An unusual cause of toe necrosis

Peripheral vascular disease is a rare feature of pheochromocytoma. This potentially catastrophic but curable tumor should be suspected in combination of distal necrosis with hypertension and palpable pulses. We report such an unusual case of pheochromocytoma presenting as toe necrosis.

Transient neuronal injury followed by intravascular injection during an ultrasound guided stellate ganglion block

Ultrasound guidance for pain interventions is becoming increasing recognized as a useful imaging tool. One of the common interventions where it is gaining wider acceptance is during the performance of a stellate ganglion block. The following is a unique report where intravascular and neuronal injury occurred during the performance of an ultrasound guided stellate ganglion block followed by dysphagia. 41 year old male, with a diagnosis of complex regional pain syndrome, was referred to our clinic for further management. He underwent a diagnostic ultrasound guided stellate ganglion block after having tried conservative therapies. The stellate ganglion block provided him with complete pain relief for over five weeks. During a subsequent therapeutic stellate ganglion block, performed by an experienced pain medicine fellow with more than 50 ultrasound guided proceduresclinician, the patient developed a transient injury to the brachial plexus upon needle entry. Subsequent redirection and injection of an ml of injectate resulted in an intravascular injection producing tinnitus. After the tinnitus decreased, he underwent another stellate block using an out of plane approach without any further complications. Two days later, he reported chest and throat discomfort which resolved over the next few days possibly due to a retropharyngeal hematoma. He declined further interventions and was subsequently managed with 3 tablets of oxycodone a day. This report highlights the importance of vigilance and meticulous planning during the performance of ultrasound guided pain interventions.

Airway difficulty in Mallampati 'class zero' patients: a prospective double-blind observational study

CONTEXT

Assessment of Mallampati class is an integral part of preoperative airway evaluation. Increasing Mallampati class is known to be associated with greater difficulty with intubation, but some cases of airway difficulty in Mallampati 'class zero' patients have been reported.

OBJECTIVE(S)

We undertook this study to evaluate intubation difficulty and to correlate this with indirect laryngoscopy findings in Mallampati class zero patients. The incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation were also evaluated.

DESIGN

Prospective double-blind observational study.

SETTING

A tertiary care medical college hospital in Karnataka, India.

STUDY PERIOD

September 2010 to April 2011.

PATIENTS

Patients of either sex, 18 years and older, presenting for preanaesthetic examination for elective surgery were evaluated. All patients with Mallampati class zero airway undergoing general anaesthesia with tracheal intubation were included. Exclusion criteria were upper airway disorder, unstable cervical spine, increased risk for aspiration, ischaemic heart disease, increased intracranial pressure, respiratory distress, those unable to sit upright, or infected with hepatitis B, hepatitis C, HIV or pulmonary tuberculosis, or requiring emergency surgery. All underwent indirect laryngoscopy performed by the otorhinolaryngologist and subsequently, direct laryngoscopy performed by the anaesthesiologist. Intubation difficulty was assessed by the Cormack & Lehane grades.

MAIN OUTCOME MEASURES

Evaluation of intubation difficulty and correlation with indirect laryngoscopy findings in Mallampati class zero patients. Estimation of the incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation.

RESULTS

Twenty women and thirteen men, aged 18-65 years, of Mallampati class zero were identified out of 1937 (incidence, 1.7%). The data of 27 patients were analysed. Two patients had 'difficult' mask ventilation. All had a 'predicted easy' airway on indirect laryngoscopy and 'easy' (Cormack & Lehane grade 1 or 2) tracheal intubation. Upon direct laryngoscopy, the epiglottis was described as 'large' in 10 (37%) patients.

CONCLUSION

A Mallampati class zero per se is not associated with difficult airway unless other airway characteristics contribute to the difficulty. Even though the epiglottis may be large and overhanging, it rarely causes airway difficulty in Mallampati class zero airway.

