Seronegative Autoimmune Hepatitis A Clinically Challenging Difficult Diagnosis

Autoimmune hepatitis (AIH) is a complex liver disease of unknown cause which results in immune-mediated liver injury with varied clinical presentations. Seronegative AIH follows a similar course to autoantibody-positive disease and diagnosis may be challenging. There are no single serologic tests of sufficient diagnostic specificity, and delay in appropriate treatment may lead to progression of the liver disease and liver failure. The revised conventional diagnostic criteria (RDC) scoring for AIH is complex and not routinely used in the clinical practice. The more recent simplified diagnostic criteria (SDC) scoring proposed by International Autoimmune Hepatitis Group in 2008 has wider application in routine practice facilitating the diagnosis of AIH with a specificity and sensitivity of ~90%. In this report, we describe a case of seronegative autoimmune hepatitis diagnosed using RDC. SDC score calculated in our case was 4 and was not diagnostic for AIH. We subsequently used the complex revised diagnostic criteria for definitive diagnosis. Some of the patients previously diagnosed as cryptogenic active hepatitis of unknown etiology probably had an unrecognized diagnosis of seronegative autoimmune hepatitis. SDC scoring may not be applicable in patients with seronegative autoimmune hepatitis. These patients should be reassessed by using RDC.

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Partial response of pulmonary adenocarcinoma with symptomatic brain metastasis to nivolumab plus high-dose oral corticosteroid: a case report

Nivolumab, a monoclonal antibody targeting the programmed death-1 receptor, is indicated in locally advanced or metastatic non-small cell lung cancer, with progression after platinum-based chemotherapy. Up-to-...

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Idiopathic abdominal cocoon: a rare presentation of small bowel obstruction in a virgin abdomen. How much do we know?

Abdominal cocoon is an extremely rare condition that has been mainly associated with young adolescent women. It was first described in 1978 by Foo et al. We present here a case that describes an otherwise healthy adult man who presented with intestinal obstruction and was found to have an abdominal cocoon, also known as a peritoneal sac. The patient was taken for a laparotomy and the sac was released through blunt dissection along the avascular planes. He was discharged in good condition 3 days postoperatively. We discuss some of the current literature and previously reported cases on this condition.

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Two otherwise healthy young brothers present with intermittent claudication, just a coincidence?

Popliteal artery entrapment syndrome (PAES) is a recognised cause of lower limb peripheral arterial disease in young adults. We describe the cases of two otherwise healthy brothers who presented with the condition 5 years apart. The first brother, who is also the first author of this case report, presented aged 19 with worsening, right-sided, exercise-induced lower leg pain and transient foot pallor. Imaging confirmed PAES and irreversible localised arterial damage. Surgery was performed to release the entrapment and resect the section of diseased artery. The limb was revascularised using an autologous interposition saphenous vein graft. The second brother began experiencing left-sided, exercise-induced lower leg pain aged 24. Again, imaging revealed PAES and irreversible arterial damage. A similar revascularisation procedure was performed. Both siblings fully recovered and are symptom free. Arterial duplex scans have confirmed patent grafts. A correlation in siblings has only been reported in the literature five times previously.

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Black swans: challenging the relationship of anaesthetic-induced unconsciousness and electroencephalographic oscillations in the frontal cortex

The study of general anaesthesia and electroencephalographic oscillations in the frontal cortex spans at least four decades, with several notable findings:

• In 1977, Tinker and colleagues¹ proposed, based on studies of the nonhuman primate, that anteriorization—the shift of electroencephalographic power from posterior cortex to frontal cortex—correlated with unresponsiveness during general anaesthesia.
• In the early 1990s, Steriade contributed to our understanding of the neurophysiology of sleep and general anaesthesia in animals, including descriptions of three distinct oscillations involving corticothalamic networks: a slow rhythm at < 1 Hz, a delta rhythm at 1-4 Hz, and a faster theta/alpha rhythm at 7-14 Hz.²³
• In the mid-1990s, the shift of alpha oscillations to more anterior structures was identified during both propofol sedation⁴ and isoflurane/nitrous oxide anaesthesia.⁵
• In 2001, anteriorized alpha and slow-wave activity was posited by John and colleagues⁶ to be an agent-invariant marker of anaesthetic-induced unconsciousness, based on a study of 176 surgical patients.
• In 2004, the disappearance of occipital alpha oscillations and shift to high-power frontal alpha oscillations was found to be associated with propofol-induced unconsciousness in healthy human participants.⁷
• In 2013, Purdon and colleagues⁸ found, using high-density electroencephalography in human volunteers, that anteriorization of alpha and phase-amplitude coupling patterns correlated with propofol-induced unconsciousness.
• In 2014, both propofol and sevoflurane anaesthesia were found to be associated with anterior alpha and slow oscillations in surgical patients.⁹

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Beating, Fast and Slow

Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 52-year-old man presented to his…

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Anesthesia for Heart Transplantation

Publication date: Available online 5 July 2017
Source:Anesthesiology Clinics
Author(s): Davinder Ramsingh, Reed Harvey, Alec Runyon, Michael Benggon

Teaser

This review seeks to evaluate current practices in heart transplantation. The goals of this article were to review current practices for heart transplantation and its anesthesia management. The article reviews current demographics and discusses the current criteria for candidacy for heart transplantation. The process for donor and receipt selection is reviewed. This is followed by a review of mechanical circulatory support devices as they pertain to heart transplantation. The pre-anesthesia and intraoperative considerations are also discussed. Finally, management after transplantation also is reviewed.


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