Recovery In Most Patients Research Articles

Relation of Mandibular Canal Discontinuity and IAN Paresthesia in Operated Cases of Mandibular Fracture.

Mandibular fractures are common in maxillofacial trauma, often requiring surgical intervention for optimal recovery. One critical concern during such procedures is the potential for nerve damage, specifically involving the mandibular canal. This study aims to investigate whether the presence of postoperative mandibular canal discontinuity is associated with an increased risk of nerve damage. A retrospective analysis was conducted on a cohort of 72 postoperative mandibular fracture patients. In total, 58 patients had entire mandibular canal continuity, while 14 showed discontinuity. Clinical records and follow-up data were examined to assess the occurrence of nerve injury. Statistical analysis was performed to determine the significance of any correlation. Of the 14 patients with mandibular canal discontinuity, 9 (64.28%) exhibited paresthesia. In patients where mandibular canal continuity was maintained, 5 (8.62%) patients reported paresthesia. These results suggest a higher incidence of paresthesia in patients with mandibular canal discontinuity, albeit with a small sample size. Notably, only 3 patients in the discontinuity group did not show any sign of improvement, while the remaining patients in both groups demonstrated complete recovery in 6 months of follow-up period. The findings suggest a potential link between mandibular canal discontinuity and an increased risk of paresthesia in postoperative mandibular fracture patients. It is hypothesized that discontinuity may lead to nerve compression, irritation, or direct damage during healing. The observed complete recovery in most patients, including those with paresthesia, highlights the potential for the nervous system to repair itself over a period of time. However, further studies with larger sample sizes are warranted to establish a more definitive correlation. This study provides preliminary evidence that mandibular canal discontinuity may contribute to a higher incidence of paresthesia in postoperative mandibular fracture patients. Clinicians should be cautious when addressing mandibular fractures to minimize the risk of nerve damage, particularly in cases involving canal discontinuity. The encouraging trend of complete recovery among the majority of patients suggests a positive prognosis for nerve healing.

Transient acute kidney injury after chimeric antigen receptor T-cell therapy in patients with hematological malignancies.

Acute kidney injury (AKI) occurs in 30% of patients infused with chimeric antigen receptor (CAR) T-cells. The purpose of this study was to identify risk factors and long-term outcomes after AKI in patients who received CAR T-cell therapy. Medical records of 115 adult patients with R/R hematological malignancies treated with CD19-targeted CAR T-cells at Vall d'Hebron University Hospital between July 2018 and May 2021. Baseline demographic data including age, gender, ethnicity, body mass index (BMI), and co-morbidities, as well as the type of hematological neoplasia and prior lines of therapy were collected. Laboratory parameters including serum creatinine and whole blood hemoglobin were retrospectively reviewed and values were gathered for days +1, +7, +14, +21, and +28 post-infusion. A total of 24/115 (21%) patients developed AKI related to CAR T-cell therapy; 6/24 with AKI over chronic kidney disease (CKD). Two patients had AKI in the context of lymphodepleting (LD) chemotherapy and the other 22 after CAR T-cell infusion, starting at day+1 in 3 patients, day+7 in 13 patients, day +14 in 1 patient, day+21 in 2 patients, and day+28 in 3 patients. Renal function was recovered in 19/24 (79%) patients within the first month after infusion. Male gender, CKD, cytokine release syndrome (CRS), and immune effector cell-associated neurotoxicity syndrome (ICANS) were associated with AKI. Male gender, CKD, ICANS grade ≥3 and CRS grade ≥2 were identified as independent risk factors for AKI on multivariable analysis. In terms of the most frequent CAR T-cell related complications, CRS was observed in 95 (82%) patients and ICANS in 33 (29%) patients. Steroids were required in 34 (30%) patients and tocilizumab in 37 (32%) patients. Six (5%) patients were admitted to the intensive care unit (1 for septic shock, 4 for CRS grade ≥2 associated to ICANS grade ≥2, and 1 for CRS grade ≥3). A total of 5 (4.4%) patients died in the first 30 days after CAR T-cell infusion for reasons other than disease progression, including 4 cases of infectious complications and 1 of heart failure. Our results suggest that AKI is a frequent but mild adverse event, with fast recovery in most patients.

