Convexal subarachnoid haemorrhage in a patient under pembrolizumab-lenvatinib combination therapy

A woman in her 60s was brought to the emergency department due to a new-onset seizure. She was drowsy on arrival and unable to provide a clinical history. She had a medical history of advanced endometrial cancer, for which she was under the therapeutic protocol pembrolizumab plus lenvatinib. Laboratorial investigations were unremarkable. The brain CT angiography provided further insight into the case by detecting a bilateral convexal subarachnoid haemorrhage with discrete bilateral opercular vasogenic oedema, without other noticeable structural changes. Cerebrospinal fluid analysis was macroscopically haemorrhagic, but otherwise unremarkable. The brain MRI did not provide additional information. Although considered a rare adverse reaction, cerebral haemorrhage has been described for both pembrolizumab and lenvatinib. We cautiously assumed a probable drug aetiology after a thorough review of potential causes. Following discontinuation of these drugs and under anti-convulsive therapy, the patient remained asymptomatic and was discharged home.

Establishing trace element concentrations for lichens and bryophytes in the ring of fire region of the Hudson Bay Lowlands, Ontario, Canada

Peatlands dominate the landscape of the Hudson Bay Lowlands in Ontario, Canada. Recently, mineral deposits of chromium (Cr), nickel (Ni), and copper (Cu) were discovered in the region and anticipated future industrial mining operations have the potential to impact the environment. Lichens and bryophytes are considered excellent biomonitors and indicators of deposition, deriving their nutrients directly from the atmosphere. Trace element concentrations in lichens and bryophytes have not been reported in the Hudson Bay Lowlands. Here, we seek to determine the baseline trace element concentrations of six non-vascular species (Evernia mesomorpha, Bryoria spp., Cladonia stellaris, Cladonia stygia, Sphagnum fuscum, and Sphagnum capillifolium) common to the region, explore linear relationships of trace elements with iron (Fe) as a signature of particulates with geogenic origin, and calculate trace element enrichment factors. Thalli, foliage, and peat (0-30 cm) were collected from 55 locations between 2013 and 2018 and analyzed for trace elements. Thalli and foliar concentrations are among the lowest reported in the broader literature and differ substantially from peat. Fe concentrations were significantly correlated (Pearson's r ≥ 0.8) with aluminum (Al), titanium (Ti), and vanadium (V) in all six species. Enrichment factors show some anthropogenic deposition effects non-vascular organism chemistry. Most trace element concentrations in lichens and bryophytes are indicative of long-range atmospheric transport of dust, but some is attributed to industry, with only minimal inclusions from the local area. Epiphytic lichens are well suited for ongoing atmospheric biomonitoring as industrialization commences.

Transcholecystic approach for distal common bile duct stricture in a non-dilated biliary system: an alternative route

A 63-year-old patient was admitted to intensive treatment unit with biliary sepsis due to a small distal common bile duct stone. Endoscopic retrograde cholangiopancreatography was initially attempted for insertion of a biliary stent but failed due to the presence of a periampullary diverticulum. Referral to interventional radiology for percutaneous drainage was considered the next alternative even though there was no dilatation of intrahepatic ducts. Due to complete absence of intrahepatic duct dilatation, the traditional percutaneous transhepatic route was considered rather challenging. An alternative percutaneous approach via the gallbladder and subsequent catheterisation of the duodenum via the distal common bile duct was successfully performed instead without complication. We would like to describe this technique as an alternative option for drainage of the non-dilated biliary system in patients with sepsis.

Randomized control trial of non-vascularized fibular and iliac crest graft for mandibular reconstruction

BACKGROUND

Mandibular reconstruction of segmental defects caused by trauma or tumor excision is a challenge despite numerous advances in surgical and fixation techniques. Bone grafts from fibula or iliac crest are most frequently used to reconstruct mandible.

METHODS

A prospective randomized study was performed in 20 patients with benign mandibular pathology, to compare non-vascularized fibular and iliac crest bone graft for graft success, improvement in esthetics and function, and any associated donor site complications.

RESULTS

No significant difference in graft success, esthetics, function, or donor site complication were found between the two groups. Function improvement was significantly higher in fibula group as compared to iliac crest. An interesting finding of positive association between length of defect and complication was seen irrespective of the graft used, implying that patients with larger defects had higher complication rates.

CONCLUSION

Non-vascularized fibular bone graft is as better as iliac crest for reconstruction of mandibular defects of optimal length.