Standard Therapeutic Measures Research Articles

Use of Fresh Frozen Plasma in a Dramatic Case of ACE-Inhibitor Associated Angioedema

Angioedema describes a non-dependent, non-pitting and transient edema caused by the accumulation of vasoactive substances in the circulation. These vasoactive substances increase vascular permeability, causing swelling of the deep dermal, submucosal or subcutaneous tissues of the face, lips, neck, extremities or gastrointestinal tract. Urticaria may or may not accompany this condition. Angioedema is generally mediated through two pathways: histamine-mediated and bradykinin-mediated. Histamine-mediated angioedema generally responds to standard therapeutic measures (such as antihistamines, steroids and epinephrine), whereas bradykinin-mediated angioedema can be more difficult to manage in emergency departments (ED). Here, we present a patient who presented to our ED with bradykinin-mediated ACE-I-associated dramatic angioedema clinic, did not respond to standard treatments, rapidly improved with fresh frozen plasma (FFP) administration and was discharged after 6 days of follow-up in the emergency critical intensive care unit.

Emergency endotracheal intubation in critically ill patients with COVID-19: management and clinical characteristics

PurposesSARS-CoV-2 have become widespread worldwide since the outbreak. Respiratory function deteriorates rapidly in critically ill patients infected with SARS-CoV-2. Endotracheal intubation is an indispensable therapeutic measure during the development of the disease. This study was intended to describe the experience of endotracheal intubation from front-line anesthesiologists and clinical prognosis of patients infected with Coronavirus disease-19 (COVID-19).MethodsFourteen critical patients infected with COVID-19 who underwent endotracheal intubation were included in this study. We collate and analyze the blood gas results before and after tracheal intubation of patients and clinical prognostic indicators such as length of stay and. mortality. The experience of anesthesiologists who intubated patients has also been recorded in detail.ResultsPatients had a mean time of 10.6 days from initial symptoms to endotracheal intubation. Most intubated patients had one or more underlying conditions: hypertension (8, 57.14%), diabetes (5, 35.71%), and cardiovascular and cerebrovascular diseases (2, 14.29%). The oxygenation index increased significantly after intubation compared with before intubation (148.80 ± 42.25 vs 284.43 ± 60.17 p < 0.001). 85.72% of patients required extra-corporeal membrane oxygenation (ECMO) due to inability to maintain oxygen saturation with standard therapeutic measures. Two patients underwent lung transplantation because their lungs were essentially nonfunctional, and they recovered well after surgery. As of this writing, all patients were discharged after satisfactory recovery.ConclusionsReasonable selection of intubation timing is particularly important. It is crucial to increase the patient's oxygen supply and reduce oxygen consumption as much as possible during endotracheal intubation. In addition, the personal protective measures of medical personnel participating in treatment should be scientific and standardized.Graphical

Зміни мікробіоценозу статевих шляхів у вагітних після прегравідарної підготовки перед програмою допоміжних репродуктивних технологій

Purpose - to investigate changes in the genital tract microbiocenosis in pregnant women with a history of sexually transmitted infections (STIs) after pre-vitro preparation before cycles of assisted reproductive technology (ART). Materials and methods. A total of 247 women with a history of STIs and who planned pregnancy under the ART program were examined: 115 women received our proposed pre-pregnancy preparation, of whom 56 ended in pregnancy (the Group 2) and they received the proposed therapeutic and preventive measures; 132 women received standard pre-pregnancy preparation, of whom 55 ended in pregnancy (the Group 2) and they received the standard therapeutic and preventive measures. The control group comprised 30 pregnant women without a period of infertility, who became pregnant on their own. Statistical processing of the study results was carried out using standard Microsoft Excel 5.0 and Statistica 8.0 software. Results. The state of the genital tract microbiocenosis in women of the Group 1 with a history of STIs, after pregravid preparation before the ART program, compared with pregnant women of the Group 2, is characterized by a significantly higher number of lactobacilli during the gestational period (I half of pregnancy: 49 (87.5%) vs. 38 (69.1%) cases, p&lt;0.05; II half of pregnancy: 35 (68.6%) vs. 20 (44.4%) cases, p&lt;0.001), bifidobacteria (I half of pregnancy: 42 (75.0%) vs. 31 (56.4%) cases, p&lt;0.05; II half of pregnancy: 38 (74.5%) vs. 17 (37.7%) cases, p&lt;0.001), lactic acid streptococci (I half of pregnancy: 29 (51.8%) vs. 18 (32.7%) cases, p&lt;0.05; II half of pregnancy: 19 (37.2%) vs. 12 (26.6%) cases, p&lt;0.05) against the background of a simultaneous significant decrease in the level of staphylococcus strains (I half of pregnancy: 9 (18.0%) vs. 20 (36.4%) cases, p&lt;0.05; II half of pregnancy: 14 (27.4%) vs. 39 (86.6%) cases, p&lt;0.05) and other microorganisms (urea and mycoplasma, chlamydia, escherichia and proteus). Conclusions. The results of these studies show that in women with a history of STIs after pre-pregnancy preparation prior to the АRT programme, the vaginal microbiocenosis during pregnancy almost matches that of a physiological pregnancy, which positively affects the obstetric and perinatal outcomes of delivery in this group of pregnant women. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the author.

