Quantifying the Digestion of Cross-Linked Hyaluronic Acid Fillers With Hyaluronidase

BACKGROUND

Adverse events due to hyaluronic acid fillers (HAFs) may be treated with hyaluronidase, an enzyme that cleaves bonds within hyaluronic acid. This study reviews the efficacy of currently available hyaluronidase preparations in breaking down commercial, cross-linked HAFs.

METHODS

Three HAFs were used in this study (Restylane, Juvederm Voluma, and Belotero [BEL] Balance). A laser-based particle size analyzer (Malvern Mastersizer 3000) was used to calculate particle sizes in untreated HAFs (controls) and those treated with 450 units of hyaluronidase (Hylenex) for 5 and 30 minutes.

RESULTS

Particle size analysis revealed that when Restylane was treated with hyaluronidase for 5 minutes, the average particle size reduced modestly, from 472 to 440 μm. At 30 minutes, the average particle size was 419 μm. For Juvederm, the average size of particles reduced from 703 μm in controls to 676 μm after treatment with hyaluronidase for 5 minutes and 635 μm after treatment for 30 minutes. For Belotero, the average size of control particles was 410 μm, reducing to 376 μm after treatment with hyaluronidase for 5 minutes and 345 μm after treatment for 30 minutes.

CONCLUSION

After treatment with hyaluronidase for up to 30 minutes, there was only a modest breakdown of all 3 HAFs used. The results of this study raise questions regarding the efficacy of hyaluronidase in degrading cross-linked HAFs.

Asymptomatic Stroke After Hyaluronic Acid Filler Injection: Case Report and Literature Review

Vascular compromise and blindness are reported but rare complications of facial soft tissue filler injections. Stroke is an even rarer complication resulting from intraarterial injection of fillers. We present a case of a patient suffering all 3 complications following hyaluronic acid filler injection: forehead skin vascular compromise, unilateral blindness, and ipsilateral subclinical strokes. Were it not for a stroke workup protocol, the incidental strokes may have otherwise gone undetected, suggesting the incidence of stroke from intraarterial injection may be higher than reported. Further, we review the literature and recommendations for prevention and management of threatened tissue ischemia and vision loss from facial filler injection.

LEVEL OF EVIDENCE: 5

Application of microbial 3-ketosteroid Δ1-dehydrogenases in biotechnology

3-Ketosteroid Δ¹-dehydrogenase catalyzes the 1(2)-dehydrogenation of 3-ketosteroid substrates using flavin adenine dinucleotide as a cofactor. The enzyme plays a crucial role in microbial steroid degradation, both under aerobic and anaerobic conditions, by initiating the opening of the steroid nucleus. Indeed, many microorganisms are known to possess one or more 3-ketosteroid Δ¹-dehydrogenases. In the pharmaceutical industry, 3-ketosteroid Δ¹-dehydrogenase activity is exploited to produce Δ¹-3-ketosteroids, a class of steroids that display various biological activities. Many of them are used as active pharmaceutical ingredients in drug products, or as key precursors to produce pharmaceutically important steroids. Since 3-ketosteroid Δ¹-dehydrogenase activity requires electron acceptors, among other considerations, Δ¹-3-ketosteroid production has been industrially implemented using whole-cell fermentation with growing or metabolically active resting cells, in which the electron acceptors are available, rather than using the isolated enzyme. In this review we discuss biotechnological applications of microbial 3-ketosteroid Δ¹-dehydrogenases, covering commonly used steroid-1(2)-dehydrogenating microorganisms, the bioprocess for preparing Δ¹-3-ketosteroids, genetic engineering of 3-ketosteroid Δ¹-dehydrogenases and related genes for constructing new, productive industrial strains, and microbial fermentation strategies for enhancing the product yield. Furthermore, we also highlight the recent development in the use of isolated 3-ketosteroid Δ¹-dehydrogenases combined with a FAD cofactor regeneration system. Finally, in a somewhat different context, we summarize the role of 3-ketosteroid Δ¹-dehydrogenase in cholesterol degradation by Mycobacterium tuberculosis and other mycobacteria. Because the enzyme is essential for the pathogenicity of these organisms, it may be a potential target for drug development to combat mycobacterial infections.

Neurogenic fever due to injury of the hypothalamus in a stroke patient: Case report

RATIONALE

Neurogenic fever is a non-infectious source of fever in a patient with brain injury, especially hypothalamic injury. We report on a stroke patient with neurogenic fever due to injury of hypothalamus, demonstrated by using diffusion tensor imaging (DTI).

PATIENT CONCERNS

A 28-year-old male patient was admitted to the rehabilitation department of university hospital at 30 months after onset. Brain MRI showed leukomalactic lesions in hypothalamus, bilateral medial temporal lobe, and bilateral basal ganglia. He showed intermittent high body temperature (maximum:39.5°C, range:38.5-39.2°C), but did not show any infection signs upon physical examination or after assessing his white blood cell count and inflammatory enzyme levels such as erythrocyte sedimentation rate and C-reactive protein. In addition, 8 age-matched normal (control) subjects (4 male, mean age: 26.6 years, range: 21-29years) were enrolled in the study.

DIAGNOSIS

Intraventricular hemorrhage and intracerebral hemorrhage in the left basal ganglia.

INTERVENTIONS

He underwent extraventricular drainage and ventriculoperitoneal shunting for hydrocephalus.

OUTCOMES

DTI was performed at 30 months after onset, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were obtained for hypothalamus. The FA and ADC values of patient were lower and higher, respectively, by more than two standard deviations from control values. Injury of hypothalamus was demonstrated in a stroke patient with neurogenic fever.

LESSIONS

Our results suggest that evaluation of hypothalamus using DTI would be helpful in patients show unexplained fever following brain injury.

Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage

BACKGROUND

Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion.

METHODS

This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests.

RESULTS

157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87).

CONCLUSIONS

Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.

