Clinical management of quadriplegia in low and middle-income countries: a patients road to physiotherapy, prostheses and rehabilitation

Here we discuss the follow-up case of a 27-year-old male patient from rural Philippines, who was neglected by local health services after losing all four of his limbs as a result of a high-voltage electrical accident. The case follows the patient's road to accessing prostheses, rehabilitation health services and physiotherapy. Significant disparities were found between the government health services and the private sector with respect to quality, accessibility and affordability. Access to affordable healthcare is a basic human right that must be a priority for low-income and middle-income countries.

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Successful management of persistent distressing neuropsychiatric symptoms by clozapine in a patient suffering from dementia with Lewy bodies

Dementia with Lewy bodies (DLB) is the second most common neurodegenerative dementia associated with poor prognosis and high carers' burden. Neuropsychiatric symptoms worsen this prognosis and are a high source of distress for service users and their carers. However, there is currently insufficient evidence to support the pharmacological and non-pharmacological management of these symptoms. Acetylcholinesterase inhibitors are the first-line pharmacological option, but challenging risky behaviours may persist despite their use. Antipsychotic medications are indicated in such clinical scenarios, but there is very limited evidence to support the efficacy and safety of these medications for managing neuropsychiatric symptoms in DLB. Hence, we report an individual with DLB with severe distressing persistent visual hallucinations and agitation. After multiple treatment options had failed, clozapine was successfully initiated with substantial improvement in both clinical and functional outcomes. Further studies are warranted for evaluating the efficacy of clozapine in managing neuropsychiatric symptoms in DLB.

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Linezolid-induced pancytopenia

Linezolid is a bacteriostatic antibiotic of the Oxazolidinone class; it works by inhibiting the initiation of protein synthesis on bacterial ribosomes. Due to its excellent bioavailability after oral dosing, it has become an important tool in combating multi-drug-resistant bacteria including glycopeptide-resistant enterococci and methicillin-resistant Staphylococcus aureus. Side effects are multiple and potentially serious. We report the case of an 87-year-old man who developed pancytopenia secondary to a 6-week course of linezolid. Withdrawal of the antibiotic was decided as the treatment and resolution of the pancytopenia was evident within 2 weeks. Clinicians should be aware of this side effect of linezolid therapy and that weekly full blood count monitoring is paramount.

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Calvarial osteomyelitis and intracranial extension post-Mohs micrographic surgery

Mohs micrographic surgery (MMS) is a specialised micrographic technique used for the treatment of locally invasive skin cancers. Despite being a relatively low risk surgery, the overall complication rates range between 1.6% and 3%. Common complications include postoperative haemorrhage, haematoma formation, wound infection, wound dehiscence and flap/graft necrosis. Osteomyelitis after dermatological cancer surgery is exceedingly rare. There have only been two cases of osteomyelitis in association with Mohs surgery reported in the literature to date. Here, we describe an epidemiologically atypical patient who initially presented with fever and altered mental status and later found to have calvarial osteomyelitis, intracranial abscess (empyema) and meningoencephalitis as a result of Mohs surgery. Although rare, it is a predictable side effect postsurgery, and prevention of such complications are critical to decrease morbidity and mortality in patients undergoing MMS.

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Neurogenic pulmonary oedema complicating a lateral medullary infarct

Neurogenic pulmonary oedema (NPO) is a rare clinical syndrome of pulmonary oedema occurring secondary to an insult of the central nervous system (CNS). The exact aetiology of this disorder is unknown. NPO can be fatal and poor awareness and identification of this entity, particularly in terms of misdiagnosis as primary pulmonary or cardiac disease, can result in suboptimal management and outcomes. We describe the presentation and management of a 68-year-old woman with an acute left lateral medullary stroke complicated by pulmonary oedema. The likely aetiology is discussed, and important learning points are highlighted.

