Primary solitary plasmacytoma of the liver – successful treatment with fractionated stereotactic radiotherapy (Cyberknife®): a case report

Solitary plasmacytoma of the liver is a very rare and aggressive form of plasma cell dyscrasia. To the best of our knowledge, very few cases have been reported without systemic disease. We reported a rare case...

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Calcified amorphous tumor of the heart with mitral annular calcification: a case report

Calcified amorphous tumor of the heart is a rare, non-neoplastic cardiac mass characterized by nodular calcium in the background of amorphous degenerating fibrinous material. Clinical diagnosis of calcified am...

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Echocardiography and passive leg raising in the postoperative period: A prospective observational study.

BACKGROUND: Signs of hypovolaemia are frequent in the postoperative period, but not all patients need or respond to fluid administration. An increase in cardiac output (CO) after passive leg raising (PLR) has been demonstrated to be useful as a volume response predictor in non-surgical, spontaneously breathing patients. OBJECTIVE: The objective of this study was to evaluate the accuracy of transthoracic echocardiography after PLR to predict fluid responsiveness in post-surgical patients. DESIGN: A prospective observational study. SETTING: A tertiary hospital between January and July 2015. PATIENTS: Fifty-one spontaneously breathing postoperative patients with suspected hypovolaemia (arterial hypotension, oliguria, tachycardia or delayed capillary refill) were considered for the study. INTERVENTION: Demographic and personal data were collected, as well as heart rate variations, mean arterial pressure during PLR and after administering 500 ml of Ringer's lactate solution. CO was measured by transthoracic echocardiography. MAIN OUTCOME MEASURES: The primary outcome was measurement of CO before and after PLR and Ringer's lactate administration. RESULTS: Forty-one patients were included in the study (six patients were excluded because of a poor echocardiographic window and four because of misalignment of the Doppler and outflow tract of the left ventricle). Twenty-two patients (54%) were considered responders to fluid therapy, with an increase of stroke volume greater than or equal to 15% after 500 ml lactated Ringer's infusion. The highest area under the curve was found for an increase in CO (0.91 +/- 0.05; 95% confidence interval 0.78 to 0.97). An increase in CO greater than 11% after the PLR manoeuvre predicts a volume response with 68% sensitivity and 100% specificity. CONCLUSION: This is the first study showing that measurement of CO after PLR can predict volume response in spontaneously breathing postoperative patients. (C) 2017 European Society of Anaesthesiology

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Anaesthetic management of patients with myopathies.

: The anaesthetic management of patients with myopathies is challenging. Considering the low incidence and heterogeneity of these disorders, most anaesthetists are unfamiliar with key symptoms, associated co-morbidities and implications for anaesthesia. The pre-anaesthetic assessment aims at the detection of potentially undiagnosed myopathic patients and, in case of known or suspected muscular disease, on the quantification of disease progression. Ancillary testing (e.g. echocardiography, ECG, lung function testing etc.) is frequently indicated, even at a young patient age. One must differentiate between myopathies associated with malignant hyperthermia (MH) and those that are not, as this has significant impact on preoperative preparation of the anaesthesia workstation and pharmacologic management. Only few myopathies are clearly associated with MH. If a regional anaesthetic technique is not possible, total intravenous anaesthesia is considered the safest approach for most patients with myopathies to avoid anaesthesia-associated rhabdomyolysis. However, the use of propofol in patients with mitochondrial myopathies may be problematic, considering the risk for propofol-infusion syndrome. Succinylcholine is contra-indicated in all patients with myopathies. Following an individual risk/benefit evaluation, the use of volatile anaesthetics in several non-MH-linked myopathies (e.g. myotonic syndromes, mitochondrial myopathies) is considered to be well tolerated. Perioperative monitoring should specifically focus on the cardiopulmonary system, the level of muscular paralysis and core temperature. Given the high risk of respiratory compromise and other postoperative complications, patients need to be closely monitored postoperatively. (C) 2017 European Society of Anaesthesiology

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Blunt Traumatic Injury to the Aortic Root and Aortic Valve.