Viscoelastic Haemostatic Assays in Cardiovascular Critical Care

The initiation and management of anticoagulation is a fundamental practice for a wide variety of indications in cardiovascular critical care, including the management of patients with acute MI, stroke prevention in patients with AF or mechanical valves, as well as the prevention of device thrombosis and thromboembolic events with the use of mechanical circulatory support and ventricular assist devices. The frequent use of antiplatelet and anticoagulation therapy, in addition to the presence of concomitant conditions that may lead to a propensity to bleed, such as renal and liver dysfunction, present unique challenges. The use of viscoelastic haemostatic assays provides an additional tool allowing clinicians to strike a delicate balance of attaining adequate anticoagulation while minimising the risk of bleeding complications. In this review, the authors discuss the role that viscoelastic haemostatic assay plays in cardiac populations (including cardiac surgery, heart transplantation, extracorporeal membrane oxygenation, acute coronary syndrome and left ventricular assist devices), and identify areas in need of further study.

Neurological and clinical status from early time point to long-term follow-up after in-hospital cardiac arrest

AIM

We aimed to evaluate neurological profiles of patients with in-hospital cardiac arrest (IHCA) from early time points to long-term follow-up periods.

METHODS

For this prospective cohort study, we established a neurological rapid response team, and serially evaluated the neurological status of patients with IHCA from the initial resuscitation to 12 months after the onset of IHCA. The primary outcome was good neurological status defined as a Clinical Performance Category score of 1-2 at 12 months after IHCA. The secondary outcomes included the awakening and neurological recovery during the first week, the survival and neurological status at hospital discharge, and the survival at 12 months.

RESULTS

A total of 291 adult patients with IHCA were included. On the first day and during the first week after IHCA, the awakening was achieved in 61 (21.0 %) and 119 patients (40.9 %), respectively; and neurological recovery in 12 (4.1 %) and 46 patients (15.8 %), respectively. Epileptic seizures developed in 9.7 % following restoration of spontaneous circulation. At hospital discharge, 106 patients (36.4 %) had survived; among them, 63.2 % showed good neurological status. At 12 months, 63 (21.6 %) patients survived; among them, 81.7 % showed good neurological status (17.0 % among all patients with IHCA). Of patients without awakening during the first 3 and 7 days, 2.7 % and 1.2 % showed good neurological status at 12 months, respectively.

CONCLUSIONS

Among patients with IHCA, awakening and neurological recovery were remarkable throughout the first week. Survival and good neurological status were substantial at 12 months after IHCA.

Practical Guidance for Prevention and Management of Glucocorticoid-Induced Osteoporosis for the Allergist/Immunologist

Osteoporosis is a silent disorder with dire consequences, and glucocorticoid use remains the most common iatrogenic cause illustrated by the fact that 30% to 50% of subjects on such long-term therapy experience fractures (Oimomi M, Nakamichi T, Ohara T, Sakai M, Igaki N, Hata F, et al. Fructose-related glycation. Diabetes Res Clin Pract 1989;7:137-9; Reid IR. Glucocorticoid osteoporosis--mechanisms and management. Eur J Endocrinol 1997;137:209-17). By directly affecting bone quality while actively used, glucocorticoids increase the risk of fracture that is independent of a subject's bone density status at the time (Weinstein RS. True strength. J Bone Miner Res 2000;15:621-5). A large number of subjects seen in an allergy and immunology clinic have asthma, chronic rhinosinusitis, or other chronic inflammatory diseases, necessitating the use of these medications and placing them at higher risk for this disease. Data on the effects of both oral and inhaled glucocorticoids on fracture risk are presented. This review concretizes the importance of osteoporosis, its pathophysiology, and provides practical guidelines to prevent and treat it. Management recommendations are tailored to 2 different age groups. The first group consists of children, adolescents, and adults 40 years or younger with a focus on attaining peak bone mass. The second group consists of adults 40 years or older where the use of imaging modalities and Fracture Risk Assessment Tool scores helps triage subjects into fracture risk categories. Those at moderate to high risk require bone-sparing medications. Universal preventive measures for both groups are reviewed. Complicated and severe cases may need additional expertise by an endocrinologist or rheumatologist.

Mechanophysiologically active patch for closure of atrial septal defect

Closure of atrial septal defects (ASDs) can be achieved by various methods right from direct closure to patch closure using various materials viz. pericardium, Dacron and Teflon, to device closure using percutaneous techniques. Although percutaneous techniques are the most commonly practised method in developed countries, a subset of patients will require surgical closure. Various patch materials have been used for long, but all of them have some complications and risks associated with them. We report a case of novel technique of ASD closure done using a pedicled, vascularised and contractile right atrial wall flap.

A Review of the use of Transcranial Doppler Waveform Morphology for Acute Stroke Assessment

Acute ischemic stroke is a source of long-term disability in the United States, of which a large portion of cases are a result of large vessel occlusion (LVO). LVO strokes have high rates of morbidity and mortality due to difficulty of treatments in achieving recanalization. Recently, however, results of randomized clinical trials have shown that treatment options are expanding in both availability and efficacy. As these methods of intervention become more optimal, so must the preceding methods of assessment. Transcranial Doppler (TCD) ultrasound is a non-invasive method of evaluating cerebral hemodynamics, and has a long history in stroke assessment. Despite the importance of information provided by a TCD exam, its utilization in the acute stroke workflow has remained low because of its dependence on expert analysis. Here, we review the evolution of morphological analysis of TCD waveforms for the indication, localization, and monitoring of acute LVO.

An overview of management of intracranial hypertension in the intensive care unit

Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient's head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.

Neuroinflammation Treatment via Targeted Delivery of Nanoparticles

The lack of effective treatments for most neurological diseases has prompted the search for novel therapeutic options. Interestingly, neuroinflammation is emerging as a common feature to target in most CNS pathologies. Recent studies suggest that targeted delivery of small molecules to reduce neuroinflammation can be beneficial. However, suboptimal drug delivery to the CNS is a major barrier to modulate inflammation because neurotherapeutic compounds are currently being delivered systemically without spatial or temporal control. Emerging nanomaterial technologies are providing promising and superior tools to effectively access neuropathological tissue in a controlled manner. Here we highlight recent advances in nanomaterial technologies for drug delivery to the CNS. We propose that state-of-the-art nanoparticle drug delivery platforms can significantly impact local CNS bioavailability of pharmacological compounds and treat neurological diseases.