Acute Otitis Media and Facial Paralysis in Children: A Systemic Review and Proposal of an Operative Algorithm.

Fifteen studies published between 2000 and 2022 were selected, including 120 patients (62 M/58 F) with an average age of 4.96 years old (range = 4 months-16 years; SD: 4.2). The paralysis frequently has a sudden onset and is of a severe grade (medium House-Brackmann (HB) score at onset: 4.68; SD: 0.5); however, it tends to have an almost complete recovery in most patients (88.49% HB 1 at follow-up). Its first-line treatment must be based on the use of antibiotics (beta-lactam antibiotics as penicillins or cephalosporins). Corticosteroids should be used concomitantly for their anti-inflammatory and neuroprotective actions; however, there is no unanimity between authors about their application. Myringotomy, with or without ventilation tube insertion, is indicated in cases where the tympanic membrane is intact. Other kinds of surgery should be performed only in patients who have a worsening of their AOM symptoms or a worsening in HB score even with clinical treatment. The obtained data show that a conservative treatment can be sufficient for complete recovery in most patients, and it is preferred as the first-line therapy. Mastoidectomy should be performed only in patients with acute mastoiditis and without symptom improvement after a conservative approach. There are insufficient data in the current literature to provide clear selection criteria for patients who need to undergo mastoidectomy with facial nerve decompression. The choice of this treatment is based on an individual center expertise. Further studies are needed to clarify the role of corticosteroids and the role of facial nerve decompression in this clinical scenario.

Real-World Effectiveness and Safety of Hetrombopag for Delayed Platelet Engraftment Post-Allogeneic Hematopoietic Stem Cell Transplantation

Background: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) serves as a critical therapeutic approach for various malignant and non-malignant hematopoietic disorders. Notwithstanding successful hematopoietic recovery in most patients following allo-HSCT, a subset may encounter delayed platelet engraftment (DPE), a prevalent and potentially serious complication that stems from myeloablative conditioning. Occurring in approximately 5%-37% of allo-HSCT recipients, DPE is a known harbinger of increased transplant-related mortality and diminished quality of survival. Despite its clinical significance, a well-established standard treatment protocol for post-allo-HSCT DPE remains elusive. Multiple platelet transfusions, often administered in such cases, not only exacerbate the economic burden but also induce toxicities, thereby undermining the patient's quality of life. An alternative to platelet transfusion lies in the utilization of thrombopoietin-receptor agonists (TPO-RAs), advocated for enhancing platelet engraftment. These agents interact with the thrombopoietin receptor, stimulating intracellular signaling pathways inclusive of JAK/STAT, PI3K/AKT, and ERK1/2, which in turn, promote megakaryocyte proliferation and differentiation, thereby augmenting platelet production. Hetrombopag, a novel, orally administered, non-peptide, small-molecule TPO-RA, has been validated to effectively boost platelet engraftment and reduce the necessity for platelet transfusions post-allo-HSCT in a pilot study. Our study sought to investigate the effectiveness and safety of hetrombopag in treating DPE following allo-HSCT within a real-world setting. Methods: In this retrospective study, we evaluated adult patients with hematopoietic disorders who underwent allo-HSCT and subsequently experienced DPE in our center, treated with hetrombopag between March 2022 and April 2023. Given the lack of a consensus definition, we deemed DPE as a platelet count (PLT) < 20 × 10 9/L or a significant and rapid decreasing trend past day 28 post-allo-HSCT. Hetrombopag dosages of 2.5 mg, 5 mg, or 7.5 mg/day were prescribed based on individual patient conditions. Response criteria post-treatment were as follows: complete response: PLT > 50 × 10 9/L without platelet transfusion; partial response: PLT between 20 and 50 × 10 9/L without platelet transfusion; no response: PLT < 20 × 10 9/L. Results: A total of 20 patients were included in the analysis, with a median age of 52, and 60% of them were male. Hetrombopag administration commenced at a median of 58 days following allo-HSCT at a median dose of 5 mg/day, with a median treatment duration of 44 days. The initial platelet count was 24.5 × 10 9/L and serum ferritin levels stood at 3351.1 ng/mL. Post-hetrombopag treatment, platelet counts escalated to 67.5 × 10 9/L while serum ferritin levels decreased to 2726.0 ng/mL. Of the 20 patients, 13 patients (65%) exhibited a complete response, 6 patients (30%) achieved a partial response, and 1 patient (5%) displayed no response. Hetrombopag was well tolerated with only 5 patients reporting increased alanine aminotransferase/aspartate aminotransferase or total bilirubin levels (all grade 1 or 2), and the association with hetrombopag was undetermined. Conclusion: Our findings suggest that hetrombopag yields a sustained response with acceptable tolerability in patients who experienced DPE following allo-HSCT, and could potentially offer a novel approach for managing such patients. Future large-scale, prospective studies are warranted to further assess the potential benefits of hetrombopag for improving patient outcomes following allo-HSCT.

