Inadvertent Placement of Thoracic Epidural Catheter in Pleural Cavity: A Case Report and Review of Published Literature

Thoracic epidural placement is considered the gold standard for pain management for abdominal or thoracic surgery. It provides analgesia superior to that provided by opioids with a decreased risk of pulmonary complications. Insertion of a thoracic epidural catheter requires the knowledge and expertise of an anesthetist; epidural catheter insertion may be challenging especially when sited in the higher thoracic region, in patients with unusual neuraxial anatomy, patients unable to position adequately for insertion or morbidly obese patients. Postoperatively the anesthetic team is required to look after the patient and assess for any complications such as hypotension. Even though the incidence of complications may be low; however, some of these could have detrimental consequences for the patients such as epidural abscess, hematoma formation, and temporary or permanent neurological damage. In this case report, we will discuss a patient who underwent a three-stage esophagectomy for esophageal squamous cell carcinoma under general anesthesia with epidural analgesia. The epidural catheter (Portex® Epidural Minipack System with NRFit® connector, ICUmedical, USA) was found in the intrapleural space during video-assisted thoracoscopy for the thoracic part of esophagectomy. To facilitate surgical access, the catheter was removed immediately, and the patient was given patient-controlled analgesia with morphine for postoperative pain control.

Delivering results to clients: a question of satisfying needs or desires?

Demand for genitourinary (GU) medicine services is outstripping supply. Improving efficiency can modulate the supply side of the equation, e.g. decreasing the number of clients having to return for their results. This survey explored how clients at two central London GU medicine clinics would like to receive their results and their views were reflected against what was offered by London GU medicine clinics. There was a significant difference between the result delivery services that the clients wanted and what the clinics provided ( P <0.0001, χ2). Of the clients, 92% wanted to know their results regardless of outcome whereas 22% of London clinics would only inform clients of positive results. This study questions the importance and feasibility of patient choice, an important aspect of the National Strategy for Sexual Health and HIV. Clinics may not individually be able to provide choice but between them, they do provide a wide range of alternatives for the client.

Dissociative electron attachment to gas phase glycine: exploring the decomposition pathways by mass separation of isobaric fragment anions

Dissociative electron attachment to gas phase glycine generates a number of fragment ions, among them ions observed at the mass numbers 15, 16 and 26 amu. From stoichiometry they can be assigned to the chemically rather different species NH(-)/CH(3)(-)(15 amu), O(-)/NH(2)(-)(16 amu) and CN(-)/C(2)H(2)(-)(26 amu). Here we use a high resolution double focusing two sector mass spectrometer to separate these isobaric ions. It is thereby possible to unravel the decomposition reactions of the different transient negative ions formed upon resonant electron attachment to neutral glycine in the energy range 0-15 eV. We find that within the isobaric ion pairs, the individual components generally arise from resonances located at substantial different energies. The corresponding unimolecular decompositions involve complex reaction sequences including multiple bond cleavages and substantial rearrangement in the precursor ion. To support the interpretation and assignments we also use (13)C labelling of glycine at the carboxylic group.

Effect of immunization with six sperm peptide vaccines on fertility of female mice