Optic nerve sheath diameter change in prediction of malignant cerebral edema in ischemic stroke: an observational study

Background

In acute large anterior circulation infarct patients with large core volume, we evaluated the role of optic nerve sheath diameter (ONSD) change rates in prediction of malignant progression.

Methods

We performed a retrospective observational study including patients with anterior circulation acute ischemic stroke with large ischemic cores from January 2010 to October 2017. Primary outcome was defined as undergoing decompressive surgery or death due to severe cerebral edema, and termed malignant progression. Patients were divided into malignant progressors and nonprogressors. Malignant progression was divided into early progression that occurred before D1 CT, and late progression that occurred afterwards. Retrospective analysis of changes in mean ONSD/eyeball transverse diameter (ETD) ratio, and midline shifting (MLS) were evaluated on serial computed tomography (CT). Through analysis of CT at baseline, postprocedure, and at D1, the predictive ability of time based change in ONSD/ETD ratio in predicting malignant progression was evaluated.

Results

A total of 58 patients were included. Nineteen (32.8%) were classified as malignant; 12 early, and 7 late progressions. In analysis of CT_{postprocedure}, A 1 mm/hr. rate of change in MLS during the CT_baseline-CT_{postprocedure} time phase lead to a 6.7 fold increased odds of early malignant progression (p < 0.05). For ONSD/ETD, 1%/hr. change lead to a 1.6 fold increased odds, but this association was trending (p = 0.249). In the CT_D1, 1%/day change of ONSD/ETD in the CT_baseline-CT_D1 time phase lead to a 1.4 fold increased odds of late malignant progression (p = 0.021) while 1 mm/day rate of change in MLS lead to a 1.5 fold increased odds (p = 0.014).

Conclusions

The rate of ONSD/ETD changes compared to baseline at D1 CT can be a predictor of late malignant progression along with MLS. ONSD/ETD change rates evaluated at postprocedure did not predict early malignant progression.

The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy

BACKGROUND/OBJECTIVE

Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry.

METHODS

Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h.

RESULTS

We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants.

CONCLUSIONS

Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.

A comparison of the time constant of the cerebral arterial bed using invasive and non-invasive arterial blood pressure measurements

OBJECTIVE

The time constant of the cerebral arterial bed (τ), which is an index of brain haemodynamics, can be estimated in patients using continuous monitoring of arterial blood pressure (ABP), transcranial Doppler cerebral blood flow velocity (CBFV) and intracranial pressure (ICP) if these measures are available. But, in some clinical scenarios invasive measurement of ABP is not feasible. Therefore, in this study we aimed to investigate whether invasive ABP can be replaced with non-invasive ABP, monitored using the Finapres photoplethysmograph (fABP).

APPROACH

Forty-six recordings of ICP, ABP, fABP, and CBFV in the right and left middle cerebral arteries were performed daily for approximately 30 min in 10 head injury patients. Two modelling approaches (constant flow forward [CFF, pulsatile blood inflow and steady blood outflow] and pulsatile flow forward [PFF, where both blood inflow and outflow are pulsatile]) were applied to estimate τ using either invasive ABP (τ_CFF, τ_PFF) or non-invasive ABP (fτ_CFF, fτ_PFF).

MAIN RESULTS

Bland-Altman analysis showed quite poor agreement between the fτ and τ methods of estimation. The fτ method produced significantly higher values than the τ method when calculated using both the CFF and PFF models (p < .001 for both). The correlation between fτ_CFF and τ_CFF was moderately high (r _s = 0.63; p < .001), whereas that between fτ_PFF and τ_PFF was weaker (r _s = 0.40; p = .009).

SIGNIFICANCE

Our results suggest that using non-invasive ABP for estimation of τ is inaccurate in head injury patients.

Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan

There are limited recommendations for fasting in many chronic diseases such as adrenal insufficiency (AI). Research in such situations highlights potential for complications and need for education for patients with AI undertaking fasting during Ramadan. This article aimed to provide up-to-date guidance for healthcare professionals to educate, discuss and manage patients with AI who are considering fasting in Ramadan and is religiously compatible. Latest guidance on this topic and the evidence base for steroid dosing are reviewed and discussed. Risk stratification for patients with AI and optimal strategies for management, including steroid dosing, are detailed. Our review highlights that patients with AI wishing to fast should undergo a thorough risk assessment ideally several months before Ramadan. 'High risk' and 'Very high risk' patients should be encouraged to explore alternative options to fasting discussed below. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick day rules, instructions on when to terminate their fast or abstain from fasting, carry steroid warning information and must have a valid intramuscular (IM) hydrocortisone pack and know how to administer this. Switching patients with AI desiring to fast from multiple daily hydrocortisone replacement to prednisolone 5 mg once daily at dawn (during Suhoor or Sehri) is recommended and discussed. Patients on fludrocortisone for AI should be advised to take their total dose at dawn. We provide practically relevant case-based scenarios to help with the application of this guidance. Future efforts need to focus on healthcare professional awareness and further research in this setting.

Prediction of deep vein thrombosis by ultrasonography and D-dimer in Asian patients with ischemic stroke

Background

Deep vein thrombosis (DVT) is an important complication of ischemic stroke, although the incidence of DVT is regarded as being lower in Asian than in non-Asian patients. Here, we investigated the incidence and factors associated with DVT in Asian patients with ischemic stroke.

Methods

Acute ischemic stroke patients received lower extremity ultrasonography (LEUS) to diagnose the presence of DVT. Clinical characteristics and laboratory results, including D-dimer level, were compared between patients with and without DVT. Independent risk factors for DVT were investigated using multivariable analysis. Similar analysis was performed to identify factors associated with elevated D-dimer level (> 0.5 mg/dl) in acute ischemic stroke patients.