Assessment of skin test with varicella-zoster virus antigen for predicting the risk of herpes zoster

The Shozu Herpes Zoster (SHEZ) Study was designed to clarify the incidence of and predictive and immunological factors for herpes zoster in a defined community-based Japanese population. As part of this series, a total of 5683 residents aged ⩾50 years received a varicella-zoster virus (VZV) skin test with VZV antigen, and 48 h later, the erythema and oedema were assessed by measuring the longest diameter. The diameters of both the erythema and oedema decreased with the increasing age of the subject. Sixty-three subjects contracted herpes zoster within a year after receiving the VZV skin test. Analysis of the herpes zoster incidence ratevs.the skin test reaction revealed that the shorter the diameter of erythema or oedema, the greater the likelihood of herpes zoster. These results demonstrated that the VZV skin test is an excellent surrogate marker for predicting the risk of herpes zoster.

CT-guided stellate ganglion blockade vs. radiofrequency neurolysis in the management of refractory type I complex regional pain syndrome of the upper limb

OBJECTIVE

To describe and evaluate the feasibility and efficacy of CT-guided radiofrequency neurolysis (RFN) vs. local blockade of the stellate ganglion in the management of chronic refractory type I complex regional pain syndrome (CRPS) of the upper limb.

METHODS

Sixty-seven patients were included in this retrospective study between 2000 and 2011. All suffered from chronic upper limb type I CRPS refractory to conventional pain therapies. Thirty-three patients underwent stellate ganglion blockade and 34 benefited from radiofrequency neurolysis of the stellate ganglion. CT guidance was used in both groups. The procedure was considered effective when pain relief was ≥50 %, lasting for at least 2 years.

RESULTS

Thirty-nine women (58.2 %) and 28 men (41.8 %) with a mean age of 49.5 years were included in the study. Univariate analysis performed on the blockade and RFN groups showed a significantly (P < 0.0001) higher success rate in the RFN group (67.6 %, 23/34) compared with the blockade group (21.2 %, 7/33) with an odds ratio of 7.76.

CONCLUSION

CT-guided radiofrequency neurolysis of the stellate ganglion is a safe and successful treatment of chronic refractory type I CRPS of the upper limb. It appears to be more effective than stellate ganglion blockade.

KEY POINTS

• Complex regional pain syndrome is painful, disabling and often refractory to treatment. • Sixty-seven percent of patients had lasting pain relief (2 years) after radiofrequency neurolysis. • Retrospective study showed a significantly higher success rate for radiofrequency neurolysis. • CT guidance is mandatory for a successful and safe procedure.

Efficacy of ultrasonography guided stellate ganglion blockade in the stroke patients with complex regional pain syndrome

Objective

To compare the efficacy of ultrasonography guided stellate ganglion block (US-SGB) with that of blind SGB in management of the stroke patients with complex regional pain syndrome (CRPS) type 1.

Method

Forty-two patients with post-stroke CRPS were randomly assigned to either US-guided SGB (22 patients) or blind SGB group (20 patients). The mean age of US-guided SGB and blind SGB groups was 61.3±5.6 years and 59.1±4.5 years. We performed two blockades at 7-day intervals on the affected side of patients with CRPS. Pain intensity, using a visual analog score (VAS), score of CRPS clinical severity, and the amounts of affected hand swelling with a hand volumeter were assessed before, 2 weeks and 4 weeks after treatment.

Results

In both groups, VAS and the amount of hand swelling were significantly decreased after 2 weeks and after 4 weeks. Between two groups, VAS difference of US-guided SGB group and that of blind SGB group were 2.61±1.09, 1.88±0.62 at 2 weeks and 3.67±1.03, 3.13±0.62 at 4 weeks, respectively. US-guided SGB group showed more significant improvement in mean change of VAS compared to the blind SGB group (p-value<0.05).

Conclusion

Both US-guided SGB and blind SGB techniques were effective in relieving pain in subacute stroke patients with CRPS. US-guided SGB was better in pain relief but has no advantages in reduction of hand swelling in this study.