Assessment of Autophagy Markers Suggests Increased Activity Following LVAD Therapy

Left ventricular reverse remodeling in heart failure is associated with improved clinical outcomes. However, the molecular features that drive this process are poorly defined. Left ventricular assist devices (LVADs) are the therapy associated with the greatest reverse remodeling and lead to partial myocardial recovery in most patients. In this study, we examined whether autophagy may be implicated in post-LVAD reverse remodeling. We found expression of key autophagy factors increased post-LVAD, while autophagic substrates decreased. Autolysosome numbers increased post-LVAD, further indicating increased autophagy. These findings support the conclusion that mechanical unloading activates autophagy, which may underly the reverse remodeling observed.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

SARS-CoV-2-specific T-cell responses after COVID-19 recovery in patients with rheumatic diseases on immunosuppressive therapy

BackgroundIn patients with immune-mediated rheumatic diseases (RMD), the development of T-cell responses against SARS-CoV-2 may be impaired by either the immune disturbances associated with the disease, or by the effects of immunosuppressive therapies. We aimed at determining the magnitude of SARS-CoV-2-specific interferon (IFN)-γ-producing T-cell response after COVID-19 recovery in a cohort of patients with RMD on different immunosuppressive therapies. Patients and methods53 adult patients with inflammatory or autoimmune RMD and 61 sex and age-matched non-RMD patients with confirmed COVID-19 were included. Peripheral blood mononuclear cells were obtained and T-cell-IFN-γ antigen-specific responses against the S1 domain of the spike glycoprotein, the nucleoprotein (N) and the membrane (M) protein from SARS-CoV-2 were assessed by FluoroSpot assay. ResultsPatients with RMD and COVID-19 showed positive T-cells-IFN-γ responses to SARS-COV-2 antigens, in a similar proportion and magnitude as non-RMD patients at a median of 298 [151–316] and 165 [162–167] days after COVID-19 respectively. Among RMD patients 83%, 87% and 90%, and among non-RMD patients, 95%, 87% and 93% responded to S1, N and M protein respectively. Similar responses were observed in the different diagnostic and therapeutic groups, including conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), TNF-α inhibitors, IL-17 inhibitors, rituximab, JAK inhibitors or other immunosuppressants. ConclusionT-cell responses to the main SARS-CoV-2 antigens are present after COVID-19 recovery in most patients with RMD and are not impaired by immunosuppressive therapies.