Spermatozoon is an exciting target for contraceptive vaccine development. Several sperm antigens (native or recombinant) and sperm peptides cause various degrees of contraceptive effect in female mice. No single antigen/ peptide has shown to cause a complete block in fertility in the mouse model. To enhance the efficacy of the vaccine, six sperm peptides were selected for the present study namely mFA-12,19, mFA-1117136, YLP12, P10G, A9D and SP56. These have been shown to cause > 50% to > 80% reduction in fertility when used individually for immunization. The present study was undertaken to test the hypothesis that the vaccination with all the six peptides together will enhance the contraceptive efficacy by an additive effect resulting in a complete block of fertility in the mouse model. Six vaccines were prepared by conjugating the six synthetic peptides with the recombinant binding subunit of cholera toxin (rCTB). Female CD-1 mice were immunized intramuscularly with all the six peptide vaccines. Each animal received a total of five injections at 2- to 3- week intervals of all of the six vaccines and each vaccine was injected at a separate site. Approximately four weeks after the last injection, the animals were mated. Immunization of each mouse with all six peptides resulted in a dose-dependent inhibition of fertility. At 150 micro g dose, there was an overall 45% reduction compared to controls. Several mice produced antibodies (> or = 2SD units) against these peptides in the serum and the genital tract but the titers were low, and many animals did not respond to several peptides. No animal produced antibodies to all six peptides in serum or the genital tract. When the antibody titers against all six peptides disappeared after > 10 months from circulation and the genital tract, all the animals regained fertility. These findings indicate that the immunization with the six sperm peptide vaccines induce antibodies in serum and the genital tract that cause a reversible long-term contraceptive effect in female mice. The inhibition in fertility was up to 45% rather than a complete block that seems to be due to low antibody titers, especially in the genital tract. It was interesting to note that even with such low titers there was a significant reduction in fertility after immunization with multipeptide vaccine. Multipeptide vaccination is an exciting approach and the present preliminary data warrant further studies.

Haemophagocytic syndrome associated with hepatitis-B virus infection responding to etoposide

Haemophagocytic syndrome (HPS) secondary to viral infections usually has a variable course and can be life-threatening. We report a 53-year-old male patient who presented with fever, hepatosplenomegaly and pancytopenia. He had deranged liver function, abnormal clotting and markedly elevated serum ferritin. Bone marrow biopsy showed prominent haemophagocytosis. The patient was investigated thoroughly and found to have evidence of chronic hepatitis B-virus (HBV) infection by serological tests and liver biopsy. Other conditions associated with HPS such as lymphoma, malignancy and other viral or bacterial infections were not present. The patient did not respond to steroids, intravenous immunoglobulins or cyclosporin but responded to etoposide and became apyrexial. He also became HBV negative on lamivudine. The patient died of infection later on but there was no evidence of recurrence of HPS. To the best of our knowledge this is the first case report of HPS associated with isolated HBV infection.

Spherocytosis preceding the development of myelodysplasia

We report two patients with prominent spherocytosis in the peripheral blood who later went on to develop myelodysplasia. There was no evidence of a myelodysplastic syndrome at the time of presentation. Morphological abnormalities of the peripheral blood along with possible explanations of spherocytosis are discussed.

Hypocalcemia due to hypoparathyroidism in beta-thalassemia major patients

BACKGROUND

This is a retrospective analysis of case records of AA(2)-thalassemia major patients who developed hypoparathyroidism (HPT). The objective of this study was to assess the prevalence of hypocalcemia and hypoparathyroidism in AA(2)-thalassemia major patients being followed at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia.

PATIENTS AND METHODS

Diagnosis was based on low serum calcium (S/Ca), high serum phosphate (Po4), normal serum magnesium and alkaline phosphatase, and low serum parathyroid hormone levels. Other parameters analyzed included age, sex, serum ferritin levels, age of onset of HPT, any symptoms of hypocalcemia, and presence of other complications in these patients.

RESULTS

Out of 40 patients, eight (20%) were diagnosed to have HPT. The mean age at diagnosis was 13.6 years (range 11-16 years), mean serum calcium was 1.88 mmol/L (range 1.58-2.04), mean serum ferritin was 7490 AA(1/4)g/L (range 2000-23,064) and mean serum phosphate was 1.88 mmol/L (range 1.50-2.73). Serum parathyroid hormone (PTH) levels were low in most of the patients. Only two patients (25%) had mild symptoms of hypocalcemia. Growth retardation was present in all patients, while four patients had liver dysfunction, two had diabetes mellitus and two had cardiac dysfunction.

CONCLUSION

HPT due to iron overload may develop in a significant number of thalassemia major patients, especially when chelation therapy is not optimal, therefore, all thalassemics should be carefully watched for this complication from early in their second decade.