Minimal volume of local anesthetic required for an ultrasound-guided SGB

BACKGROUND

 Compared with the blind technique, ultrasound-guided stellate ganglion block (SGB) reduces the amount of local anesthetic needed for a successful block. The purpose of this study is to determine the minimal, optimal volume of local anesthetic required for successful ultrasound-guided SGB and to reduce its adverse effects.

METHODS

 Thirty-five patients with postherpetic neuralgia and complex regional pain syndrome of the upper extremity and the facial area were selected. For ultrasound-guided SGB by subfacial method, each patient was injected with 0.5% mepivacaine mixed with contrast media in 2 mL, 3 mL, and 4 mL doses at 2-week intervals. After the procedure, the spread of contrast media in the spine was checked by fluoroscopy. Ptosis and conjunctival flushing were rated and recorded. Adverse effects, such as hoarseness, foreign body sensation, swallowing difficulty, and upper arm weakness, were also recorded.

RESULTS

 Out of the 35 initial patients, the results for 33 patients who received all three SGBs were included in this study. The contrast media spread to 4.80 ± 0.82, 4.94 ± 0.86, and 5.09 ± 0.97 total spinal segments in the 2 mL, 3 mL, and 4 mL groups, respectively. The cephalad spread of contrast media was 2.16 ± 0.74, 2.23 ± 0.85, and 2.30 ± 0.78 spinal segments for the 2 mL, 3 mL, and 4 mL groups, respectively, and the caudad spread of contrast media was 2.64 ± 0.51, 2.70 ± 0.61, and 2.89 ± 0.64 segments in the 2 mL, 3 mL, and 4 mL groups, respectively. There were no significant statistical differences in any segments for the three groups (P > 0.05). Review of the fluoroscopic images showed spread of the contrast media below the C7-T1 junction in all three groups. Ptosis developed in all three groups after the procedure.

CONCLUSION

 In conclusion, when performing an ultrasound-guided SGB, 2 mL dosage was sufficient for a successful block as the previous, conventional volume. Therefore, when performing an ultrasound-guided SGB, we recommend the 2 mL dosage of local anesthetics for a successful block.

Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study

PURPOSE

Stellate (cervicothoracic) ganglion block (SGB) can be associated with serious complications, such as esophageal and vascular injury. The objective of this study was to evaluate the potential for vascular and esophageal injury in healthy subjects by examining the sonoanatomy of the neck relevant to the SGB at the sixth (C6) and seventh (C7) cervical vertebral levels and determining the incidence of blood vessels and esophagi in the simulated path of needle insertion in the conventional and two different ultrasound-guided approaches used to perform a SGB.

METHODS

Ultrasound scanning of the neck at the C6 and C7 cervical vertebral levels was performed in 100 adult subjects, and the following measurements were obtained: the degree of deviation of the esophagus relative to the larynx/trachea; the likelihood of encountering a vessel in the simulated path of needle insertion in the two different approaches to SGB; the incidence of the vertebral artery being situated outside the foramen transversarium at the C6 level; and the distance of the simulated path of needle insertion in the anterior and lateral approaches to SGB at the C6 level.

RESULTS

The position of the esophagus was found to be variable but lateral to the airway in 50% and 74% of the subjects at C6 and C7, respectively. The esophagus covered more than half of the distance between the airway and the carotid artery in 14% and 44% of the subjects at the C6 and C7 levels, respectively. With the anterior approach, a major vessel was observed in up to 29% and 43% of patients at the C6 and C7 levels, respectively. The vertebral artery was outside the foramen transversarium in 7% of subjects at the C6 level.

CONCLUSION

Major blood vessels and the esophagus are in close proximity to needle pathways during the anterior approach to SGB performed with either anatomic landmarking or fluoroscopic guidance. An ultrasound-guided lateral approach at the C6 level may possibly confer a greater margin of safety for performing SGB.