BIRD FANCIER'S DISEASE: A CASE OF HYPERSENSITIVITY PNEUMONITIS

TOPIC: Occupational and Environmental Lung Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: The immunologic lung disease through inhalation and sensitization of an aerosolized antigen is termed hypersensitivity pneumonitis (HP). Here we describe a case of HP from exposure to avian antigen. CASE PRESENTATION: A 42 y/o F presented with progressively worsening dyspnea at rest & exertion, pleuritic chest pain, dry cough for past 2 months. She denied sick contacts or recent travel. On exam BP: 122/76mmHg, HR 107bpm, RR 30bpm, SpO2 82% on room air. Physical exam, significant for b/l crackles. Labs: WBC 16.33 k/mm3, ABG PaO2 of 45mmHg. CXR showed b/l airspace opacities & CT-thorax showed b/l diffuse GGO. ECHO showed LVEF 55% with normal global systolic function with mildly elevated PASP. Treatment was initiated with hi-flo oxygen and her SpO2 improved to 97%. QuantiFERON Gold, urine legionella, Mycoplasma IgM, and respiratory multiplex viral panel were negative. Cardiac CT revealed patent coronaries. Spirometry revealed severe restrictive ventilatory defect. Further questioning revealed that patient got parakeets a few months prior to onset of symptoms. She was then started on methylprednisolone for possible HP. Bronchoscopy with BAL and transbronchial biopsies showed no bacterial/fungal/viral growth. Cytology was unremarkable and biopsies revealed mild inflammatory changes with lymphocytes and aggregates of intralaveolar foamy macrophages. The CD4:CD8 ratio was 0.89. Patient clinically improved with steroid therapy and gradually weaned from supplemental oxygen. She was discharged on oral prednisone with close follow up where she continued to improve after removal of her parakeets DISCUSSION: HP an immune-mediated response from repeated inhalation, sensitization, & hyperresponsiveness to various organic particles which can be mammalian or avian proteins, fungi, bacterial, or chemicals. Based on duration of exposure & symptoms onset, HP can be divided into acute, subacute, or chronic. Acute HP presents as flu-like illness, subacute HP has insidious onset of symptoms, dyspnea on exertion or reduced exercise capacity. Physical exam reveals inspiratory crackles. Imaging usually demonstrates GGO, mosaic attenuation and centrilobular nodules. BAL reveals lymphocytic predominant cells with CD8 alveolitis. Histopathology usually demonstrates cellular bronchiolitis with predominant lymphocytic or plasmocytic infiltrates. It can also present as interstitial mononuclear infiltrates or loosely-formed granulomas. Treatment for HP is avoidance of antigen exposure. Role of steroids in treating HP is not well known, however general practice is slow tapering steroid regimen for about 3-6 months duration. Prognosis is usually good with complete recovery in most patients; a few may progress to chronic fibrosing HP. CONCLUSIONS: A high level of suspicion should be present in diagnosing HP with a thorough history and prompt management must be initiated to prevent progression of disease. REFERENCE #1: Selman M, Pardo A, King TE Jr. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Is J Respir Crit Care Med. 2012; 186:314-24. REFERENCE #2: Costabel U, Bonella F, Guzman J. Chronic hypersensitivity pneumonitis. Clin Chest Med. 012; 33:15163. REFERENCE #3: Camarena A, Juárez A, Mejía M, Estrada A, Carrillo G, Falfán R, Zuñiga J, Navarro C, Granados J, Selman M. Major histocompatibility complex and tumor necrosis factor-alpha polymorphisms in pigeon breeder's disease. Am J Respir Crit Care Med. 2001;163:1528-33. DISCLOSURES: no disclosure on file for Jagadish Akella; No relevant relationships by Alex Diaz, source=Web Response no disclosure on file for Iqbal Javed; No relevant relationships by Raghavendra Sanivarapu, source=Web Response

Investigating the Viability of Motor Imagery as a Physical Rehabilitation Treatment for Patients With Stroke-Induced Motor Cortical Damage.

Although around 83% of individuals survive a stroke, they usually experience a significant loss in their motor execution (ME) capabilities due to their acquired cortical infarction. The loss of significant ME capabilities due to stroke damage was previously thought to be irreversible. Active movement therapies show considerable promise but depend on motor performance, excluding many otherwise eligible patients. Motor imagery (MI), a process that involves the use of mirror neurons to imagine motor activity, has emerged as a possible avenue to re-acquire some physical abilities lost to stroke damage. This paper examines previous studies to compare the strength of brain activation and connectivity in individuals who have brain lesions and those who do not as they all attempt ME and MI tasks. This paper reviews case studies investigating the direct effect of motor imagery in conjunction with physical therapy and the limitations of motor imagery based on the location of cortical damage and other variables, such as age. The findings analyzed in this review indicate that MI would serve as a beneficial addition to physical therapy and a viable option to stimulate motor evoked potentials (MEPs) in individuals not capable of pursuing physical therapy due to severe motor impairment. Regardless of the presence of brain lesions, motor imagery has consistently had a positive impact on motor rehabilitation either in boosting treatment or stimulating neuromuscular pathways. Therefore, we have concluded that MI is a viable supplemental treatment plan for motor recovery in most patients with motor cortical atrophy.