Single SPECT measures of cerebral cortical perfusion reflect time-index estimation of dementia severity in Alzheimer's disease

To determine the relationship between cerebral cortical blood flow loss and the temporal development of the dementia in Alzheimer's disease (AD), SPECT was studied in a cross section of AD patients with a broad range of impairment.

METHODS

Thirty patients with a diagnosis of probable AD had their mini-mental state examination scores transformed into time-index values to give an estimation of dementia severity relative to the developmental time course. SPECT images were obtained using 99mTc-ethyl cysteinate dimer and a 3-head camera. Cortical surface perfusion was analyzed, including modified Talairach standardization, to obtain cortical elements from the convexity (each representing about 0.25 cm2 at the surface, 6.6-mm cortical depth) referenced to the mean perfusion of the full greater cerebellar hemisphere. These element ratios were analyzed (individually and by averages of estimated Brodmann's areas and brain regions) using linear regression with the time-index value.

RESULTS

For individual posterotemporal and inferoparietal Brodmann's areas (21, 22 and 39, 40, respectively) the correlation coefficients between cortical perfusion ratios and dementia severity ranged between -0.67 and -0.78 (P < 0.001). Perfusion ratios from these regions declined 2.5%-4.2% for each estimated year of progression. Prefrontal area perfusion showed less association with severity. Perfusion in primary cortical regions had no significant association with dementia severity.

CONCLUSION

Cerebral cortical perfusion loss is temporally related to development of dementia. The spatial pattern of high, significant correlations between cortical perfusion and dementia severity shows a regional distribution that corresponds closely to the distribution of AD pathology described in autopsy studies.

Granulocyte-Macrophage Colony-Stimulating Factor in Newly Diagnosed Adult Patients with Acute Lymphoblastic Leukemia Treated with Conventional Chemotherapy

Twenty consecutive adult patients with newly diagnosed acute lymphoblastic leukemia (ALL) were treated with conventional therapy consisting of daunorubicin, vincristine, prednisone and L-asparaginase in standard doses. Granulocyte-macrophage colony-stimulating factor (GM-CSF) was administered at a single subcutaneous daily dose of 5 microgram per kilogram body weight for fourteen days starting on day 7 of chemotherapy. Twenty two adult patients with acute lymphoblastic leukemia and similar risk characteristics who received the same chemotherapeutic regimen without GM-CSF served as a historical control group. The complete remission rate and the rate of early mortality were similar in both groups of patients. Patients treated with GM-CSF showed significantly faster neutrophil recovery above 0.5 × 10(9)/L than the control patients (P < 0.005). The incidence of febrile episodes and the rate of documented infection were similar in the two groups of patients.

Dexamethasone suppression test, schizophrenia and movement disorder

The dexamethasone suppression test (DST) was administered to 20 patients with schizophrenic illness. Ten of these patients also had tardive dyskinesia (TD). The scores on TD and parkinsonism scales were significantly higher in DST nonsuppressors. There was also a significant positive correlation between the post-dexamethasone cortisol level and the movement disorder scales.

Carbohydrate craving and increased appetite associated with antidepressant therapy

The symptom of carbohydrate craving and increased appetite (CHH) was studied in 180 outpatients receiving antidepressant treatment. One hundred and fifty-eight of these patients had a DSM-III diagnosis of panic disorder and 17, major depression. The incidence of CHH was similar in both diagnostic groups. Thus, antidepressant treatment is associated with CHH in patients with diagnoses, other than depression. Desipramine was least likely to induce CHH compared to imipramine, amitriptyline and doxepin. Most patients who developed CHH on imipramine no longer experienced this side effect when switched to desipramine. CHH was not more frequent among women and not associated with antidepressant dosage or treatment response. Histamine H-1 receptor blockade may be an important factor in the etiology of CHH.

A laboratory procedure for the induction of flashbacks

The authors administered infusions of lactate intravenously to seven patients with a DSM-III diagnosis of posttraumatic stress disorder, six of whom also met DSM-III criteria for panic disorder. The lactate infusions resulted in flashbacks in all seven patients and panic attacks in six patients. The authors conclude that with further development intravenous lactate infusion may be used to study flashbacks and other dissociative phenomena and to determine the relationship between flashbacks and panic anxiety.