Varicella-zoster virus-specific enzyme-linked immunospot assay responses and zoster-associated pain in herpes zoster subjects

Varicella-zoster virus (VZV)-specific cell-mediated immunity (CMI) responses were compared over time following an episode of herpes zoster (HZ) with those of age-, race-, and gender-matched healthy controls (HC) without HZ, using a validated gamma interferon (IFN-γ) enzyme-linked immunospot (ELISPOT) assay. The zoster brief-pain inventory (ZBPI) was used to assess zoster-associated pain. HZ patients (n = 140) had significantly higher IFN-γ ELISPOT responses to VZV antigen than did HC (n = 140). ELISPOT geometric mean count (GMC) responses (with 95% confidence intervals [CI]) for subjects who presented within 72 h were as follows: for HZ patients ≥ 60 years of age, at day 0 the GMC was 110 and at week 2 the GMC was 235; for HZ patients 21 to 59 years of age, at day 0 the GMC was 111 and at week 2 the GMC was 198; for HC ≥ 60 years of age, at day 0 the GMC was 19 and at week 2 the GMC was 18; and for HC 21 to 59 years of age, at day 0 the GMC was 59 and at week 2 the GMC was 56. The mean pain score (95% CI) across age groups at 1 week postrash (n = 106) was 6.0 (5.5, 6.5) and at 2 weeks postrash (n = 119) was 3.5 (2.9, 4.0). The percentage of HZ patients with substantial pain (score ≥ 3) at 6 weeks postrash increased with age from 8% for patients 21 to 49 years of age to 16% for patients 50 to 59 years of age to 22% for patients ≥ 60 years of age. The VZV-specific CMI response was substantially boosted by an episode of HZ, as measured by ELISPOT results. Older adults had lower VZV-specific cellular immunity than younger subjects at baseline, but the boosting effect of HZ was substantial for all age groups. HZ patients experienced considerable zoster-associated acute (1 to 2 weeks after rash) pain across age groups, while chronic pain increased with age.

Thymoma removal in a cat with acquired myasthenia gravis: a case report and literature review of anesthetic techniques

HISTORY AND PRESENTATION: A 12 year old, 4.2 kg, domestic long hair, castrated male cat was presented with regurgitation, inability to retract the claws, general weakness, cervical ventroflexion and weight loss. A thymic mass was evident on radiographs. Acetylcholine receptor antibody titer was positive for acquired myasthenia gravis (MG). Thymectomy via midline sternotomy was scheduled. ANESTHETIC MANAGEMENT:  Oxymorphone and atropine were administered subcutaneously as premedication, and anesthesia was induced with etomidate and diazepam given intravenously to effect. The cat's trachea was intubated and anesthesia was maintained with isoflurane in oxygen, and continuous infusions of remifentanil and ketamine. Epidural analgesia with preservative-free morphine was administered prior to surgery. Postoperative analgesia was provided by oxymorphone subcutaneously, interpleural bupivacaine, and fentanyl infusion. Postoperative complications included airway obstruction, hypoxemia and hypercapnia.

FOLLOW-UP

The cat was discharged 3 days after surgery. Discharge medications included pyridostigmine and prednisone. Nine days after surgery, the cat had a significant increase in its activity level, and medications were discontinued. Histopathologically, the mass was consistent with a thymoma. Approximately 6 weeks later the cat became weak again and pyridostigmine and prednisone administration was resumed.

CONCLUSION

The perioperative management of patients with MG for transsternal thymectomy is a complex task. The increased potential for respiratory compromise requires the anesthesiologist to be familiar with the underlying disease state, and the interaction of anesthetic and non-anesthetic drugs with MG. Careful monitoring of ventilation and oxygenation is indicated postoperatively.