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Symptomatic pulmonary restriction secondary to diaphragmatic eventration and megacolon in adult

Description 

A 70-year-old woman with a medical history significant for toxic megacolon secondary to Clostridium difficile infection treated 40 years prior with partial colectomy and known diaphragmatic eventration presents with a 3-day history of progressive shortness of breath and dyspnoea on exertion. The patient had never previously been symptomatic nor suffered blunt trauma and had a strong personal conviction to avoid surgery. CT imaging revealed a massive left diaphragmatic displacement containing spleen, stomach and colon with mediastinal shift, compression of the left lung and a pericardial effusion (figure 1). Due to persistent tachycardia and presence of pericardial effusion on CT, a transthoracic echocardiogram was obtained, which demonstrated a large pericardial effusion concerning for tamponade physiology. The patient developed supraventricular tachycardia for which cardiology was consulted and two doses of adenosine were administered with resolution. The patient was upgraded to surgical intensive care and taken to the operating...

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Vessel wall enhancement by gadolinium-enhanced MRI in a patient with delayed stenosis after mechanical thrombectomy

Description 

Delayed stenosis of targeted vessels is a reported complication of stent retriever-based mechanical thrombectomy.1 We report a case of delayed stenosis with MRI findings that may be related to the underlying stenotic mechanism.

A 46-year-old woman was brought to our hospital with sudden left hemiparesis and unilateral spatial neglect. MRI revealed occlusion of the right middle cerebral artery (MCA) and acute cerebral infarction (figure 1A,B). Emergent mechanical thrombectomy was performed with one stent retriever pass following two aspiration catheter passes, and a red thrombus was retrieved (figure 1C,D). We thought that an embolism had caused the vessel occlusion as no abnormalities were visualised at the occluded site on day 2 (figure 1E). Despite detailed examinations, we could not determine the embolic source during the patient's hospitalisation, so we administered low-dose aspirin. She was discharged on day 46.

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Indapamide-induced bilateral choroidal effusion in pseudophakic patient.

We describe a case of indapamide-induced bilateral choroidal effusion, first time reported in pseudophakic patient, associated with no change in visual acuity and stable refraction.

A 70-year-old man was referred for ophthalmic assessment, with binasal visual field defect for 2 days. He had been started on treatment with indapamide 3 weeks earlier. His ophthalmic history included bilateral cataract surgery and intraocular lens implant. Fundal examination revealed bilateral choroidal effusions; B-scan ultrasonography was used to measure the extent of the choroidal detachment and the anterior chamber depth. Discontinuation of indapamide resulted in spontaneous resolution of choroidal effusion after 3 days. Our case is the first in the literature that describes bilateral choroidal effusion induced by indapamide in a pseudophakic patient. The lack of myopic shift likely resulted in a later presentation, enhancing the theory that lens thickening and/or accommodative spasm may play a crucial role in pathophysiology.

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Spontaneous disenclavation of phakic intraocular iris claw lens

Description 

A 35-year-old male patient came to the outpatient department with sudden onset painless diminution of vision and diplopia in RE since last 3 days. The vision was 20/200 in the RE and 20/20 in the LE. The patient was a known case of myopia with history of phakic eye iris claw intraocular lens (IOL) of both eyes done 12 years back. There was no history of trauma. His best-corrected visual acuity in the right eye was 20/20 with –3DS, –0.50DC x 90 in the OD. The intraocular pressure in the OD was 13 mm Hg and 15 mm Hg in the OS. On slit lamp examination nasal disenclavation of the iris claw lens was noted, the edge of which was bisecting the non-dilated pupillary plane. The IOL was hanging inferiorly with the optic touching the corneal endothelium inferiorly and with the other end fixed at the 9 o'clock position (figure 1). The cornea...

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POEMS syndrome: diagnostic delay and successful treatment with lenalidomide, cyclophosphamide and prednisone followed by autologous peripheral stem cell transplantation

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (POEMS) syndrome is a rare systemic disease, often unrecognised in the primary care setting. POEMS syndrome is associated with plasma cell dyscrasias and upregulation of vascular endothelial growth factor leading to systemic oedema, papilloedema and pulmonary hypertension. A wide constellation of presenting symptoms often leads to late diagnosis. Unrecognised and untreated disease rapidly leads to death from neuropathic exhaustion or cardiopulmonary failure. Treatment is extrapolated from other plasma cell dyscrasias such as multiple myeloma. Autologous peripheral blood stem cell transplantation (PBSCT) is often an important component of treatment. There is no established standard of care for POEMS syndrome. Therapies include lenalidomide, bortezomib and targeted monoclonal antibodies. We present a patient with POEMS syndrome who achieved rapid complete response to triple therapy consisting of lenalidomide, cyclophosphamide and prednisone, followed by high-dose chemotherapy and PBSCT.