No abstract available

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Opioid Reduction Following Interventional Procedures for Chronic Pain: A Synthesis of the Evidence.

The past decade has witnessed the tremendous growth of procedures to treat chronic pain, which has resulted in increased third-party scrutiny. Although most of these procedures appear to be associated with significant pain relief, at least in the short and intermediate term, their ability to improve secondary outcome measures, including function and work status is less clear-cut. One of these secondary outcome measures that has garnered substantial interest in the pain and general medical communities is whether interventions can reduce opioid intake, which is associated with significant risks that in most cases outweigh the benefits in the long term. In the article, we examine whether procedural interventions for chronic pain can reduce opioid intake. Most studies that have examined analgesic reduction as a secondary outcome measure have not separated opioid and nonopioid analgesics, and, among those studies that have, few have demonstrated between-group differences. Reasons for failure to demonstrate opioid reduction can be broadly classified into procedural, design-related, clinical, psychosocial, biological, and pharmacological categories, all of which are discussed. In the future, clinical trials in which this outcome is examined should be designed to evaluate this, at least on a preliminary basis. (C) 2017 International Anesthesia Research Society

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Blood Product Utilization Among Trauma and Nontrauma Massive Transfusion Protocols at an Urban Academic Medical Center.

BACKGROUND: Hospital-wide massive transfusion protocols (MTPs) primarily designed for trauma patients may lead to excess blood products being prepared for nontrauma patients. This study characterized blood product utilization among distinct trauma and nontrauma MTPs at a large, urban academic medical center. METHODS: A retrospective study of blood product utilization was conducted in patients who required an MTP activation between January 2011 and December 2015 at an urban academic medical center. Trauma MTP containers included 6 red blood cell (RBC) units, 5 plasma units, and 1 unit of apheresis platelets. Nontrauma MTP containers included 6 RBC and 3 plasma units. RESULTS: There were 334 trauma MTP activations, 233 nontrauma MTP activations, and 77 nontrauma MTP activations that subsequently switched to a trauma MTP ("switched activations"). All nontrauma MTP activations were among bleeding patients who did not have a traumatic injury (100% [233/233]). Few patients with a nontrauma activation required ad hoc transfusion of RBC units (1.3% [95% confidence interval (CI), 0.3%-3.7%]) or plasma (3.4% [95% CI, 1.5%-6.7%]), and only 45.5% (95% CI, 39.0%-52.1%) required ad hoc transfusion of apheresis platelets. Compared to trauma and switched activations, nontrauma activations transfused a lower median number of RBC, plasma, and apheresis platelet units (P

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Maternal Salvage With Extracorporeal Life Support: Lessons Learned in a Single Center.

The American Heart Association scientific statement on cardiac arrest in pregnancy did not endorse extracorporeal life support for lack of cohort data. We studied all pregnancy and peripartum cases of extracorporeal life support in 1 medical center (n = 11), including collapse due to infection (n = 6, 55%), thromboembolism (n = 3, 27%), and cardiac disease (n = 2, 18%). Half of the cases (n = 5, 45%) involved extracorporeal cardiopulmonary resuscitation. Most mothers survived (n = 7, 64% [95% confidence interval, 32%-88%]). Deaths were attributable to oxygenator blockage (n = 1) and late sepsis (n = 3). The 2 unique clinical challenges were maintenance of high peripartum cardiac outputs and balancing anticoagulation with hemostasis. (C) 2017 International Anesthesia Research Society

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High-Sensitivity Cardiac Troponin T Improves the Diagnosis of Perioperative MI.