Experimental infection of Cynomolgus Macaques (Macaca fascicularis) with human varicella-zoster virus

Varicella-zoster virus (VZV) is a member of the alphaherpesvirus family and the causative agent of chickenpox and shingles. To determine the utility of cynomolgus macaques (Macaca fascicularis) as a nonhuman primate model to evaluate VZV-based simian immunodeficiency virus/human immunodeficiency virus (SIV/HIV) vaccines, we experimentally inoculated 10 animals with the parental Oka (Oka-P) strain of VZV derived from MeWo or Telo-RF cells. VZV DNA could be detected in the lungs as late as 4 days postinfection, with replicating virus detected by shell vial culture assay in one case. Infection did not result in any overt clinical symptoms but was characterized by humoral and cell-mediated immunity in a time frame and at a magnitude similar to those observed following VZV vaccination in humans. The cell line source of VZV inoculum influenced both the magnitude and polyfunctionality of cell-mediated immunity. Animals mounted a vigorous anamnestic antibody response following a second inoculation 12 weeks later. Inoculations resulted in transient increases in CD4(+) T-cell activation and proliferation, as well as a sustained increase in CD4(+) T cells coexpressing CCR5 and α4β7 integrin. In contrast to previous failed attempts to successfully utilize attenuated VZV-Oka as an SIV vaccine vector in rhesus macaques due to suboptimal infectivity and cellular immunogenicity, the ability to infect cynomolgus macaques with Oka-P VZV should provide a valuable tool for evaluating VZV-vectored SIV/HIV vaccines.

Complications after cardiovascular surgery in a case of undiagnosed spinal-bulbar muscular atrophy (Kennedy disease)

Neurodegenerative diseases are often associated with life-threatening declines in respiratory and swallowing mechanisms. We report the case of a 70-year-old man who had postoperative dysphagia and respiratory failure that required reintubation after coronary artery bypass surgery. Impairment of the patient's speech, swallowing, and respiratory mechanisms identified during postoperative clinical and instrumental examinations was suggestive of a neurodegenerative disease. Genetic testing confirmed a diagnosis of spinal-bulbar muscular atrophy (Kennedy disease). This case report aims to highlight increased morbidity in patients with undiagnosed neuromuscular disorders in the critical care setting and the benefits of vigilant postoperative monitoring and multidisciplinary involvement throughout the care of complex patients.

The Shozu Herpes Zoster (SHEZ) study: rationale, design, and description of a prospective cohort study

Background

The incidence and risk factors for herpes zoster have been studied in cross-sectional and cohort studies, although most such studies have been conducted in Western countries. Evidence from Asian populations is limited, and no cohort study has been conducted in Asia. We are conducting a 3-year prospective cohort study in Shozu County in Kagawa Prefecture, Japan to determine the incidence and predictive and immunologic factors for herpes zoster among Japanese.

Methods

The participants are followed for 3 years, and a telephone survey is conducted every 4 weeks. The participants were assigned to 1 of 3 studies. Participants in study A gave information on past history of herpes zoster and completed health questionnaires. Study B participants additionally underwent varicella-zoster virus (VZV) skin testing, and study C participants additionally underwent blood testing. If the participants develop herpes zoster, we evaluate clinical symptoms, measure cell-mediated immunity and humoral immunity using venous blood sampling, photograph skin areas with rash, conduct virus identification testing by polymerase chain reaction (PCR) and virus isolation from crust sampling, and evaluate postherpetic pain.

Results

We recruited 12 522 participants aged 50 years or older in Shozu County from December 2009 through November 2010. The participation rate was 65.7% of the target population.

Conclusions

The present study is likely to provide valuable data on the incidence and predictive and immunologic factors for herpes zoster in a defined community-based population of Japanese.

Delayed chest closure assessed by transesophageal echocardiogram in single-lobe lung transplantation

A 6-year-old girl with idiopathic interstitial pneumonia successfully underwent living-donor right single-lobe lung transplantation from her mother. Her mother's right lower lobe was 207% bigger than her right chest cavity, and attempting chest closure caused significant compression and narrowing of the right pulmonary vein anastomosis, as assessed by transesophageal echocardiogram. Her chest was temporarily closed without rib approximation. The following day, her chest could be completely closed. The pulmonary vein anastomosis, confirmed by transesophageal echocardiogram, was now patent. Currently, 7 months after the transplantation, she is well without limitations.