Clinical characteristics of enterovirus A71 neurological disease during an outbreak in children in Colorado, USA, in 2018: an observational cohort study

In May, 2018, Children's Hospital Colorado noted an outbreak of enterovirus A71 (EV-A71) neurological disease. We aimed to characterise the clinical features of EV-A71 neurological disease during this outbreak. In this retrospective observational cohort study, children (younger than 18 years) who presented to Children's Hospital Colorado (Aurora, CO, USA) between March 1 and November 30, 2018, with neurological disease (defined by non-mutually exclusive criteria, including meningitis, encephalitis, acute flaccid myelitis, and seizures) and enterovirus detected from any biological specimen were eligible for study inclusion. The clinical characteristics of children with neurological disease associated with EV-A71 were compared with those of children with neurological disease associated with other enteroviruses during the same period. To explore the differences in clinical presentation of acute flaccid myelitis, we also used a subgroup analysis to compare clinical findings in children with EV-A71-associated acute flaccid myelitis during the study period with these findings in those with enterovirus D68 (EV-D68)-associated acute flaccid myelitis at the same hospital between 2013 and 2018. Between March 10 and Nov 10, 2018, 74 children presenting to Children's Hospital Colorado were found to have enterovirus neurological disease; EV-A71 was identified in 43 (58%) of these children. The median age of the children with EV-A71 neurological disease was 22·7 months (IQR 4·0-31·9), and most of these children were male (34 [79%] children). 40 (93%) children with EV-A71 neurological disease had findings suggestive of meningitis, 31 (72%) children showed evidence of encephalitis, and ten (23%) children met our case definition of acute flaccid myelitis. All children with EV-A71 disease had fever and 18 (42%) children had hand, foot, or mouth lesions at or before neurological onset. Children with EV-A71 disease were best differentiated from those with other enteroviruses (n=31) by the neurological findings of myoclonus, ataxia, weakness, and autonomic instability. Of the specimens collected from children with EV-A71, this enterovirus was detected in 94% of rectal, 79% of oropharyngeal, 56% of nasopharyngeal, and 20% of cerebrospinal fluid specimens. 39 (93%) of 42 children with EV-A71 neurological disease who could be followed up showed complete recovery by 1-2 months. Compared with children with EV-D68-associated acute flaccid myelitis, children with EV-A71-associated acute flaccid myelitis were younger, showed neurological onset earlier after prodromal symptom onset, had milder weakness, showed more rapid improvement, and were more likely to completely recover. This outbreak of EV-A71 neurological disease, the largest reported in the Americas, was characterised by fever, myoclonus, ataxia, weakness, autonomic instability, and full recovery in most patients. Because EV-A71 epidemiology outside of Asia remains difficult to predict, identification of future outbreaks will be aided by prompt recognition of these distinct clinical findings, testing of non-sterile and sterile site specimens, and enhanced enterovirus surveillance. None.

Approach to the treatment of trichomoniasis associated with sexual transmitted infections