BACKGROUND: The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. We hypothesized that using a recently introduced novel high-sensitivity cTnT (hscTnT) assay would increase the detection rate of perioperative MI. METHODS: In this ancillary study of the Vitamins in Nitrous Oxide trial, readjudicated incidence rates of myocardial injury (new isolated cTn elevation) and MI were compared when diagnosed by contemporary cTnI versus hscTnT. We probed various relative (eg, >50%) or absolute (eg, +5 ng/L) hscTnT change metrics. Inclusion criteria for this ancillary study were the presence of a baseline and at least 1 postoperative hscTnT value. RESULTS: Among 605 patients, 70 patients (12%) had electrocardiogram changes consistent with myocardial ischemia; 82 patients (14%) had myocardial injury diagnosed by contemporary cTnI, 31 (5.1%) of which had an adjudicated MI. After readjudication, 67 patients (11%) were diagnosed with MI when using hscTnT, a 2-fold increase. Incidence rates of postoperative myocardial injury ranged from 12% (n = 73) to 65% (n = 393) depending on the hscTnT metric used. Incidence rates of MI using various hscTnT change metrics and the presence of ischemic electrocardiogram changes, but without event adjudication, ranged from 3.6% (n = 22) to 12% (n = 74), a >3-fold difference. New postoperative hscTnT elevation, either by absolute or relative hscTnT change metric, was associated with an up to 5-fold increase in 6-month mortality. CONCLUSIONS: The use of hscTnT compared to contemporary cTnI increases the detection rate of perioperative MI by a factor of 2. Using different absolute or relative hscTnT change metrics may lead to under- or overdiagnosis of perioperative MI. (C) 2017 International Anesthesia Research Society

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Bispectral Index Measurements Are Not Degraded During Aeromedical Evacuations.

For a decade, depth of anesthesia monitoring has become a reality in the operating room. It provides valuable help for managing anesthesia, especially for unstable patients. This might be particularly relevant during aeromedical evacuation. In this study, we aimed to assess the validity of the bispectral index (BIS) during long-range patient transportation aboard fixed-wing aircraft. BIS was recorded in 30 patients, 25 under anesthesia and 5 awake, during aeromedical evacuations performed by the French Air Force. BIS index was available and analyzable (signal quality index above 50%) more than 90% of time. Despite potential pitfalls related to mechanical or electrical interference, BIS monitor can be reliably used to monitor depth of anesthesia during individual strategic aeromedical evacuations. (C) 2017 International Anesthesia Research Society

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Perioperative Fluid Management.

No abstract available

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Organizational Contributors to the Variation in Red Blood Cell Transfusion Practices in Cardiac Surgery: Survey Results From the State of Michigan.

BACKGROUND: While large volumes of red blood cell transfusions are given to preserve life for cardiac surgical patients, indications for lower volume transfusions (1-2 units) are less well understood. We evaluated the relationship between center-level organizational blood management practices and center-level variability in low volume transfusion rates. METHODS: All 33 nonfederal, Michigan cardiac surgical programs were surveyed about their blood management practices for isolated, nonemergent coronary bypass procedures, including: (1) presence and structure of a patient blood management program, (2) policies and procedures, and (3) audit and feedback practices. Practices were compared across low (N = 14, rate: 0.8%-10.1%) and high (N = 18, rate: 11.0%-26.3%) transfusion rate centers. RESULTS: Thirty-two (97.0%) of 33 institutions participated in this study. No statistical differences in organizational practices were identified between low- and high-rate groups, including: (1) the membership composition of patient blood management programs among those reporting having a blood management committee (P= .27-1.0), (2) the presence of available red blood cell units within the operating room (4 of 14 low-rate versus 2 of 18 high-rate centers report that they store no units per surgical case, P= .36), and (3) the frequency of internal benchmarking reporting about blood management audit and feedback practices (low rate: 8 of 14 versus high rate: 9 of 18; P= .43). CONCLUSIONS: We did not identify meaningful differences in organizational practices between low- and high-rate intraoperative transfusion centers. While a larger sample size may have been able to identify differences in organizational practices, efforts to reduce variation in 1- to 2-unit, intraoperative transfusions may benefit from evaluating other determinants, including organizational culture and provider transfusion practices. (C) 2017 International Anesthesia Research Society

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Warning criteria for intraoperative neurophysiologic monitoring.