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy

Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon.

Anesthesia and myasthenia gravis

Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevoflurane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely.

Evaluation of effectiveness of stellate ganglion block (SGB) treatment of sudden hearing loss

CONCLUSION

A stellate ganglion block (SGB) based on the goal of improving internal ear circulatory disturbance appears to be beneficial for the treatment of sudden hearing loss.

OBJECTIVES

To evaluate the effectiveness of SGB for sudden hearing loss.

METHODS

This retrospective study reviewed the medical records of 49 patients who received SGBs and 496 patients who received only conservative therapy, primarily with systemic steroids, for treatment of sudden hearing loss. Propensity scores were used in pairwise matching of these patients to avoid selection biases between the two treatment modalities.

RESULTS

Propensity score matching yielded 48 pairs. The mean therapeutic effect of the SGB was calculated to be 0.40 ± 0.20 (mean ± standard error, p = 0.051).

Paradigm shifting vaccines: prophylactic vaccines against latent varicella-zoster virus infection and against HPV-associated cancer

We compare the design, mechanism of action, and clinical efficacy of two recently licensed paradigm shifting vaccines. Zostavax is the first vaccine licensed to prevent disease in patients already infected with a pathogen, and is contrasted with Gardasil and Cervarix, the first vaccines designed and licensed specifically to prevent cancers.

Management and prevention of herpes zoster: A Canadian perspective

Varicella-zoster virus reactivation leads to herpes zoster - the main complication of which is postherpetic neuralgia (PHN). Rapid antiviral therapy initiated within 72 h of rash onset has been shown to accelerate rash healing, reduce the duration of acute pain and, to some extent, attenuate the development and duration of PHN. Other adjunctive therapies such as analgesics, antidepressants and some anticonvulsants are frequently required in the management of severe PHN. A live, attenuated zoster vaccine has been recently shown to significantly decrease herpes zoster incidence, PHN and the overall burden of illness when administered to adults older than 60 years of age. This new prophylactic modality has been reported to be cost-effective in the Canadian context, especially in the 60- to 75-year-old age group.

Revalidation of a modified and safe approach of stellate ganglion block

Stellate ganglion block (SGB) is very effective in management of chronic regional pain syndrome (CRPS-1). However, serious complication may occur due to accidental intravascular (intra-arterial) injection of local anaesthetic agents. Abdi and others, has suggested a modified technique in which fluoroscopy-guided block is given at the junction of uncinate process and body of vertebra at C7 level. In this approach vascular structures remain away from the trajectory of needle and thus avoid accidental vascular injection. We have used this technique of SGB in nine patients who were treated for CRPS-I. The blocks were effective in all the patients all the time without any vascular or other serious complication.

The DRESS syndrome: a literature review

The Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a severe adverse drug-induced reaction. Diagnosing DRESS is challenging due to the diversity of cutaneous eruption and organs involved. We used the RegiSCAR scoring system that grades DRESS cases as "no," "possible," "probable," or "definite" to classify cases reported in the literature. We also analyzed the clinical course and treatments of the cases. A total of 44 drugs were associated with the 172 cases reported between January 1997 and May 2009 in PubMed and MEDLINE. The most frequently reported drug was carbamazepine, and the vast majority of cases were classified as "probable/definite" DRESS cases. Hypereosinophilia, liver involvement, fever, and lymphadenopathy were significantly associated with "probable/definite" DRESS cases, whereas skin rash was described in almost all of the cases, including "possible cases." Culprit drug withdrawal and corticosteroids constituted the mainstay of DRESS treatment. The outcome was death in 9 cases. However, no predictive factors for serious cases were found. This better knowledge of DRESS may contribute to improve the diagnosis and management of this syndrome in clinical practice.

Depth by ultrasound from skin surface to the C6 transverse process while applying pressure

BACKGROUND

A stellate ganglion block is commonly performed on the anterior tubercle of sixth cervical spine's transverse process. When the procedure is performed, identifying the anatomical landmarks and confirming the depth of the needle insertion to the transverse process are essential for ensuring safety. The purpose of this study was to determine the depth of the needle insertion from the skin to the transverse process for a safe stellate ganglion block.