Potential Cell-Based and Cell-Free Therapy for Patients with COVID-19.

Since it was first reported, the novel coronavirus disease 2019 (COVID-19) remains an unresolved puzzle for biomedical researchers in different fields. Various treatments, drugs, and interventions were explored as treatments for COVID. Nevertheless, there are no standard and effective therapeutic measures. Meanwhile, mesenchymal stem cell (MSC) therapy offers a new approach with minimal side effects. MSCs and MSC-based products possess several biological properties that potentially alleviate COVID-19 symptoms. Generally, there are three classifications of stem cell therapy: cell-based therapy, tissue engineering, and cell-free therapy. This review discusses the MSC-based and cell-free therapies for patients with COVID-19, their potential mechanisms of action, and clinical trials related to these therapies. Cell-based therapies involve the direct use and injection of MSCs into the target tissue or organ. On the other hand, cell-free therapy uses secreted products from cells as the primary material. Cell-free therapy materials can comprise cell secretomes and extracellular vesicles. Each therapeutic approach possesses different benefits and various risks. A better understanding of MSC-based and cell-free therapies is essential for supporting the development of safe and effective COVID-19 therapy.

Improving the Effectiveness of Therapeutic Measures for Generalized Periodontitis in Patients with Hypertension

The program of standard therapeutic measures in 45 patients with Generalized Chronic Periodontitis (GCP) and background hypertension, group I(a), included hirudotherapy, for comparison, the effectiveness of traditional treatment was evaluated in 40 patients, group I(b), who refused to use medical leeches. In the second comparison group (35 patients), patients with GCP, but normal blood pressure, also received only a set of traditional methods of treatment. The inclusion of hirudotherapy in the program of therapeutic measures in patients with GCP and hypertension makes it possible to optimize the onset of a persistent therapeutic effect, lengthen the period of remission of the pathological process in periodontal disease and significantly improves the quality of life of patients.

A clinical case of successful treatment of complete abruption of the trachea from the larynx

Tracheobronchial injuries as a consequence of chest blunt trauma are rare. Blunt traumas of the cervical part of the trachea are a rarer pathology presenting a serious diagnostic problem for a clinician. Traumas of the larynx and the trachea account for 40 to 80% of lethality. The tracheas cervical part is vulnerable despite that it is covered with the neck muscles, spine, clavicles, and mandible. In cut/stab wounds, the tracheas cervical part is often damaged together with the adjacent structures. In blunt trauma, under a direct action of a traumatizing agent, the mobile trachea displaces toward the spine, accompanied by damage to the tracheal cartilages, its membranous part, and the soft surrounding tissues with preservation of the integrity of the skin.&#x0D; Tracheal ruptures along the distance up to 1 cm from the cricoid cartilage account for not more than 4% of all tracheal ruptures. A complete tracheal rupture and its abruption from the larynx are extremely rare pathology. Because of severe respiratory disorders, most victims die at the site where their injury occurred.&#x0D; This article presents a clinical case of the successful treatment of patient Z., 41 years of age, with complete tracheal abruption from the larynx. The cause of tracheal damage was blunt neck trauma in a traffic accident. A peculiarity of this clinical case was that the victim arrived at a specialized thoracic surgery unit with a functioning tracheostomy two days after the trauma.&#x0D; Conclusion. Tracheal trauma is a potentially fatal condition. Therefore, early diagnosis of tracheobronchial damage is essential since it permits timely surgical intervention and diminished risk of lethal outcome. When dealing with patients with trauma of the head, neck, and chest with non-corresponding clinical data and the absence of effective recommended standard therapeutic measures, a clinician should become alert and exclude the tracheal and bronchial damage.&#x0D; X-ray computed tomography and fibrotracheobronchoscopy are strongly recommended as reliable methods to diagnose tracheobronchial damages. In a surgical intervention, it is necessary to perform the primary suture on the trachea, avoid preventive tracheostomy, and delay interventions associated with poorer prognosis and a high complication rate.