Purpose of review: Intraoperative changes in somatosensory (SEP) and motor evoked potentials (MEPs) may indicate potential injury to the spinal cord and will require timely intervention to prevent permanent damage. This review focuses on the validity of currently recommended warning criteria for intraoperative evoked potential monitoring. Recent findings: Current guideline recommends a decrease in SEP amplitude by 50% and MEP amplitude by 50-100% as warning signals for injury to the ascending sensory and descending motor pathway, respectively. On the basis of cohort studies, the diagnostic accuracy of SEP and MEP to predict postoperative neurologic deficits was variable. Importantly, 0.1-4.1% of monitored patients suffered postoperative neurologic deficit despite apparently normal SEP and MEP recordings (i.e. false negative events). These data suggested that the true warning criteria may be lower than previously acknowledged. A systematic review of studies that reported changes in SEP or MEP monitoring and postoperative neurological outcome showed an association between changes in monitoring signals and postoperative neurological deficits. However, the confidence intervals were wide and it is not possible to determine a threshold value in SEP or MEP amplitude beyond which may indicate neurologic deficit. Summary: Current recommendations for warning criteria during intraoperative evoked potential monitoring are empirically derived. Until a threshold that predicts spinal cord injury can be accurately determined, it remains difficult to define the clinical utility of intraoperative neurophysiologic monitoring. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Regional anesthesia in diabetic peripheral neuropathy.

Purpose of review: The aim of this review is to summarize recent relevant literature regarding regional anesthesia in the diabetic neuropathic patient and formulate recommendations for clinical practice. Recent findings: Diabetic neuropathic nerves, but not nerves of diabetic patients per se, exhibit complex functional changes. As a result, they seem more sensitive to local anesthetics, and are more difficult to stimulate. When catheters are used postoperatively, diabetes is an independent risk factor for infection. Summary: The pathophysiologic mechanisms underlying diabetic polyneuropathy are complex. Several pathways are thought to contribute to the development of diabetic neuropathy, triggered most importantly by chronic hyperglycemia. The latter induces inflammation and oxidative stress, causing microvascular changes, local ischemia and decreased axonal conduction velocity. Regional anesthesia is different in patients with diabetic neuropathy in several regards. First, the electric stimulation threshold of the nerve is markedly increased whereby the risk for needle trauma in stimulator-guided nerve blocks is theoretically elevated. Second, the diabetic nerve is more sensitive to local anesthetics, which results in longer block duration. Third, local anesthetics have been conjectured to be more toxic in diabetic neuropathy but the evidence is equivocal and should not be a cause to deny regional anesthesia to patients with a valid indication. Lastly, when peripheral nerve catheters are used, diabetes is an independent predisposing factor for infection. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Acupuncture for chronic pain: an update and critical overview.

Purpose of review: Acupuncture is now recommended for several chronic pain conditions. Despite supportive evidence of its effectiveness, this ancient approach is often misunderstood, and may still be underused in mainstream practice. A critical review on its effectiveness and practice integration, and mechanisms of action is essential to the medical community that is continuing to seek nonopioid therapies for chronic pain. Recent findings: Mounting evidence supports the effectiveness of acupuncture to treat chronic low back, neck, shoulder, and knee pain, as well as headaches. Additional data are emerging that support the use of acupuncture as an adjunct or alternative to opioids, and in perioperative settings. Findings related to its mechanisms of action include transient receptor potential cation channel vanilloid 1 activation in the periphery, microglial suppression in the cerebral cortex and spinal cord, and regulation of cytokines and other key inflammatory factors in the spinal cord. Incremental integration of acupuncture into pain medicine practices and training programmes continues to grow. Summary: Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. Further studies on its use as an adjunct or alternative to opioids, and in perioperative settings are needed. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Coagulation management in patients undergoing neurosurgical procedures.

