Acute necrotic hemorrhagic leukoencephalitis related to COVID-19: a report of 2 cases

Acute necrotic hemorrhagic leukoencephalitis (ANHLE) is a subform of acute disseminating leukoencephalitis which is a post viral or vaccination uncommon disease with poor prognosis. Radiological findings include multiple or diffuse lesions involving the white matter and sparing the cortex with or without rim enhancement. In addition to areas of hemorrhages with possible involvement of basal ganglia and thalami. We describe the imaging findings for 2 cases of ANHLE; a 59-years-old male and a 47-years-old female. Both of them were tested positive of SARS-COVID2 with presentation of consciousness loss and respiratory failure. CT and MRI brain show global white matter changes associated with acute hemorrhagic necrosis, although uncommon, are compatible with postviral acute necrotic hemorrhagic leukoencephalitis with end point of death for the first patient and coma for the second patient.

A case report of spinal dural arteriovenous fistula: origins, determinants, and consequences of abnormal vascular malformations

A spinal dural arteriovenous fistula is an abnormally layered connection between radicular arteries and venous plexus of the spinal cord. This vascular condition is relatively rare with an incidence of 5–10 cases per million in the general population. Diagnosis of spinal dural arteriovenous fistula is differentiated by contrast-enhanced magnetic resonance angiography or structural magnetic resonance imaging, but a definitive diagnosis requires spinal angiography methods. Here, we report a case of a 67-year-old female with a spinal dural arteriovenous fistula, provide a pertinent clinical history to the case nosology, and discuss the biology of adhesive proteins, chemotactic molecules, and transcription factors that modify the behavior of the vasculature to possibly cause sensorimotor deficits.

Fifty-four emergent cricothyroidotomies: are surgeons reluctant teachers?

BACKGROUND

Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that, although most cricothyroidotomies occur in the emergency department (ED), they are rarely performed by EM physicians.

METHODS

We conducted a retrospective analysis of all emergent cricothyroidotomies performed at two large level one trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined.

RESULTS

Fifty-four cricothyroidotomies were performed. Patients were: mean age of 50, 80% male and 90% blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an Emergency Medical Services (EMS) provider (n = 6, 11%) and a EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared to in-hospital procedures (p < 0.0001).

CONCLUSIONS

1. Pre-hospital cricothyroidotomy results in serious complications. 2. Despite the ubiquitous presence of emergency medicine physicians in the ED, all crico-thyroidotomies were performed by a surgeon, which may represent a serious emergency medicine training deficiency.

Status of HIV infection among the pregnant women attending in outpatient department

Human immunodeficiency virus (HIV) infection has been spreading rapidly in the developing countries and vertical transmission also taking place. This study has been done to find out the prevalence of HIV infection among the pregnant women, so that necessity of routine screening test can be identified. It is a cross sectional study. Five hundred two pregnant women were included. Three ml venous blood was taken and then HIV screening test was done by ELISA method. All reactive tests were confirmed by Western blot antibody testing. The positive cases were followed up and necessary treatment was given. Delivery was conducted in this hospital. Baby's blood was tested to see vertical transmission after 18 months. Most of the subject were educated housewife, mean age was 25 years. Six (6%) husband was overseas service holder, 12% were smoker and 1.6% had drug addiction. Eight (8%) subject had previous history of blood transfusion and 49% subject or her husband had history of surgery or got parental therapy. 2% subject gave the history of familial disharmony and 2% had multiple sex partners. HIV infection was found in 2 patients (0.4%). Both of them got infection from their husband. One husband was over seas service holder and another one was injecting drug user. For the prevention of spread, reduction of vertical transmission and providing early management to the positive patient all pregnant women should be screened for HIV routinely.