Emerging entities in NUTM1-rearranged neoplasms.

Structural alterations of NUTM1 were originally thought to be restricted to poorly differentiated carcinomas with variable squamous differentiation originating in the midline organs of children and adolescents. Termed NUT carcinomas (NCs), they were defined by a t(15;19) chromosomal rearrangement that was found to result in a BRD4-NUTM1 gene fusion. However, the use of DNA and RNA-based next-generation sequencing has recently revealed a multitude of new NUTM1 fusion partners in a diverse array of neoplasms including sarcoma-like tumors, poromas, and acute lymphoblastic leukemias (ALLs) that we propose to call NUTM1-rearranged neoplasms (NRNs). Intriguingly, the nosology of NRNs often correlates with the functional classification of the fusion partner, suggesting different oncogenic mechanisms within each NRN division. Indeed, whereas NCs are characterized by their aggressiveness and intransigence to standard therapeutic measures, the more positive clinical outcomes seen in some sarcoma and ALL NRNs may reflect these mechanistic differences. Here we provide a broad overview of the molecular, nosological, and clinical features in these newly discovered neoplastic entities. We describe how aberrant expression of NUTM1 due to fusion with an N-terminal DNA/chromatin-binding protein can generate a potentially powerful chromatin modifier that can give rise to oncogenic transformation in numerous cellular contexts. We also conclude that classification, clinical behavior, and therapeutic options may be best defined by the NUTM1 fusion partner rather than by tumor morphology or immunohistochemical profile.

Hypertrophic cardiomyopathy: genetics and clinical perspectives.

Hypertrophic cardiomyopathy (HCM) is the most common inherited heart disease and defined by unexplained isolated progressive myocardial hypertrophy, systolic and diastolic ventricular dysfunction, arrhythmias, sudden cardiac death and histopathologic changes, such as myocyte disarray and myocardial fibrosis. Mutations in genes encoding for proteins of the contractile apparatus of the cardiomyocyte, such as β-myosin heavy chain and myosin binding protein C, have been identified as cause of the disease. Disease is caused by altered biophysical properties of the cardiomyocyte, disturbed calcium handling, and abnormal cellular metabolism. Mutations in sarcomere genes can also activate other signaling pathways via transcriptional activation and can influence non-cardiac cells, such as fibroblasts. Additional environmental, genetic and epigenetic factors result in heterogeneous disease expression. The clinical course of the disease varies greatly with some patients presenting during childhood while others remain asymptomatic until late in life. Patients can present with either heart failure symptoms or the first symptom can be sudden death due to malignant ventricular arrhythmias. The morphological and pathological heterogeneity results in prognosis uncertainty and makes patient management challenging. Current standard therapeutic measures include the prevention of sudden death by prohibition of competitive sport participation and the implantation of cardioverter-defibrillators if indicated, as well as symptomatic heart failure therapies or cardiac transplantation. There exists no causal therapy for this monogenic autosomal-dominant inherited disorder, so that the focus of current management is on early identification of asymptomatic patients at risk through molecular diagnostic and clinical cascade screening of family members, optimal sudden death risk stratification, and timely initiation of preventative therapies to avoid disease progression to the irreversible adverse myocardial remodeling stage. Genetic diagnosis allowing identification of asymptomatic affected patients prior to clinical disease onset, new imaging technologies, and the establishment of international guidelines have optimized treatment and sudden death risk stratification lowering mortality dramatically within the last decade. However, a thorough understanding of underlying disease pathogenesis, regular clinical follow-up, family counseling, and preventative treatment is required to minimize morbidity and mortality of affected patients. This review summarizes current knowledge about molecular genetics and pathogenesis of HCM secondary to mutations in the sarcomere and provides an overview about current evidence and guidelines in clinical patient management. The overview will focus on clinical staging based on disease mechanism allowing timely initiation of preventative measures. An outlook about so far experimental treatments and potential for future therapies will be provided.