Purpose of review: Management of coagulation in neurosurgical procedures is challenging. In this contest, it is imperative to avoid further intracranial bleeding. Perioperative bleeding can be associated with a number of factors, including anticoagulant drugs and coagulation status but is also linked to the characteristic and the site of the intracranial disorder. The aim of this review will be to focus primarily on the new evidence regarding the management of coagulation in patients undergoing craniotomy for neurosurgical procedures. Recent findings: Antihemostatic and anticoagulant drugs have shown to be associated with perioperative bleeding. On the other hand, an increased risk of venous thromboembolism and hypercoagulative state after elective and emergency neurosurgery, in particular after brain tumor surgery, has been described in several patients. To balance the risk between thrombosis and bleeding, it is important to be familiar with the perioperative changes in coagulation and with the recent management guidelines for anticoagulated patients undergoing neurosurgical procedures, in particular for those taking new direct anticoagulants. We have considered the current clinical trials and literature regarding both safety and efficacy of deep venous thrombosis prophylaxis in the neurosurgical population. These were mainly trials concerning both elective surgical and intensive care patients with a poor grade intracranial bleed or multiple traumas with an associated severe traumatic brain injury (TBI). Summary: Coagulation management remains a major issue in patients undergoing neurosurgical procedures. However, in this field of research, literature quality is poor and further studies are necessary to identify the best strategies to minimize risks in this group of patients. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Myocardial infarction masquerading as myocarditis in a patient with factor V Leiden: unmasked with MR

We present a case of a 21-year-old man presenting with sharp left-sided chest pain. A CT pulmonary angiogram was negative, ECG was unremarkable and a mild troponin rise was observed. Myocarditis was suspected as the most likely diagnosis, particularly in view of the patient's previous diagnosis of myocarditis 3 years prior. A cardiac MRI was indicative of an acute mid-anterior myocardial infarction (MI) and an old inferior MI with an associated aneurysm. A subsequent angiogram revealed a subtotal occlusion in the second diagonal artery, likely precipitated by homozygous factor V Leiden.

This case illustrates the value of MRI in differentiating acute MI from myocarditis when clinical suspicion is low, as in this young patient with atypical chest pain. Further, it demonstrates the value of MRI in detecting previous MIs and reinforces the importance of searching for precipitants of MI in young patients.

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Primary greater omental GIST presenting with acute intra-abdominal haemorrhage

Primary omental gastrointestinal stromal tumours (GISTs) are classified as extra-GISTs with a reported incidence of <1% of all GISTs. There are only a few cases in the English literature reporting omental GIST with none reporting acute intra-abdominal haemorrhage as a presenting feature. We report a case of a 67-year-old man who presented with haemorrhage from a primary omental GIST requiring emergency laparotomy.

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Disseminated cryptococcosis in an immunocompetent patient

Cryptococcosis is a fungal infection which is commonly associated with immune-compromised state. Disseminated infection in immunocompetent individuals is extremely rare. We present a case of a 56-year-old African American patient who presented with unilateral knee pain and swelling and was subsequently diagnosed with cryptococcal bone mass with dissemination of infection.

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Catastrophic cervical spinal injury in an amateur college wrestler

A young amateur wrestler presented with a burst fracture of the seventh cervical vertebra with complete paraplegia. He was treated with surgery for spine stabilisation and was actively rehabilitated. Adolescents and teenagers are indulging in high-contact sports like wrestling, without proper training and technical know-how, which can lead to severe injuries and possibly, permanent handicap or death. Trainers, assistants and institutions should be well equipped to diagnose and provide initial care of people with a spinal injury to prevent a partial injury from progressing to complete injury. Athletes, coaches and the public should be aware of methods of first aid and how to transport a patient with a cervical spine injury. Authorities should take steps to improve infrastructures in training institutions and ambulance services. Specialised spinal centres should be established throughout the country for management and rehabilitation of patients with paraplegia.

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Adult Wilms tumour: an illustration of multimodality imaging characteristics

Description

A 39-year-old woman was noted to have hypertension and a palpable abdominal mass at a routine general practitioner appointment. Her medical history was unremarkable.

An ultrasound of the abdomen demonstrated a large mass arising from the left kidney with a smooth echotexture and patchy areas of signal heterogeneity (figure 1).

Figure 1

Ultrasound: there is a large mass arising from the left kidney measuring 22x13 cm. The renal mass demonstrated poor intrinsic vascularity on power Doppler assessment.

A CT scan showed an expansile hypoenhancing solid tumour arising from the mid-upper pole of the left kidney (figure 2).