In recent years, mixed infection (trichomonas, gardnerella, chlamydia, mycoplasma, yeast-like fungi) is often found and is insensitive to antibacterial drugs. Therefore after treatment, the inflammatory process for a long time can be maintained by pathogenic microorganisms, which must be considered when prescribing therapy to such patients. The main decisive factor in the treatment of mixed urogenital infections is the appointment in the complex therapy of effective antibacterial drugs of a wide spectrum in sufficient daily doses and duration, that is allows obtaining positive results of treatment in most patients.Objective of the study. Analyze in women the anamnestic data and clinic of trichomoniasis associated with other sexually transmitted infections. Develop a comprehensive method for the treatment of trichomoniasis and concomitant urogenital infections.Materials and methods. Study include 31 women aged from 20 to 31 years. At examination along with trichomonads a concomitant urogenital infection (gardnerella, chlamydia, mycoplasma, yeast-like fungi) was detected in the patients. Diagnosis was carried out using standard techniques. In case of a mixed infection (trichomonas, gardnerella, chlamydia, mycoplasma, yeast-like fungi), antiprotozoal drugs were prescribed from the 1st day of treatment. After antiprotozoal treatment antimicrobials with a broad spectrum of action were prescribed from the 11th day of treatment. In the presence of a candidal infection from the 1st day of treatment an antifungal drug was used.Results. Analysis of the therapeutic efficacy of the proposed complex treatment of trichomoniasis and concomitant urogenital infection showed clinical recovery in the majority of patients. This was evidenced by the disappearance of subjective clinical symptoms, objective inflammatory changes in the mucous membrane of the genital organs, and the negative results of laboratory studies after completion of the course of treatment.Conclusion. The proposed comprehensive treatment of women with trichomoniasis associated with other sexually transmitted infections makes it possible to increase the effectiveness of therapy, promotes the elimination of pathogens and clinical recovery in most patients.

Symptom profile of patients receiving antibiotics for upper respiratory tract infections in general practice: an observational study using smartphone technology.

Upper respiratory tract infections (URTIs) are a common presentation in general practice and are linked to high rates of inappropriate antibiotic prescription. There is limited information about the trajectory of patients with this condition who have been prescribed antibiotics. To document the symptom profile of patients receiving antibiotics for URTIs in Australian general practice using smartphone technology and online surveys. In total, 8218 patients received antibiotics after attending one of the 32 general practice clinics in Australia from June to October 2017: 4089 were identified as URTI presentations and were the cohort studied. Patients completed the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) 3 and 7 days after visiting their general practitioner (GP). Six hundred fourteen URTI-specific patients responded to at least one symptom survey (RR 15%). The majority of patients reported moderate to mild symptoms at 72 hours [median global symptom severity score 37 (IQR 19, 59)] post-GP visit which reduced to very mild symptoms or not sick by day 7 [11 (IQR 4, 27)]. Patients receiving antibiotics for URTI reported the same level of symptom severity as patients in previous studies receiving no treatment. The recovery of most patients within days of receiving antibiotics for URTI mimics the trajectory of patients with viral URTIs without treatment. Antibiotics did not appear to hasten recovery. Monitoring of patients in this context using smart phone technology is feasible but limited by modest response rates.

Results of surgical treatment of myelomeningoceles in a small neurosurgical unit in the Zenica cantonal hospital

O bjective − To analyse the results of the surgical treatment of myelomeningocele in the Zenica Cantonal Hospital in a five-year period. P atients and methods − This retrospective study included 10 patients with myelomeningocele, surgically treated at the Department of Neurosurgery, Zenica Cantonal Hospital, in the 2011-2016 period. Patients were assessed based on their history, symptoms and neurological state. In all cases we performed a detailed neurological examination and craniospinal Magnetic Resonance Imaging. In most cases we performed surgery within the first 72 hours after birth. In three patients we did not perform early surgery because the parents did not give consent for the operation in this period. All patients were hospitalized at the Department of Paediatrics, Zenica Cantonal Hospital. The patients were followed up by a neurosurgeon, a paediatric surgeon and a paediatrician. R esults − In our research, the incidence of myelomeningoceles in females and males was equal. In most cases the surgery is the most devastating congenital malformation compatible with survival. Newborns with late antenatal diagnosis must undergo surgery as soon as possible, preferably within 24-72 hours. Despite limited resources and conditions we documented a significant recovery in most patients. Conclusion − Myelomeningocele is the most devastating congenital malformation compatible with survival. Newborns with late antenatal diagnosis must undergo surgery as soon as possible, preferably within 24-72 hours. Despite limited resources and conditions we documented significant recovery in most patients.