Characteristics of infertile couples

The objective of the study was to evaluate the sociodemographic characteristics and to find out the causes of infertility among the couple attending out patient department of infertility unit in Bangabandhu Sheikh Mujib Medical University (BSMMU) from January to December 2007. This is a descriptive observational study. Data were analyzed done manually and statistical analysis was calculated by Statistical package for social sciences (SPSS) program. During this period 3184 patients were attended out patient department (OPD) of infertility unit (IU-I & II). Among them primary infertility was present in 1971(61.90%) and secondary infertility in 1213(38%) cases. One thousand four hundred and two (1402) patient's complete data were reviewed from OPD register book of IU-I. The mean duration of the infertility was 4.7(4.52) years. The mean age of female patient was 26.5±5.35 years. The mean age of male patient was 34.56±6.33 years. A positive male factor problem alone was found in 13% couples, female factors in 71.46% couples and unexplained infertility in 15.47% couples. Among the male factor Oligozoospermia (33.33%) was the most common cause of male infertility. Anovulation (52.16%) was the most common cause of female infertility and major cause of anovulation was Polycystic ovary syndrome (PCOS) (29.90%). Fibroid uterus, Bilateral tubal block and Pelvic inflammatory disease (PID) were significantly (p<0.001) higher in secondary infertility. Endometriosis and unexplained infertility were significantly (p<0.001) higher in primary infertility. Distribution of other causes of infertility was same for both primary and secondary infertility.

Ethical awareness in surgical management

Getting information about disease has been suffering, the management needed, procedure and complication of that management, is the right of the patients. Giving that information to the patients is the responsibility of the physician/surgeons. The objective of this study was to assess the existing awareness of the surgeons and female patients regarding ethical issues of medical practices. This observational study was undertaken in the gynecological department of two tertiary hospital of the capital city of Bangladesh. One hundred fifty five patients were interviewed who were underwent surgical management for different gynecological problems. Mean age of the studied population was 41 (SD+/-10) years. All of them were from lower and lower middle economical classes. Sixty three percents (63%) were illiterate. Consent for the surgery was given by the husband in 52% cases, by son in 22% cases, by herself in 1% case and remaining by other relatives. About 50% of the patients did not know the name of their disease, 75% of them never talked with the surgeon. Only in 31% cases surgeon spontaneously explained them about her disease. Most of them had no knowledge about anaesthesia, operating time, need of blood transfusion, operating complications and long-term effects of the surgery they had. The result of this study showed very poor awareness about medical ethics and patient's right.

Laser Doppler imaging determines need for excision and grafting in advance of clinical judgment: a prospective blinded trial

INTRODUCTION

Clinicians' judgment as to which burns require excision and grafting remains one aspect of burn care without objective measurements. This study presents a prospective, blinded trial to assess decision to operate by laser Doppler imaging (numerical criteria) versus the clinical judgment of an experienced burn surgeon.

METHODS

A number of 23 patients were enrolled in this prospective trial and 41 representative wounds of indeterminate depth were selected for observation. Daily determination of need to operate (burn depth) was made by a single burn surgeon. Laser Doppler imager (LDI) scans of the same wounds were simultaneously obtained, and not revealed to the clinician. Data analysis compared quickness of decision to operate by LDI to the clinician's judgment. Concurrence of decisions by either method was compared.

RESULTS

A total of 23 patients and 41 wounds were analyzed. LDI and the surgeon agreed in determination of wound depth 56% of the time (23/41, P=0.031). Biopsy confirmation was obtained for 21 wounds. The surgeon's determination of burn depth was accurate in 71.4% of wounds biopsied (15/21). When the LDI scan median flux indicated need for excision, it was 100% accurate (7/7). When both the surgeon and the LDI were correct in assessing wound depth, LDI would have saved median number of 2 days (minimum=0, maximum=4).

CONCLUSION

LDI allowed for earlier, objective determination of need to operate. Concurrence with clinical judgment in this blinded study was excellent. LDI should be seen as an effective aid to clinical judgment when contemplating excision of burns with indeterminate depth.