Figure 2

Sagittal contrast enhanced CT: There is a large heterogeneous mass arising from the left kidney. The arrow points to normal renal parenchyma at the lower pole. The mid and upper poles of the left kidney are largely replaced...

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Effect of swallowing maneuver on fentanyl-induced coughing

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Persistent fever and right hypochondrium pain

Description

A 39-year-old patient was admitted to our hospital for 10 days fever (up to 40°C) with pain in the right hypochondrium. Abdominal echography performed at the onset of symptoms was normal. Blood tests showed C-reactive protein 311 mg/L, leucocytes count 24x10⁹ /L (neutrophils count at 19, 29x10⁹/L), bilirubin 1.1 mg/dL, lactate dehydrogenase (LDH) 254 U/L, aspartate aminotransferase (ASAT) 67 U/L, alanin aminotransferase (ALAT) 66 U/L, gammaGlutamyltransferase (gGT) 79 U/L and alkaline phosphatase 221 U/L. Chest X-ray showed an infiltrate in the right lung base. A diagnosis of pneumonia was made and treatment with cefuroxime started. Since fever and right hypochondrium pain persisted despite antibiotherapy for 5 days, abdominal CT scan was performed, which demonstrated a large hepatic mass of 10x7 cm (figure 1). Percutaneous drainage revealed a thick and brown liquid; 'chocolate-like' (figure 2). Complementary information came from anamnesis: the patient usually lives in Cambodia and he has had dysentery 3 months ago. Clinical and biological...

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Intracardiac mass from Burkitt's lymphoma in an immunocompromised patient: a very rare form of presentation

Description

A 64-year-old man presented at the emergency department for lipothymia, nausea and palpitations for a few days duration. He was diagnosed with HIV infection 10 years ago. He never was compliant with his antiretroviral therapy (ART).

Pertinent physical findings included tachycardia and tachypnoea. Laboratory work-up revealed elevated troponin 0.30 ng/mL, elevated brain natriuretic peptide (PBNP) 4435 pg/mL and elevated creatinine 1.8 mg/dL with urea in normal range (40 mg/dL). Blood exams revealed CD4+ T cell count of 47 cells/µL with HIV RNA copies of 213 025/mL. The chest CT scan showed thickening of the lateral slope of the right cardiac cavities and atrioventricular septum, with involvement of the pericardial cavity; three pericardiac ganglia close to the right atrium, the largest with 16 mm (figure 1A). The pelvic CT scan showed kidneys with small hyperdensal, peripheral foci, predominantly on the right (figure 1B). Transthoracic echocardiography demonstrated heterogeneous ecodense mass centred on the lateral...

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A rare case of spontaneous tracheal perforation

Description

A 25-year-old man presented with spontaneous surgical emphysema resulting in swelling of his upper torso, neck and face. He had an allogeneic bone marrow transplant (BMT) 1 year earlier for acute myeloid leukaemia, complicated by severe refractory chronic graft-versus-host disease (GVHD). The CT thorax demonstrated a tracheal defect causing pneumomediastinum, marked surgical emphysema and features of atypical pulmonary infection (figure 1). The flexible bronchoscopy confirmed the presence of two anterior perforations in the cervical trachea (figure 2). No samples were taken for microscopy as the patient desaturated during bronchoscopy and the procedure was abandoned.

Figure 1

CT thorax shows a defect in the anterior wall of the trachea causing pneumomediastinum and marked surgical emphysema. The lungs show patchy areas of ground-glass opacification suspicious of an atypical infection.

Figure 2

Bronchoscopy reveals two perforations in the anterior tracheal...