Results

During the study period, 289 patients were enrolled, and 38 (13.1%) showed DVT. Female sex (OR = 2.579, 95% CI = 1.224–5.432; p = 0.013) and a high National Institutes of Health Stroke Scale (NIHSS) score (OR = 1.191 95% CI = 1.095–1.294; p = 0.005) were independently associated with the presence of DVT, although D-dimer level was not. Stroke mechanism, especially cardioembolic stroke (OR = 3.777, 95% CI = 1.532–9.313; p = 0.004; reference: large artery atherosclerosis), NIHSS score (OR = 1.087, 95% CI = 1.002–1.179; p = 0.001) and thrombolysis (OR = 12.360, 95% CI 2.456–62.213; p = 0.002) were independently associated with elevated abnormal D-dimer levels.

Conclusion

The severity of ischemic stroke, but not the D-dimer level, was associated with the presence of DVT in Asian ischemic stroke patients. D-dimer level was influenced by the stroke mechanism. LEUS in patients with severe neurological deficit, rather than screening with D-dimer, may be more beneficial for diagnosing DVT in Asian patients with acute ischemic stroke.

A critical evaluation of glucocorticoids in the management of severe COVID-19

•

Dexamethasone reduces the risk of death in patients critically ill with COVID-19.

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No evidence of benefit from other complementary and/or supportive treatments was seen in critically ill COVID-19 hospitalized patients.

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Synthetic glucocorticoids switch off cytokine storm, and consequent severe respiratory and multi-organ failures in patients with COVID-19.

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Effects of synthetic glucocorticoids might be confounded by the contemporary use of other complementary drugs.

The viral infection by SARS-CoV-2 has irrevocably altered the life of the majority of human beings, challenging national health systems worldwide, and pushing researchers to rapidly find adequate preventive and treatment strategies. No therapies have been shown effective with the exception of dexamethasone, a glucocorticoid that was recently proved to be the first life-saving drug in this disease. Remarkably, around 20 % of infected people develop a severe form of COVID-19, giving rise to respiratory and multi-organ failures requiring subintensive and intensive care interventions. This phenomenon is due to an excessive immune response that damages pulmonary alveoli, leading to a cytokine and chemokine storm with systemic effects. Indeed glucocorticoids’ role in regulating this immune response is controversial, and they have been used in clinical practice in a variety of countries, even without a previous clear consensus on their evidence-based benefit.

Misdiagnosis of a multi-organ involvement hematogenous disseminated tuberculosis as metastasis: a case report and literature review

Background

Tuberculosis (TB) is a great mimicker and diagnostic chameleon, and prone to be diagnosed as malignancy. Even though many reports have described the differences between pulmonary TB and lung cancer, the atypical systemic hematogenous disseminated TB (HDTB) is very rare and more confusing in clinical practice.

Case presentation

A 73-year-old man, HIV-negative, was hospitalized to the local county hospital because of chest pain, low-grade fever, asthenia, anorexia and weight loss for the pasting two months. The CT findings of the two lungs showed multiple round or round-like nodules of different sizes, with clear boundaries and partial fusion. The level of serum CA19–9 was significantly higher than normal, and progressively increased. There were multiple enlarged lymph nodes in the neck, mediastinum, abdominal cavity and pelvic cavity. The symptoms were diagnosed as hematogenous spread of gastrointestinal tumor in the local county hospital. However, when transferred to our provincial hospital, through comprehensive dynamic analysis, this patient was diagnosed as atypical systemic HDTB, no cancer at all. Through routine anti-TB therapy for one year, the patient was recovered very well at the follow-up of half year after withdrawal.

Conclusions

In the past, most TB misdiagnosis cases involved in single organ and were finally confirmed through invasive examination. This case enriched clinical experiences in the diagnosis of atypical HDTB. We encouraged clinicians to establish a dynamic thinking for diagnosis and treatment and emphasized the value of biopsy and ¹⁸F-FDG-PET in distinguishing TB and cancer.

Anti-inflammatory effect of Salsola komarovii extract with dissociated glucocorticoid activity

Background

Glucocorticoids (GCs) are anti-inflammatory drugs widely used to treat acute and chronic inflammatory diseases. However, despite their excellent efficacy, the long-term use of GCs is relatively limited owing to their adverse effects. Recent studies have sought to reduce these adverse effects by developing dissociated GCs that bind to GC receptors (GRs) to induce potent anti-inflammatory effects without the transcription of GC response element (GRE)-promoted genes. Some species of the genus Salsola are used in traditional Chinese medicine to treat cancer, hypertension, and inflammation. In this study, we investigated the potential dissociated GC activities and underlying mechanisms of Salsola komarovii (SK), which is native to Korea.

Methods

To determine whether SK ethanol extract (SEE) directly interacts with the GR, an in vitro fluorescence polarization based-GR competitor assay was performed. The effect of SEE on the transcriptional activity of nuclear factor (NF)-κB and GRE was confirmed in HepG2 cells using the Cignal reporter assay. The anti-inflammatory effect of SK was determined by assessing lipopolysaccharide (LPS)-induced interleukin (IL)-6 production. To confirm whether SEE induces GRE-driven gene expression, preadipocyte differentiation followed by lipid deposition was performed in the presence of SEE.

Results

SEE exhibited GR binding activity in the fluorescence polarization competitive binding assay and induced GR nuclear translocation. It also interfered with the nuclear translocation of NF-κB and the NF-κB-dependent transcriptional activity based on the immunofluorescence analysis and reporter assay, respectively. SEE exerted anti-inflammatory effects by reducing LPS-induced IL-6 production as effectively as hydrocortisone (positive control). SK did not induce GRE-driven gene expression and preadipocyte differentiation, which is one of the major adverse effects of GCs.

Conclusions

Collectively, these results suggest that SK could be a novel and safe anti-inflammatory agent with dissociated GC properties and, therefore, it has great potential for use in treating inflammatory disorders.