P228 Reversible axonal conduction blocks and sonographic distal median-nerve enlargement in a young patient with acute motor axonal neuropathy

Objectives To present a patient with acute motor axonal neuropathy (AMAN) of benign course. AMAN is a subtype of Guillain-Barre syndrome (GBS), characterized by reduced compound muscle action potentials (CMAP) and the absence of demyelinating findings. Patient Following a diarrhea, the 19-year-old male patient presented with distally pronounced moderate quadriparesis without sensory or autonomic symptoms. Cerebrospinal fluid was normal. The first electrophysiological evaluationshowed generalized very low/absent distal CMAPs without demyelinating signs. Electromyography (EMG) showed no denervation. Nerve ultrasound showed a distally enlarged median nerve with normal parameters of other nerves. Recovery started spontaneously and was accelerated by treatment with immunoglobulins. Follow-up electrophysiological study was performed 10 weeks after symptom-onset, showing significant but partial recovery of CMAP amplitudes without denervation in EMG. Discussion AMAN encountered in North-America and Europe is a rare and severe condition with poor outcome, due to widespread axonal degeneration. However, in the Far-East AMAN is a common and benign GBS type, with complete recovery in most patients. In this type, axonal dysfunction leads to reversible axonal conduction failure, rather than axonal degeneration, which may be confused with conduction blocks of demyelinating origin associated with acute inflammatory demyelinating polyneuropathy (AIDP). Conclusion The benign form of AMAN with reversible motor axonal conduction failure may occasionally be encountered in Europe as well, and may cause confusion in the electrophysiological diagnosis of GBS. Whereas AIDP patients generally have proximally enlarged nerves in the ultrasound, our AMAN-patient showed a distally enlarged median nerve, possibly related to the distal conduction failure.

Successful Treatment of Gastric Sleeve Leaks With Insertion of Removable Self Expanding Metal Stents: A Case Series

Background: Laparoscopic sleeve gastrectomy, a standard procedure for the surgical treatment of patients with obesity is associated with post operative gastric sleeve leak and cause significant morbidity and mortality. Case presentation: We describe four cases of patients with leak after gastric sleeve surgery for morbid obesity. Post operatively the patients were noted to have gastric sleeve leak. All four patients underwent placement of the self expandable metal stent in the leaking gastric sleeve. The stents were left in place for four to eight weeks for the leaks to heal and then removed. All four patients showed healing of the leak after the stent was removed and no further leaks were observed. In one patient the stent was noted to migrate and functionally obstruct at the distal end due to narrowing and mucosal swelling at the gastric sleeve. The stent was fully recovered and replaced with another stent. The leak later healed well and the stent was subsequently removed after six weeks. Discussion: Gastric sleeve surgery is usually done for morbid obesity. Although the surgery helps in reducing morbidity, it also has its known complications including gastric sleeve leak, staple line bleeding, strictures and enterocutaneous fistulas. Out of all the complications gastric sleeve leak causes highest morbidity. Removable stent placement is fairly new treatment option for gastric sleeve leaks and is gaining popularity. The stent placement helps in recovery in most patients. Gastric leaks at proximal and mid aspect can be treated with endoscopic stent placement. The complications related to stent placement include stent blockage, migration or kinking. Conclusion: Gastric sleeve leaks can be treated successfully with removable self expandable metal stents placed endoscopically and is associated with fewer complications.

Thoracic epidural spinal angiolipoma with coexisting lumbar spinal stenosis: Case report and review of the literature.

Spinal angiolipomas (SALs) are uncommon benign lesions that may present insidiously with back pain or acutely with weakness due to tumor bleeding/thrombosis. Given their rarity, these lesions are often overlooked in the differential diagnosis of epidural masses. The purpose of this article is to report the case of an epidural SAL and to conduct a literature review on the topic. A case report and review of the literature using the PubMed/Medline databases. All case reports and case series were reviewed up to June 2015. A 65-year old female presented with neurogenic claudication and magnetic resonance imaging (MRI) revealed lumbar spinal stenosis. Following decompressive surgery, she experienced symptom resolution, but three months postoperatively she presented to the emergency department with acute paraparesis. A thoracic MRI revealed a lesion located between T8 and T10 causing severe spinal cord compression. Following emergent laminectomy and en bloc resection, the patient regained function and the lesion was diagnosed as SAL. Our literature review revealed 178 reported cases, with a female and thoracic predominance. The majority of patients underwent surgical treatment, achieving a gross total resection in most cases. Similarly, complete symptom resolution was the most common outcome. Spinal angiolipomas are uncommon spinal tumors. However, they may be treated as any other space-occupying lesion, and surgical resection allows for complete symptom recovery in most patients.