METHODS

One hundred patients were enrolled for this study. The patients' heights, weights, and neck circumferences were measured. In the supine position, the anterior tubercle of the transverse process were palpated and pressed with the examiner's fingers. While spreading the fingers, an ultrasound probe was placed with the same strength as the fingers and the depth from the skin to the transverse process was measured.

RESULTS

The mean depth from the skin to the transverse process in men was 9.5 ± 2.7 mm on the left side and 9.7 ± 2.5 mm on the right side, whereas in women, it was 8.0 ± 2.2 mm on the left side and 8.2 ± 2.0 mm on the right side. There was no significant difference between the right and left sides among or between the genders but men showed greater depths than women. Although both genders showed a correlation between body mass index and depth, only men showed a correlation between the neck circumference and depth.

CONCLUSIONS

In this study, the mean depth from the skin to the transverse process did not exceed 10 mm in both genders and the maximum depth was 16.6 mm.

Less maintenance immunosuppression in lung transplantation following hematopoietic stem cell transplantation from the same living donor

Living-donor lobar lung transplantation (LDLLT) is one of the final options for saving patients with pulmonary complications after hematopoietic stem cell transplantation (HSCT). We retrospectively investigated 19 patients who had undergone LDLLT after HSCT in Japan. Eight patients underwent LDLLT after HSCT in which one of the donors was the same living donor as in HSCT (SD group), while 11 received LDLLT from relatives who were not the HSCT donors (non-SD group). In the SD group, three patients underwent single LDLLT. The 5-year survival rate was 100% and 58% in the SD and non-SD groups, respectively. In the SD group, postoperative immunosuppression was significantly lower than in the non-SD group. Two patients died of infection and one died of post-transplant lymphoproliferative disease (PTLD) in the non-SD group, while only one patient died of PTLD 7 years after LDLLT in the SD group. Hematologic malignancy relapsed in two patients in the non-SD group. For the three single LDLLTs in the SD group, immunosuppression was carefully tapered. In our study, LDLLT involving the same donor as for HSCT appeared to have advantages related to lower immunosuppression compared to LDLLT from relatives who were not the HSCT donors.

Facial palsy as unusual complication of spontaneous intraparotid hematoma

A 55-year-old healthy female without trauma history visited our hospital for rapidly progressive enlarging right side painful neck mass within 5 days and also with comorbid House-Brackmann Grade V facial palsy for 2 days. Magnetic resonance imaging showed heterogenous mass derived from parotid to parapharyngeal space. Much blood clot could be observed at exploratory operation. Only inflammatory change, but not tumor, was mentioned in pathology report. Facial palsy was kept stationary in Grade III from postoperative 6 months.

Anesthesia for patients undergoing transsternal thymectomy for juvenile myasthenia gravis

Background:

Juvenile myasthenia gravis (JMG) is the rare form of myasthenia gravis presenting in childhood and adolescence. When medical management fails, thymectomy is offered for these patients. Complete resection of the thymus is best achieved through transsternal thymectomy. Anesthetic management of patients with JMG is challenging, particularly in regards to the goals of postoperative pain control, respiratory function, and extubation.

Methods:

We retrospectively reviewed the medical records of 13 patients, ranging in age from 6 to 22 years, who underwent transsternal thymectomy for JMG. Information on patient demographics, characteristics of their disease and treatment, anesthetic management, and postoperative course were collected.

Results:

All patients had undergone multiple treatment modalities and presented for surgery because of inadequate symptom control with medical management. As expected for a pediatric population, anesthesia induction was age dependent. 40% of the patients underwent an inhalation induction and 60% underwent an intravenous induction. Anesthesia was maintained with a low-dose inhalation agent in all patients, supplemented in 84% of patients with a remifentanil infusion, and in 69% of patients with an epidural infusion. Muscle relaxants were avoided in all patients. With this regimen, 92% of patients could be extubated successfully in the operating room.