Severe pain-related adverse events of percutaneous dilatational tracheostomy performed by a neurointensivist compared with conventional surgical tracheostomy in neurocritically ill patients

Background

We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients.

Methods

This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications.

Results

A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187–0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (β: -8.64, 95% CI: − 15.070 – -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (β: 6.38, 95% CI: 0.166–0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047).

Conclusions

This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.

Perioperative Coagulopathy in Patients with Normal Preoperative Coagulation Screen: A Couple of Coagulopathic Clinical Case Conundrums

Perioperative coagulopathy impacts patient outcome by influencing intraoperative hemodynamics and blood loss. We present two cases which despite having normal preoperative coagulation profiles and normotension during the surgery had intraoperative coagulopathy and unusual bleeding. These cases required a multidisciplinary approach to manage them successfully. A thorough knowledge of the coagulation cascade along with a high-degree of suspicion and early recognition of coagulation is required. Abnormalities are critical for a timely intervention. Point-of-care tests like thromboelastography (TEG) as well as platelet function studies helped us arrive at an early diagnosis and initiate prompt treatment.

Δ1-Dehydrogenation and C20 Reduction of Cortisone and Hydrocortisone Catalyzed by Rhodococcus Strains

Prednisone and prednisolone are steroids widely used as anti-inflammatory drugs. Development of the pharmaceutical industry is currently aimed at introducing biotechnological processes and replacing multiple-stage chemical syntheses. In this work we evaluated the ability of bacteria belonging to the Rhodococcus genus to biotransform substrates, such as cortisone and hydrocortisone, to obtain prednisone and prednisolone, respectively. These products are of great interest from a pharmaceutical point of view as they have higher anti-inflammatory activity than the starting substrates. After an initial lab-scale screening of 13 Rhodococcus strains, to select the highest producers of prednisone and prednisolone, we reported the 200 ml-batch scale-up to test the process efficiency and productivity of the most promising Rhodococcus strains. R. ruber, R. globerulus and R. coprophilus gave the Δ1-dehydrogenation products of cortisone and hydrocortisone (prednisone and prednisolone) in variable amounts. In these biotransformations, the formation of products with the reduced carbonyl group in position C₂₀ of the lateral chain of the steroid nucleus was also observed (i.e., 20β-hydroxy-prednisone and 20β-hydroxy-prednisolone). The yields, the absence of collateral products, and in some cases the absence of starting products allow us to say that cortisone and hydrocortisone are partly degraded.

Pneumocephalus and Chemical Meningitis after Inadvertent Dural Puncture during Lumbar Epidural Injection

Inadvertent dural puncture (IDP) is one of the complications of lumbar epidural steroid injections (ESIs). We report a case in which pneumocephalus and chemical meningitis developed at the same time after an IDP during a lumbar interlaminar ESI. A 60-year-old woman presented to the emergency room with thunderclap headache and febrile sensation 3 hours after receiving a lumbar interlaminar ESI. Brain computed tomography (CT) scan showed multiple small foci of air within the subarachnoid space and ventricle. After the admission, the patient was afebrile and reported mild improvement of headache with analgesics. However, 2 days after the admission, headache worsened and fever recurred. Follow-up brain CT scan revealed resolution of the pneumocephalus. A diagnostic lumbar puncture for cerebrospinal fluid (CSF) examination revealed the findings suggestive of aseptic (chemical) meningitis rather than bacterial meningitis. With symptomatic treatment, headache improved and there was no fever after 48 hours. No bacteria, Mycobacterium, or fungi grew in the CSF for 7 days. This case shows an IDP during a lumbar ESI can cause pneumocephalus and chemical meningitis at the same time and efforts should be made to reduce the risk of IDP during lumbar ESIs.

Loss of Potential Donors Due to Hemodynamic Maintenance

BACKGROUND

Statistics indicate low utilization of potential donors, where only about one-third are converted into actual donors. In this context, it is plausible to argue that many potential donors are not hemodynamically stable for harvesting multiple organs since the procedures for maintaining parameters of stability may not be a priority in all critical care units in the country. Thus, it is necessary to identify losses of potential donors due to hemodynamic maintenance since reversing this situation enable minimizing mortality on waiting lists.

METHODS

This was a retrospective quantitative study, based on information sent to Notification, Organ Procurement, and Distribution Centers by reporting hospitals in the state of São Paulo, using the Death Information Form regarding the specifics of each death registered in their intensive care units and emergency rooms.

RESULTS

Hemodynamic instability contributed to a loss of 537 potential donors, corresponding to 61.9% of failures to obtain potentially transplantable organs.

CONCLUSION

Of the 33,175 cases of death reported, 867 fulfilled the criteria to be possible and potential donors (ie, patients diagnosed with brain death). Among these cases, 38.1% fulfilled Criterion 3 (ie, they were hemodynamically stable and in ideal organ donation condition). Therefore, this study concludes that losses due to maintenance occurred in 537 brain dead patients. This finding highlights the importance of investing in the development of competencies of professionals who work in critical care units to increase the number of multiple organ and tissue donors and reduce waiting lists.

A New Inexpensive Simulation Model for Ultrasound Assessment of Optic Nerve Sheath Diameter

BACKGROUND

Sonographic measurement of optic nerve sheath diameter (ONSD) is becoming increasingly accepted as a diagnostic modality to detect elevations in intracranial pressure. As this technique becomes more widespread, methods to address the inherent operator-dependent nature of this modality will need to be developed. We propose a novel low-cost model to accurately simulate sonographic ONSD measurement for purposes of training and assessment.

METHODS

We designed models composed of medical tubing of various diameters readily available from typical hospital supplies and suspended them in gelatin. The models were evaluated by ultrasound by three expert point-of-care sonographers using a standard linear array probe and technique proposed in the literature.

RESULTS

This model generates faithful simulation of the ONS that closely approximates in vivo images and can be used to produce accurate, reproducible measurements. Materials are low cost and easy to acquire and assemble.