Visceral ischemia after cardiopulmonary bypass

The diagnosis and management of gastrointestinal complications associated with cardiopulmonary bypass is often hindered by a complicated clinical picture and equivocal examination. To better define the incidence, risk factors, and mortality, we reviewed the records of all patients undergoing cardiopulmonary bypass from 1988 through 1996. The database for this study comprised 14,521 patients who underwent cardiac surgery. The patients (543) with gastrointestinal complications were identified, and those with major complications (166) were individually reviewed. Major complications included pancreatitis, gastritis, laparotomy, gastric ulcer, cholecystitis, colonic perforation, gastrointestinal bleeding, diverticulitis, bowel obstruction, perforation, and visceral ischemia. Our results were the following. 1) Gastrointestinal complications were noted in 3.7 per cent (543) of patients with major complications occurring in 1.2 per cent. In 166 patients, 187 major complications were noted. 2) Visceral ischemia, an infrequent but usually fatal (71%) complication, occurred in 24 (0.17%). 3) Of the ischemic events, 83 per cent (20 of 24) affected the bowel; with the colon involved 80 per cent of the time (16 of 20). 4) Patients with visceral ischemia were more likely to be female (relative risk 2.1), have longer pump times (92.2 versus 74.2), have cardiac procedures other than coronary artery bypass graft (relative risk 2.6), and have end-stage renal disease (relative risk 16.7). We conclude that, given the incidence and mortality related to visceral ischemia, especially to the colon, patients with risk factors (end-stage renal disease, female sex, non-coronary artery bypass graft, and longer pump times) should undergo routine endoscopic examination of the colon early after bypass and when clinically indicated thereafter.

A placental-derived tissue matrix as a bowel wall substitute in rats: preliminary study

BACKGROUND

Occasionally, conventional closure of an intestinal wall defect (fistula) is not possible. The development of a biologic material that can be used in this setting would solve a significant clinical problem. We hypothesized that a collagen patch (connective tissue matrix [CTM]) designed to allow tissue regeneration was such a material.

METHODS

To test this hypothesis, we performed a laparotomy on 75 male Sprague-Dawley rats (experiment A) and removed 25% of the anterior cecal wall (1 cm in diameter) to compare intestinal wound healing in four situations: (1) control (no repair), (2) fibrin glue repair, (3) primary repair, and (4) repair with CTM (human placental bilayer, types I, III, and IV). Animals were killed at 1, 2, 4, and 6 weeks. Healing was graded by bursting pressure expressed in millimeters of mercury, histologic score (0 to 4), and mortality rates. After this, we used the same protocol to remove 80% of the cecal wall (1.5 x 2.0 cm) in 19 animals (experiment B) to compare (5) fibrin glue repair alone with (6) CTM repair in a situation in which the defect was too large for primary repair.

RESULTS

CTM repair of a lethal cecal wall defect (experiment A) is equivalent to either primary repair or fibrin glue repair. When the defect is too large for primary repair (experiment B), repair with fibrin glue also does not work. However, in this same setting, CTM repair is successful (p < 0.00001).

CONCLUSIONS

Intestinal wall defects not suitable for conventional closure can be repaired successfully with a collagen patch, with histologic characteristics similar to those seen with primary repair.

Does resuscitation produce a reperfusion injury?

Conceptually, shock with resuscitation should produce cellular changes that parallel those observed in a single organ exposed to ischemia with reperfusion, i.e., a transient worsening of the injury pattern after reperfusion with the degree of recovery reflecting the magnitude of the ischemic injury. To test this hypothesis, 74 male Sprague Dawley rats (300-400 g) were randomized into two groups with controls and exposed to 1) hemorrhagic shock (mean arterial pressure < 50 mm Hg) for 2 hours before sacrifice, or 2) shock (2 hours) with reinfusion of shed blood over 1 hour before sacrifice. Mean arterial pressure, blood loss, serum lactate, base excess, and bicarbonate were serially measured to determine the degree of tissue ischemia. At sacrifice, hepatic mitochondrial function was determined by the respiratory control ratio. Our findings were as follows: 1) Hemorrhagic shock produced significant (P < 0.001) tissue ischemia and impairment of mitochondrial function (P < 0.001), 2) resuscitation rapidly corrects the metabolic sequelae of tissue ischemia, and 3) mitochondrial function was unaffected by resuscitation. We conclude that resuscitation rapidly corrects the tissue ischemia associated with hemorrhagic shock, without producing any measurable reperfusion injury at the mitochondrial level.

