye. Tranexamic acid was discontinued to prevent vision loss in the following eye. She remains with no perception of light vision in the affected eye.

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Pulsed radiofrequency in chronic pain.

Purpose of review: The increasing number of publications on pulsed radiofrequency (PRF) treatment of chronic pain reflects the interest for this technique. We summarize the literature for PRF in five indications: radicular pain, trigeminal neuralgia (TN), occipital neuralgia, shoulder and knee pain. Recent findings: The efficacy and safety of PRF adjacent to the dorsal root ganglion was documented on cervical and on lumbar level. PRF has been used for the treatment of TN. The observed duration of effect is shorter than that of conventional radiofrequency, but no neurological complications are reported with PRF. PRF of the nervi occipitales is superior to steroid injections in occipital neuralgia. Several studies showed that PRF of the nervus suprascapularis may relief shoulder pain and can improve mobility of the shoulder joint. For the treatment of knee pain, different nerves have been targeted for PRF treatment. Summary: PRF treatment has progressively gained a place in the management of chronic pain syndromes. The concept is appealing because long-lasting effects are reported without complications. Future research is needed with high quality randomized controlled trials and identification of the optimal parameters of PRF in clinical practice. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Regional anesthesia and analgesia in cancer care: is it time to break the bad news?.

Purpose of review: There is ongoing controversy regarding the tumor-protective effects of regional anesthesia in patients undergoing cancer surgery. Evidence of up-to-date systematic reviews will be presented alongside recent updates on the effects of opioids and local anesthetics. Recent findings: In recent years, the literature regarding the effects of regional anesthesia techniques on cancer recurrence has raised many unanswered questions. Ongoing randomized controlled trials may not be able to shed light on the controversial discussion regarding the tumor protective effects of regional anesthesia because the expected effect size and event rate in those studies may be overstated. Recent more refined animal data, provides no evidence to suggest that opioids promote cancer recurrence or facilitate the development of metastatic disease. In addition, local anesthetics have promising preclinical anticarcinogenic effects that extend beyond their voltage-gated sodium channel blocking properties and could be of therapeutic value. Summary: Cancer recurrence in patients undergoing surgery remains a global burden. Current evidence suggests that regional techniques, opioid analgesia and local anesthetics in onco-anesthesia may require a tailored individual approach due to the phenotypic and genotypic heterogeneity within and between different tumors. The authors surmise that future or ongoing randomized controlled trials regarding regional anesthesia techniques and cancer outcome may not be able to reproduce clear results, as it will be challenging to prove the efficacy of one single intervention (e.g. regional anesthesia) in an otherwise complex multifactorial perioperative oncological setting. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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