Spondylolysis in the Athlete

Spondylolysis and spondylolisthesis are common causes of low back pain in athletes. Early diagnosis is crucial in the treatment of spondylolysis, as a period of rest can lead to full recovery in most patients. Radiographs can detect most lesions, but single-photon emission computed tomography scan, bone scan, computed tomography scan, and magnetic resonance imaging may be necessary in patients with normal radiograph findings or unusual presentations. There is significant variability in the literature regarding bracing, rehabilitation, surgery, and return to play. Most patients recover with nonoperative treatment, but if surgery is necessary, pars defect repair or fusion leads to good outcomes.

Clinical experience in adults and children treated with intravenous peramivir for 2009 influenza A (H1N1) under an Emergency IND program in the United States.

Peramivir, an investigational intravenous neuraminidase inhibitor in Phase 3 trials for hospitalized patients, was made available during the 2009 H1N1 influenza pandemic under the Emergency Investigational New Drug (eIND) regulations. We describe the clinical characteristics and outcomes of all patients for whom peramivir was requested under the eIND. After obtaining eIND approval from the Food and Drug Administration and local institutional review board approval, clinicians caring for hospitalized patients with influenza administered intravenous peramivir and collected information on demographic characteristics, clinical characteristics, and outcomes. From April through October 2009, peramivir was requested for 42 patients and administered to 20 adults and 11 children. At hospitalization, all patients had rapidly progressing, radiographically confirmed viral pneumonia with respiratory failure, and all but 1 patient required mechanical ventilation. In most patients, including 1 person with documented oseltamivir-resistant infection, the illness had progressed despite oseltamivir treatment. Peramivir was administered for 1-14 days (median duration, 10 days). The 14-day, 28-day, and 56-day survival rates were 76.7%, 66.7%, and 59.0%, respectively. Peramivir was generally well tolerated. Intravenous peramivir was well tolerated and was associated with recovery in most patients hospitalized with severe 2009 H1N1 influenza viral pneumonia and treated under an eIND.

Chikungunya Fever: Focus on Peripheral Markers of Pathogenesis

Chikungunya Fever: Focus on Peripheral Markers of Pathogenesis

Celiac disease: how complicated can it get?

In the small intestine of celiac disease patients, dietary wheat gluten and similar proteins in barley and rye trigger an inflammatory response. While strict adherence to a gluten-free diet induces full recovery in most patients, a small percentage of patients fail to recover. In a subset of these refractory celiac disease patients, an (aberrant) oligoclonal intraepithelial lymphocyte population develops into overt lymphoma. Celiac disease is strongly associated with HLA-DQ2 and/or HLA-DQ8, as both genotypes predispose for disease development. This association can be explained by the fact that gluten peptides can be presented in HLA-DQ2 and HLA-DQ8 molecules on antigen presenting cells. Gluten-specific CD4+ T cells in the lamina propria respond to these peptides, and this likely enhances cytotoxicity of intraepithelial lymphocytes against the intestinal epithelium. We propose a threshold model for the development of celiac disease, in which the efficiency of gluten presentation to CD4+ T cells determines the likelihood of developing celiac disease and its complications. Key factors that influence the efficiency of gluten presentation include: (1) the level of gluten intake, (2) the enzyme tissue transglutaminase 2 which modifies gluten into high affinity binding peptides for HLA-DQ2 and HLA-DQ8, (3) the HLA-DQ type, as HLA-DQ2 binds a wider range of gluten peptides than HLA-DQ8, (4) the gene dose of HLA-DQ2 and HLA-DQ8, and finally,(5) additional genetic polymorphisms that may influence T cell reactivity. This threshold model might also help to understand the development of refractory celiac disease and lymphoma.