Portal vein thrombosis in the adult: surgical implications in an era of dynamic imaging

Extrahepatic portal vein thrombosis (EHPVT) is the leading cause of variceal hemorrhage in patients with healthy livers; however, in an era of dynamic imaging, the incidental discovery of EHPVT places a special burden on the surgeon to understand the surgical implications of the disease in this setting. During the period 1989 to 1995, 23 patients (12 males and 11 females) were found to have EHPVT. In 20 (87%), this was an unexpected finding on ultrasound (11 of 23), abdominal CT scan (9 of 23), or both (9 of 23). In two patients, the diagnosis was suspected and confirmed with angiography, whereas in the other, the lesion was discovered at surgery. Only seven (30%) had hemorrhage as a presenting complaint. More typically (61%), abdominal pain alone or pain with sepsis was the indication for evaluation. In 20 patients (87%), there was an identifiable etiology for the EHPVT. A total of 15 operations were performed on 12 patients (52%), in 7 (4, variceal hemorrhage, and 3, bowel ischemia) as a direct consequence of the EHPVT and in five, for conditions not directly related to the EHPVT. Three of the 23 patients (13%) died, two (17%) following surgery and one (9%) from advanced malignant disease. No patients with hemorrhage (seven), even those who required a shunt for decompression (three) or devascularization (one), died. We found that the diagnosis of EHPVT is usually not related to variceal hemorrhage, but rather, abdominal symptoms that serve as an indication for the imaging study. Three subsets of patients emerged: (1) those requiring no surgery (11 patients), (2) those requiring surgery related to hemorrhage (4 patients), and (3) those requiring surgery for conditions other than varices (8 patients). In any of these circumstances, mortality (13%) was related to the underlying disease process rather than EHPVT. Given the earlier recognition of EHPVT, the natural history of the disease has been altered, with outcome reflecting the underlying disease rather than the sequelae of portal hypertension.

A five-year prospective study of the health of children in different ethnic groups, with particular reference to the effect of inbreeding

A 5-year prospective study of 4,934 children of different ethnic groups has demonstrated a 3-fold increase of postneonatal mortality and childhood morbidity in the offspring of consanguineous Pakistani parents. Most of these families contained more than one consanguineous union, resulting in a mean inbreeding coefficient for their children of 0.0686. It is estimated that 60% of the mortality and severe morbidity of this group of children could be eliminated if inbreeding ceased. However consanguinity is much favoured in this minority group, and health education will have to be carefully and sensitively handled.

Why do UK-born Pakistani babies have high perinatal and neonatal mortality rates?

A prospective study of 4934 babies of different ethnic groups has confirmed the high perinatal mortality rate for Pakistanis and has shown that this was not due to a reluctance to terminate a fetus who is known to be seriously malformed. The major cause of early mortality was a high rate of lethal malformations, which occurred in about 1 in 100 Pakistani babies and which accounted for about half of their perinatal mortality. Many of these were autosomal recessive and occurred only in the offspring of consanguineous parents. However, there was also an excess of lethal cardiac malformations which were not associated with parental consanguinity. The remainder of the excess perinatal mortality was probably due to socio-economic factors. These causes are partly amenable to preventive measures, such as the referral of Pakistani women for expert ultrasonography at 18 to 20 weeks of pregnancy.

Race, consanguinity and social features in Birmingham babies: a basis for prospective study

STUDY OBJECTIVE

The aim of the study was to investigate the influence of consanguinity on children's health.

DESIGN

The study is a prospective survey from birth to five years of a cohort of babies born in a multiracial community. This report details the initial findings on consanguinity.

SETTING

Participating families live predominantly in three health districts of Birmingham, and were recruited in three local maternity hospitals.

PARTICIPANTS

Babies of 2432 European mothers, 509 Afro-Caribbean mothers, 625 Indian mothers, 956 Pakistani mothers, and 216 Bangladeshi mothers have been enrolled in the study. Eighty mothers refused to participate.

MEASUREMENTS AND RESULTS

Sociodemographic information was obtained using a structured questionnaire administered at interview. Interview data were supplemented with obstetric information from the medical records. The highest prevalence of parental consanguinity was in Pakistani Muslims (69%), whereas in Muslims from other countries it was 23%, and it was less than 1% in non-Muslims. In the majority of consanguineous Muslim pedigrees the degree of inbreeding was greater than that for first cousin parents.

CONCLUSIONS

This prospective study will allow an assessment to be made about any ill health in childhood arising from parental consanguinity, about whether screening programmes are indicated for particular autosomal recessive diseases, and about whether premarital health education might be beneficial. The study has also documented parental ages in different races and this, together with the levels of parental consanguinity in all races, will be useful in genetic methods for assessing the frequency of recessive genes, the possibility of genetic heterogeneity, and whether or not parental age effect exists for new mutations of specific genetic disorders.