CONCLUSIONS

Our model provides realistic simulated images of the ONS. Through comparison of sonographic measurements to the known tube diameters, this model serves as a promising inexpensive tool to teach the method of ultrasound assessment of ONSD or as a way to determine accuracy of this novel ultrasound technology.

Understanding and managing acute encephalitis

Encephalitis is an important cause of morbidity, mortality, and permanent neurologic sequelae  globally. Causes are diverse and include viral and non-viral infections of the brain as well as autoimmune processes. In the West, the autoimmune encephalitides are now more common than any single infectious cause, but, in Asia, infectious causes are still more common. In 2006, the World Health Organization coined the term "acute encephalitis syndrome", which simply means acute onset of fever with convulsions or altered consciousness or both. In 2013, the International Encephalitis Consortium set criteria for diagnosis of encephalitis on basis of clinical and laboratory features. The most important infectious cause in the West is herpes simplex virus, but globally Japanese encephalitis (JE) remains the single largest cause. Etiologic diagnosis is difficult because of the large number of agents that can cause encephalitis. Also, the responsible virus may be detectable only in the brain and is either absent or transiently found in blood or cerebrospinal fluid (CSF). Virological diagnosis is complex, expensive, and time-consuming. Different centres could make their own algorithms for investigation in accordance with the local etiologic scenarios. Magnetic resonance imaging (MRI) and electroencephalography are specific for few agents. Clinically, severity may vary widely. A severe case may manifest with fever, convulsions, coma, neurologic deficits, and death. Autoimmune encephalitis (AIE)  includes two major categories: (i) classic paraneoplastic limbic encephalitis (LE) with autoantibodies against intracellular neuronal antigens (Eg: Hu and Ma2) and (ii) new-type AIE with autoantibodies to neuronal surface or synaptic antigens (Eg: anti-N-methyl-D-aspartate receptor). AIE has prominent psychiatric manifestations: psychosis, aggression, mutism, memory loss, euphoria, or fear. Seizures, cognitive decline, coma, and abnormal movements are common. Symptoms may fluctuate rapidly. Treatment is largely supportive. Specific treatment is available for herpesvirus group and non-viral infections. Various forms of immunotherapy are used for AIE.

Delayed Post-Hypoxic Leukoencephalopathy Induced by an Overdose with Fentanyl Patches: A Case Report

펜타닐 첩포가 의학적으로 이용됨에 따라 간간이 펜타닐 중독 증례가 보고되고 있다. 지연성 저산소성 백색질뇌증(delayed post-hypoxic leukoencephalopathy)은 저산소증에 의한 합병증의 하나이다. 이로 인해 급성 중독으로 인한 혼수상태에서 완전히 회복하더라도, 뒤늦게 신경병적 증상이 발생하고, 이후 백색질뇌증으로 진행하기도 한다. 여기 10개의 펜타닐 첩포를 한 번에 사용하고 13시간 동안 깨어나지 못하여 본원으로 내원한 65세 환자의 증례를 소개하였다. 첫 내원 당시 촬영한 CT 소견은 정상이었으나, 20일 뒤 지연성 신경병적 증상이 발생하여 촬영한 MRI 상 양측 대뇌 백색질에 대칭적인 불균일하고 융합하는 고신호 강도 병변이 T2와 FLAIR 영상에서 관찰되었으며 이 병변은 확산 제한을 보였다. 이후 환자의 신경병적 증상은 빠르게 악화되었고 1년 후 심한 전반적 뇌 위축으로 진행하였다.

Cefepime-Induced Encephalopathy in a Tertiary Medical Center in Korea

Background and Purpose

Cefepime is a widely used fourth-generation cephalosporin. It is commonly used as a first-line antibiotic to treat various infectious diseases such as hospital-acquired pneumonia, urinary tract infections, and bacterial meningitis. The primary outcome of this study was the development of cefepime-induced encephalopathy (CIE) at a tertiary medical center in Korea. We also aimed to describe the clinical features of CIE.

Methods

We enrolled 1,793 consecutive patients treated with cefepime. The CIE group included 44 patients who experienced altered consciousness after receiving cefepime without any other obvious cause and showed full recovery after stopping cefepime. This study collected demographic data, laboratory findings, and clinical data including the cause of infection, duration for onset of altered consciousness, duration of cefepime treatment, dosage of cefepime, duration of recovering consciousness after stopping cefepime, sequelae after encephalopathy, and electroencephalography data.

Results

Forty-four (2.5%) patients were included in the CIE group. The age was significantly higher in the CIE group than in the control group (71.2±10.8 years vs. 64.7±16.1 years, mean±standard deviation; p=0.007), and females constituted a significantly large proportion in the CIE group (27 of 44, 61.4%). The CIE group had higher blood urea nitrogen (34.7±22.6 mg/dL vs. 23.0±17.5 mg/dL, p<0.001) and creatinine (2.2±2.5 mg/dL vs. 1.1±1.3 mg/dL, p<0.001), and lower estimated glomerular filtration rate (eGFR) (56.3±46.0 mL/min/1.73 mm² vs. 98.8±66.3 mL/min/1.73 mm², p<0.001). Multivariate analysis showed that only eGFR was significantly related to CIE.

Conclusions

The incidence of CIE was 2.5% in this study. It is essential to consider the possibility of CIE occurring, especially in patients with lower values of eGFR and dialysis.

Clinical Approach to Autoimmune Epilepsy

Autoimmune epilepsy is a newly emerging area of epilepsy. The concept of “autoimmune” as an etiology has recently been revisited thanks to advances in autoimmune encephalitis and precision medicine with immunotherapies. Autoimmune epilepsy presents with specific clinical manifestations, and various diagnostic approaches including cerebrospinal fluid analysis, neuroimaging, and autoantibody tests are essential for its differential diagnosis. The diagnosis is often indeterminate despite performing a thorough evaluation, and therefore empirical immunotherapy may be applied according to the judgment of the clinician. Autoimmune epilepsy often manifests as new-onset refractory status epilepticus (NORSE). A patient classified as NORSE should receive empirical immunotherapy as soon as possible. On the other hand, a morecautious, stepwise approach is recommended for autoimmune epilepsy that presents with episodic events. The type of autoimmune epilepsy is also an important factor to consider when choosing from among various immunotherapy options. Clinicians should additionally take the characteristics of antiepileptic drugs into account when using them as an adjuvant therapy. This expert opinion discusses the diagnostic and treatment approaches for autoimmune epilepsy from a practical point of view.