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An Ultrasound-Guided Lateral Approach for Proximal Sciatic Nerve Block: A Randomized Comparison With the Anterior Approach and a Cadaveric Evaluation

Background and Objectives The lateral and anterior approaches for proximal sciatic nerve (SN) block can be used in patients lying supine. We assume that the posterior femoral cutaneous nerve (PFCN) is simultaneously blocked more often via the lateral approach than via the anterior approach, given the proximity of these 2 nerves at the injection level. However, locating the SN is difficult when using the original landmark-based lateral approach. We have introduced ultrasound guidance to alleviate the technical difficulty of the lateral approach and tested the hypothesis that an ultrasound-guided lateral approach would achieve PFCN block more often than the ultrasound-guided anterior approach for SN block. Methods Forty consecutive patients undergoing knee surgery were randomly allocated to receive an SN block using an ultrasound-guided lateral or anterior approach. The primary outcome was the frequency of PFCN block 30 minutes after SN block. Secondary outcomes included the frequency of SN block, nerve depth, needle depth, and time taken to perform the block. We also assessed the spread of injectate by the lateral approach in 4 cadaveric legs. Results The frequency of PFCN block 30 minutes after SN block was higher with the lateral approach than with the anterior approach (60% vs 15%, P = 0.008). The frequency of SN block was comparable between the groups. Dye reached the PFCN in all cadaveric specimens. Conclusions The ultrasound-guided lateral approach for proximal SN block can be performed as successfully as the anterior approach and provides PFCN block more often than the anterior approach. Clinical Trial Registration: This study was registered at UMIN Clinical Trials Registry, identifier UMIN000026748. Accepted for publication March 25, 2018. Address correspondence to: Takayuki Yoshida, MD, PhD, Department of Anesthesiology, Kansai Medical University Hospital, 2-3-1 Shin-machi, Hirakata-city, Osaka 573-1191, Japan (e-mail: ytaka@mac.com). The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Dexamethasone concentration affecting rocuronium-induced neuromuscular blockade and sugammadex reversal in a rat phrenic nerve-hemidiaphragm model: An ex vivo study

BACKGROUND The concentration range of dexamethasone that inhibits neuromuscular blockade (NMB) and sugammadex reversal remains unclear. OBJECTIVE To evaluate the effects of dexamethasone on rocuronium-induced NMB and sugammadex reversal. DESIGN Ex vivo study. SETTING Asan Institute for Life Sciences, Asan Medical Center, Korea, from July 2015 to November 2015. ANIMALS One hundred sixty male Sprague–Dawley rats. INTERVENTIONS We assessed the effect of four concentrations of dexamethasone [0, 0.5, 5 (clinical concentrations) and 50 μg ml−1 (experimental concentration)] on partial NMB on 40 phrenic nerve–hemidiaphragm preparations (n=10 per concentration). Once the first twitch of train-of-four (TOF) had been depressed by 50% with rocuronium, dexamethasone was administered. To assess the effect of dexamethasone on sugammadex reversal, 120 phrenic nerve–hemidiaphragm preparations were used in three subexperiments (n=40 per experiment), using three administration regimens of rocuronium–equimolar sugammadex: a single dose, a split-dose (split 1/2 and 1/2) and a reduced split-dose (split 1/2 and 1/4). After complete NMB was achieved, dexamethasone and sugammadex were administered. MAIN OUTCOME MEASURES The change in the first twitch height, the recovery time to a TOF ratio at least 0.9, and the TOF ratio at 30 min were evaluated. RESULTS There were no significant differences in the first twitch height among groups (P = 0.532). With a single dose of sugammadex, dexamethasone did not affect the recovery time to a TOF ratio at least 0.9 (P = 0.070). After using a split-dose of sugammadex, the recovery time to a TOF ratio at least 0.9 was delayed only at a concentration of 50 μg ml−1 of dexamethasone. With a reduced split-dose of sugammadex, the TOF ratio at 30 min was lowered only by a concentration of 50 μg ml−1 of dexamethasone (P 

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