Schizophrenia-like psychosis associated with vein of Galen malformation: a case report

A 34 year old patient presented with a schizophrenia-like clinical picture, and was later found to have a large vein of Galen Arteriovenous Malformation (AVM). There are reports in the literature suggesting that vein of Galen AVMs are associated with psychiatric symptoms. However, the clinical pictures tend to be non specific. We discuss the relevance of the association of vein of Galen AVMs with schizophrenia-like symptomatology.

[Tolerance and pharmacovigilance of trazodone]

Trazodone has been approved for marketing in the United States over three years ago. During this period, over two million patients have been exposed to the compound. It is also estimated that world wide another four million individuals have been treated with the compound. This provides a fairly large clinical experience for us to draw conclusions about safety and tolerance data, both from the initial control studies and from the extensive post-marketing surveillance available as a result of this extensive clinical experience. Trazodone, "this second generation" antidepressant and its clinical efficacy and safety data, can be reviewed against the background of tricyclic antidepressants and monoamine oxidase inhibitors. These previously established therapeutic agents have been available for many years and can be used as a major reference point in making these assessments. The special areas of side effect experience with the tricyclic antidepressants have been the occurrence of significant anticholinergic side effects and the particular problems that these induce in an elderly population. In addition, the tricyclic antidepressants have been associated with a variety of cardiac effects. The other major area of concern in clinical practice is the drug interactions that may occur with the newly introduced compound. A considerable experience has been obtained with such exposure and this material will also be reviewed and presented.(ABSTRACT TRUNCATED AT 250 WORDS)

Opiate withdrawal-induced hyposensitivity to naloxone's effects on serum luteinizing hormone in the male rat

In previous studies, it was demonstrated that morphine pellet implantation markedly sensitized adult male rats to the subsequent elevations in serum luteinizing hormone (LH) levels produced by the opiate antagonist, naloxone. The present studies were carried out to examine the persistence of this phenomenon upon pellet removal and to characterize the relationship between naloxone-induced alterations in serum LH and the development and dissipation of precipitated withdrawal behavior. We found an excellent correlation between both the development and dissipation of naloxone-precipitated withdrawal behavior and hypersensitivity to naloxone's effects on serum LH. However, although there was no evidence of protracted effects of chronic morphine administration upon pellet removal as assessed by withdrawal behavior, the effects of naloxone on serum LH levels did not return to normal for nearly a week postwithdrawal. The markedly enhanced sensitivity to naloxone normally observed in the pellet-implanted animal dissipated immediately after pellet removal (6-24 hr), but, rather than exhibiting normal levels of responding, morphine-withdrawn animals were markedly hypo-sensitive to naloxone. The antagonist did not increase LH at all in pellet-withdrawn animals and, in fact, appeared to depress them at many doses in the acutely withdrawn animal; normal responses did not return until 4 to 7 days after pellet removal. The mechanisms underlying the striking withdrawal-induced reversal of naloxone's effects on serum LH levels are presently unclear, but our data are consistent with the hypothesis that chronic morphine administration induces a fundamental change in the sensitivity of the endogenous opioid-mediated control of LH, which takes some time to revert to normal upon abrupt termination of opiate administration.

Influence of preoptico-anterior and posterior hypothalamus on midline thalamic neurons

The present study was aimed at understanding the influence of the posterior hypothalamus (PH) and the preoptico-anterior hypothalamus (PO-AH) on the neurons of the midline thalamus (MTh) in encéphale isolé cats. A majority of the influenced neurons of the MTh showed increased firing on stimulation of the PH. Although the number of neurons showing increased or decreased firing on PO-AH stimulation were nearly equal, stimulus bound increased firing in many neurons was followed by a prolonged decreased firing. It is likely that the hypothalamo-thalamic circuit constitutes a parallel pathway to the reticulo-thalamic circuit for alteration of the cortical EEG.