Nursing Interventions for Patients with Intracranial Hypertension: Integrative Literature Review

Objective: the study sought to identify, in national and international publications, the principal Nursing interventions aimed at patients with intracranial hypertension. Materials and Method: integrative literature review with search in LILACS, PubMed, Scopus, Web of Science, Cinahal, and Google Scholar databases, from 2013 to 2018. Results: the sample was comprised of seven articles fulfilling the inclusion criteria. Two thematic categories were established for the Nursing interventions aimed at patients with intracranial hypertension: cognitive skills and clinical reasoning, necessary to control neuro-physiological parameters and prevent intracranial hypertension, and evidence-based practices to improve care for neuro-critical patients. Conclusions: intracranial hypertension is an event of great clinical impact, whose complications can be minimized and control through specific Nursing interventions that encompass control of neuro-physiological and hemodynamic parameters and prevention of increased intracranial pressure related with the performance of procedures by the Nursing staff.

The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke

Background

Elevated D-dimer levels are a marker of both thrombin formation and fibrinolysis. Currently D-dimer measurement is routinely used for ruling out venous thromboembolism and diagnosis/monitoring of disseminated intravascular coagulation. Recent emerging data suggest that D-dimer may become an important biomarker in ischemic stroke as well as in cardiovascular diseases.

Aims

To outline the clinical utility of D-dimer in work-up and management of ischemic stroke.

Summary

D-dimer measurement is most useful in stroke with active cancer as it can confirm etiologic diagnosis, predict recurrent stroke risk, and aid treatment decision in cancer-associated stroke. In cryptogenic stroke, high D-dimer levels can also provide clues for the cause of stroke as occult cancer and undetected cardiac embolic source as occult atrial fibrillation and may be helpful in treatment decision making of secondary stroke prevention. Serial D-dimer measurements should be further studied to monitor antithrombotic therapy effectiveness in both cardiogenic and cryptogenic etiologies.

Conclusion

Accumulating data suggests the utility of D-dimer test in the management of ischemic stroke, although the evidence is still limited. Future studies would clarify the role of D-dimer measurement in ischemic stroke.

Oral health care provided by nurses for hospitalized patients in Korea

OBJECTIVES

To investigate registered nurses' awareness and implementation of oral health care in patients who are hospitalized in general wards or intensive care units (ICUs) in South Korea.

METHODS

This research was performed as a descriptive survey of 149 nurses working in nine general hospitals with at least 100 beds in major Korean cities.

RESULTS

Approximately half (40.9%) of the survey respondents reported providing oral health care for hospitalized patients but that relevant protocols were not available at most hospitals or wards (89.5%). Nurses working in an ICU were significantly more likely to provide oral health care than those working in general wards (83.9% vs 15.1%; P < .001). Most respondents (83.2%) were aware of the importance of providing oral health care for hospitalized patients; however, the proportion considering that such care should be provided by dental hygienists was greater than that considering it should be provided by nurses (36.4% vs 26.0%; P < .001). Agreement that oral health care should be provided for hospitalized patients by dental hygienists was highest in nurses working in ICUs (53.3%; P < .001).

CONCLUSIONS

According to this survey, oral healthcare provision is generally low in hospitalized patients and differs between ICUs and general wards. Most respondents considered that dental hygienists should provide oral health care for hospitalized patients. There is an opportunity for nurses and dental hygienists to work collaboratively towards development of an evidence-based protocol for oral health care in hospitalized patients.

Fatal intracranial aneurysm rupture after thrombolytic treatment for ischemic stroke: a case report and literature review

Intravenous thrombolysis is a proven treatment of acute ischemic stroke. Its complications include intracranial hemorrhage; the risk may be increased in the presence of an unruptured aneurysm. We present a case report of a patient who suffered fatal subarachnoid hemorrhage after thrombolysis from a known aneurysm. A history of recent previously inexperienced headaches was revealed retrospectively, suggestive of sentinel bleedings. A similar patient was identified in the literature; we thus propose that this history should be excluded in patients harboring an aneurysm considered for thrombolytic treatment.

Intimal flap detected by three-dimensional curved multiplanar reconstruction image in isolated posterior inferior cerebellar artery dissection: a report of two cases

BACKGROUND

Spontaneous isolated posterior inferior cerebellar artery (PICA) dissection has been reported more frequently since high-resolution vessel wall magnetic resonance imaging (HR vw-MRI) was introduced to the field. The intimal flap or double lumen, which is commonly reported to be a direct sign of the dissection, is not easily detectable on HR vw-MRI because the size of the PICA is very small and tortuous.

CASE PRESENTATION

Two patients with posterior circulation ischemic stroke due to spontaneous isolated PICA dissection underwent HR vw-MRI. The curved multiplanar reconstruction image reconstructed using three-dimensional (3D) HR vw-MRI (3D curved MPR imaging) is helpful to observe tortuous blood vessels such as the PICA because it can visualize the entire vessel course in a single plane. In this report, routine HR vw-MRI revealed only an intramural hematoma in both patients. However, 3D curved MPR imaging discovered the intimal flap which was not observed on the routine HR vw-MRI. Therefore, these two patients were diagnosed with spontaneous isolated PICA dissection due to the intimal flap that was observed on the 3D curved MPR image.

CONCLUSION

HR vw-MRI is useful for the early diagnosis of isolated PICA dissection. Furthermore, we believe that 3D curved MPR imaging could improve the possibility of diagnosing the dissection early because it can easily confirm direct signs such as an intimal flap or double lumen.

Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation

Objectives: The use of dexmedetomidine and ketamine (DEX-KET) combination for magnetic resonance imaging (MRI) sedation has not been evaluated. We investigated the efficacy and safety of DEX-KET for sedation of patients undergoing MRI of the brain. Methods: This quasi-experimental study was conducted to compare the DEX-KET combination and midazolam for MRI sedation. We included 72 patients undergoing brain MRI following bolus injection of midazolam or DEX-KET. In August 1, 2016 a new MRI sedation protocol was implemented. After protocol implementation, bolus doses of DEX-KET were administered (DEX-KET group). Thirty-six patients from the MIDA group and 36 patients from the DEX-KET group underwent MRI sequences and were compared regarding the MRI scan time and sedation-related complications (desaturation, hypotension, cardiorespiratory arrest, and aspiration pneumonia). Results: All MRI sequences were completed for 30 patients (83.3%) from the MIDA group and for 33 patients (91.7%) from the DEX-KET group (P = 0.476). The median MRI scan time was 100.0 min (interquartile range, 87.0-111.5 min) in the MIDA group and 53.5 min (interquartile range, 45.0-60.5 min) in the DEX-KET group (P < 0.001). Complications occurred in 24 (66.7%) and 8 (22.2%) patients of the MIDA and DEX-KET group, respectively (P < 0.001). Conclusions: The efficacy of DEX-KET sedation was comparable to that of midazolam for MRI examination. DEX-KET was related to shorter scan time and lower occurrence of complications compared to midazolam.

Takotsubo Cardiomyopathy and Neurogenic Pulmonary Edema After Carotid Endarterectomy

BACKGROUND

Takotsubo cardiomyopathy (TCM) and neurogenic pulmonary edema (NPE) are rare complications of an acute ischemic stroke. In particular, TCM and NPE following carotid endarterectomy (CEA) are extremely rare. In general, TCM- and NPE-associated ischemic strokes are caused by excess catecholamine release after sympathetic nervous stimulation following stroke onset, but the mechanism triggering this stimulation is still unknown.

CASE DESCRIPTION

An 88-year-old man underwent left CEA for symptomatic carotid artery stenosis (North American Symptomatic Carotid Endarterectomy Trial, 65%). After the surgery, his respiratory condition rapidly worsened, and chest radiography revealed an infiltrative shadow on both lung fields. Transthoracic echocardiography revealed left ventricular dysfunction, suggesting TCM. Postoperative magnetic resonance imaging revealed a small infarction in the left anterior insular cortex. Eventually, his respiratory and cardiac functions gradually improved. He was finally discharged on his own from the hospital on postoperative day 9.

CONCLUSIONS

We described a very rare case of TCM and NPE following CEA. The mechanisms of TCM and NPE involve excess catecholamine release after sympathetic nervous stimulation. Our findings suggest that surgery-associated transient ischemia and reperfusion injury to the left insular cortex stimulate sympathetic nerves.

Toll-like receptors in the pathogenesis of neuroinflammation

Toll-like receptors (TLRs) are discovered as crucial pattern recognition receptors (PRRs) involved in the recognition of pathogen-associated molecular patterns (PAMPs). Later studies showed their involvement in the recognition of various damage/danger-associated molecular patterns (DAMPs) generated by host itself. Thus, TLRs are capable of recognizing wide-array of patterns/molecules derived from pathogens and host as well and initiating a proinflammatory immune response through the activation of NF-κB and other transcription factors causing synthesis of proinflammatory molecules. The process of neuroinflammation is seen under both sterile and infectious inflammatory diseases of the central nervous system (CNS) and may lead to the development of neurodegeneration. The present article is designed to highlight the importance of TLRs in the pathogenesis of neuroinflammation under diverse conditions. TLRs are expressed by various immune cells present in CNS along with neurons. However out of thirteen TLRs described in mammals, some are present and active in these cells, while some are absent and are described in detail in main text. The role of various immune cells present in the brain and their role in the pathogenesis of neuroinflammation depending on the type of TLR expressed is described. Thereafter the role of TLRs in bacterial meningitis, viral encephalitis, stroke, Alzheimer's disease (AD), Parkinson's disease (PD), and autoimmune disease including multiple sclerosis (MS) is described. The article is designed for both neuroscientists needing information regarding TLRs in neuroinflammation and TLR biologists or immunologists interested in neuroinflammation.

Head injury in the elderly - an overview for the physician

Head injury is a common cause for hospital admission and additionally 250,000 UK inpatients fall during hospital admissions annually. Head injury most commonly occurs as a result of falls from standing height in older adults. Older adults are frequently frail and multi-morbid; many have indications for anticoagulation and antiplatelet agents. The haemorrhagic complications of head injury occur in up to 16% of anticoagulated patients sustaining a head injury. These patients suffer adverse outcomes from surgery as a result of medical complications. Although geriatric trauma models are evolving to meet the demand of an ageing trauma population, medical support to trauma services is commonly delivered by general physicians, many of whom lack experience and training in this field. Determining the role of surgery and interrupted anticoagulation requires careful personalised risk assessment. Appreciation of the opposing risks can be challenging; it requires an understanding of the evidence base in both surgery and medicine to rationalise decision making and inform communication. This article aims to provide an overview for the physician with clinical responsibility for patients who have sustained head injury.

Localized Right Subclavian Artery Dissection Detected by Accident on an Ultrasound Examination: A Case Report and Literature Review

Right subclavian artery dissection was detected in a 78-year-old female victim of the Kumamoto earthquake during a carotid artery ultrasound examination. She was subsequently taken to hospital and diagnosed with localized subclavian artery dissection (LSAD) by contrast-enhanced computed tomography. There have been no previous reports of LSAD detected at a medical checkup. LSAD may progress and become severe, even in asymptomatic patients or patients with mild symptoms, and careful long-term follow-up is therefore required in all patients diagnosed with LSAD.