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A case of progressive orthopnoea and shoulder pain secondary to bilateral diaphragmatic paralysis

A 45-year-old man with a raised body mass index presented with an acute history of right lower chest pain and increasing breathlessness. C reactive protein, D dimer and cardiac echocardiography were negative, with mild bibasal atelectasis the only positive reported finding from erect chest X-ray and CT pulmonary angiogram. He was discharged with antibiotics for a chest infection. He remained severely breathless and was referred to the sleep-related breathing disorders clinic. He described shoulder pain, daytime tiredness and sleeping upright due to a ââ'¬Ëœsuffocatingââ'¬â"¢ sensation. The video demonstrates the clinical findings. The CT topogram confirmed bilateral diaphragmatic paralysis. Spirometry demonstrated an 80% reduction in forced vital capacity in the supine position, when compared with erect. Consultation with a neurologist yielded the diagnosis of neuralgic amyotrophy, leading to bilateral diaphragmatic paralysis. The respiratory symptoms have been controlled with night-time non-invasive ventilation, allowing him to sleep supine.

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A reminder of Escherichia coli sepsis-induced reversible cardiomyopathy

Cardiomyopathy is a progressive disease of myocardium causing either mechanical or electrical disturbances. Sepsis-induced cardiomyopathy (SICM) is an entity of cardiomyopathy which is reversible in 1â"2 weeks after recovery from sepsis or septic shock. SICM is thought to have unpredictable cumulative mortality towards sepsis but its exact mechanism remains elusive. We report a case of Escherichia coli SICM in a 63-year-old woman presented with sudden onset of dyspnoea on exertion and orthopnoea following nausea, vomiting and diarrhoea after consuming Chinese foods. Transthoracic echocardiogram revealed severely reduced global left ventricular ejection fraction (LVEF) of <20%âwhich returned back to normal LVEF of 57% after 10 days. Subsequent cardiac catheterisation showed non-obstructive coronaries. No specific therapy intended for reversal of SICM presents to date despite current sepsis survival guideline available for haemodynamic support. Initiation of beta blockers after recovery from septic shock has been beneficial.

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Hyperacute muscle weakness in an unusual coexistence of antisignal recognition particle and anti-Mi-2 antibodies

Idiopathic inflammatory myopathies are a heterogeneous group of systemic diseases characterised by variable phenotypes of chronic progressive muscle weakness. Myositis-specific antibodies (MSAs) include antibodies to cytoplasmic signal recognition particle (SRP) and various tRNA synthetases as well as the nuclear helicase protein Mi-2. These antibodies are typically found only in a fraction of true myositis cases and they tend to be mutually exclusive. Few cases of coexistence of two MSAs in the same patient have been reported and these cases all involve an antisynthetase antibody coexisting with either anti-SRP or anti-Mi-2 antibody. Peculiar clinical manifestations may be associated with different combinations of MSAs but the rarity of these cases makes their characterisation difficult. We report the first ever case of anti-SRP and anti-Mi-2 copositive polymyositis in a 19-year-old boy who presented with a week history of profound muscle weakness that attained its peak within 24âhours of onset.

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Giant schwannomas of the sciatic nerve

We report a very rare case of giant schwannomas of the sciatic nerve in a 39-year-old woman who presented with increasing swelling and discomfort in the posterior aspect of her right thigh. We demonstrate that even with such large tumours, surgical excision could be successfully carried out to resolve all symptoms while causing no permanent nerve damage. It remains paramount that large soft tissue tumours get referred to a sarcoma centre and be managed by a specialist multidisciplinary team.

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Is the mechanism of re-expansion pulmonary oedema in a heart-lung interaction?

The mechanism of re-expansion pulmonary oedema (Re-PE) is unclear. There are multiple variables in play when evaluating the response to evacuation of pleural fluid. We present an educational case of a critically ill patient admitted for respiratory failure who was fully dependent on ventricular pacing set at a constant rate throughout the episode of Re-PE. The transthoracic echocardiography (TTE) showed an ejection fraction of 38%, moderate mitral regurgitation (MR), mildly dilated right ventricle and moderate pulmonary hypertension. A pleural tap evacuated 850 mL of transudate, which was followed by tachypnoea and deteriorating oxygenation. Another repeat TTE revealed a Re-PE with elevated left ventricular end-diastolic pressure, severe MR, increased pulmonary hypertension and a decrease in stroke volume. There were no parallel changes in ventilation modality, heart rate, fluid therapy and vasopressor dosage. The treatment was initiated with dobutamine. The patient was extubated the next day and was later discharged to the cardiology department.

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