Conclusion:

We found that avoidance of muscle relaxants and use of remifentanil with a low-dose hypnotic agent provided a stable intraoperative course, facilitated rapid emergence, and allowed early extubation in patients with JMG undergoing transsternal thymectomy. Epidural analgesia reduced the need for intra- and postoperative intravenous opioids and did not have an adverse effect on respiratory strength.

Persistence of varicella-zoster virus viraemia in patients with herpes zoster

BACKGROUND

Herpes zoster is caused by the reactivation of varicella-zoster virus from sensory neurons. The commonest complication following zoster is chronic pain termed post herpetic neuralgia.

OBJECTIVES

To investigate the dynamics of VZV viraemia and viral load following the resolution of zoster and its relationship to PHN development.

STUDY DESIGN

Blood samples were collected at baseline, 1 month, 3 months and 6 month from a prospective study of 63 patients with active zoster. Quantification of VZV DNA in whole blood was performed using a real-time PCR assay.

RESULTS

During acute zoster, all patients had detectable VZV DNA in their blood. VZV DNA remained detectable in the blood of 91% of patients at 6 months although levels declined significantly (p<0.0001). A history of prodromal symptoms (p=0.005) and severity of pain at baseline (p=0.038) as well as taking antivirals (p=0.046) and being immunocompromised (p=0.043) were associated, with longer time to recovery from PHN. Viral DNA loads were consistently higher in patients with risk factors for PHN and higher viral DNA loads over time were associated with longer time to recovery (p=0.058 overall and 0.038 in immunocompetent).

CONCLUSIONS

Based on these observations we hypothesise that VZV replication persists following acute shingles and that higher viral DNA loads contribute to the risk factors for PHN.

Phaeochromocytoma-associated critical peripheral ischaemia

Limb Ischaemia is an exceptional complication of catecholamine toxicity caused by a phaeochromocytoma. We present a middle-aged female patient with severe subacute peripheral ishaemia, gangrene and eventual amputation of all four distal limbs due to a large non-metastatic left adrenal gland phaeochromocytoma and summarise the available literature concerning previously reported cases.

Comparison of pulmonary function test and computed tomography volumetry in living lung donors

BACKGROUND

We previously proposed calculating forced vital capacity (FVC) by the number of segments for size matching in living-donor lobar lung transplantation (LDLLT). The primary purpose of this study was to compare spirometry-obtained calculations of lower lobe volumes with three-dimensional (3D) computed tomography (CT) volumetric images. Our second goal was to compare the data of pulmonary function tests with CT volumetry in living lung donors.

METHODS

Pulmonary function test, including FVC and total lung capacity (TLC), and 3D CT volumetry were performed pre-operatively in 21 healthy donor candidates for LDLLT. The relationship of 3D CT volumetric data and calculated volume of lower lobes by the number of segments was investigated. Also studied were 3D CT volumetric data in relation to FVC and TLC. Various pre-operative variables were analyzed retrospectively.

RESULTS

According to 3D CT volumetry, the right and left lower lobe volume was 26.3% ± 2.9% and 22.6% ± 3.1% of the total lung volume, respectively. We found a significant, strong correlation between each lower lobe volume and the total lung volume. Because the calculated volumes of right and left lower lobes by the number of segments were 26.3% and 21.1%, respectively, our results implied that the volume of both lower lobes was accurately described by the number of segments. FVC was significantly associated with TLC and the total lung volume.

CONCLUSIONS

We confirmed that it would be justified to estimate graft FVC by the number of segments according to the CT volumetric data in LDLLT.

Phaeochromocytoma mimicking scleroderma

We describe a patient with adrenal phaeochromocytoma who presented with peripheral vasospasm and ischaemia and other manifestations mimicking features of systemic sclerosis, which resolved after resection of the tumor. Phaeochromocytoma should be suspected in patients with features of scleroderma who are negative for auto-antibodies.