Influence of sorbilact-L-arginin complex on dynamic characteristics of volumo- and osmoregulatory functions of kidneys in case of endogenous intoxication syndrome of purulent septic genesis

The article presents the results of studies of the influence of sorbylact -L‑ arginine complex on the dynamic characteristics of volumo- and osmoregulatory functions of the kidneys in the endogenous intoxication syndrome of purulent-septic genesis.The objective is to establish changes in the indicators of the kidneys volumo - and osmoregulatory function monitoring caused by sorbilact and L‑arginine in case of the endogenous intoxication syndrome of purulent-septic genesis.Material and methods. The parameters of volumo- and osmoregulatory functions of the kidneys in patients of four groups were studied. Group I — patients with the syndrome of systemic inflammatory response (control, SIRS). II group — patients with the endogenous intoxication syndrome (EIS), treated by standard therapy. Group III — patients with EIS, who on the basis of standard therapy were administered sorbilact. Group IV — patients with EIS, whose standard treatment were supplemented by the combined use of sorbilact and L‑arginine. The results of the first, fourth and seventh day of observation are presented.Results. On the first day of the investigation of the EIS of purulent-septic genesis, acute renal damage is recorded (Stage I, AKIN, 2007). However, the complex of standard therapeutic measures was not sufficient to restore the glomerular filtration rate throughout the study. The use of sorbilact and L‑arginine contributed to the restoration of the glomerular filtration rate and the clearance characteristics of the volumo- and osmoregulatory functions of the kidneys. Conclusion. In the syndrome of endogenous intoxication of purulent-septic genesis, the complex of sorbilact and L‑arginine implements renoprotective activity, which was determined by the restoration of the glomerular filtration rate and activation of volumetric and osmoregulatory functions according to clearance characteristics.

Extracorporeal membrane oxygenation support for life-threatening acute severe status asthmaticus.

Status asthmaticus is a life-threatening condition characterized by progressive respiratory failure due to asthma that is unresponsive to standard therapeutic measures. We used extracorporeal membrane oxygenation (ECMO) to treat patients with near-fatal status asthamticus who did not respond to aggressive medical therapies and mechanical ventilation under controlled permissive hypercapnia. Between January 2011 and October 2015, we treated 16 adult patients with status asthmaticus (8 women, 8 men, mean age: 50.5±10.6years) with veno-venous ECMO (13 patients) or veno-arterial (3 patients). Patients failed to respond to conventional therapies despite receiving the most aggressive therapies, including maximal medical treatments, mechanical ventilation under controlled permissive hypercapnia and general anesthetics. Mean time spent on ECMO was 300±11.8 hours (range 36-384 hours). PaO2, PaCO2 and pH showed significant improvement promptly after ECMO initiation p=0.014, 0.001 and <0.001, respectively, and such values remained significantly improved after ECMO, p=0.004 and 0.001 and <0.001, respectively. The mean time of ventilation after decannulation until extubation was 175±145.66 hours and the median time to intensive care unit discharge after decannulation was 234±110.30 hours. All 16 patients survived without neurological sequelae. ECMO could provide adjunctive pulmonary support for intubated asthmatic patients who remain severely acidotic and hypercarbic despite aggressive conventional therapy. ECMO should be considered as an early treatment in patients with status asthmaticus whose gas exchange cannot be satisfactorily maintained by conventional therapy for providing adequate gas change and preventing lung injury from the ventilation.

Expanding the antibody-mediated component of plasma cell-rich acute rejection: A case series.

Renal allograft rejection is mediated by T-cells (T-cell mediated rejection) or by donor-specific antibodies (DSAs) (antibody mediated rejection, ABMR). Plasma cell-rich acute rejection (PCAR) is a unique entity due to its peculiar morphology and poor prognostic behavior. All allograft biopsies done at our center from January 2013 to October 2014 were reviewed, and seven were identified with a diagnosis of PCAR with antibody mediated rejection (ABMR). The allograft biopsies were classified as per the Banff 2007 schema. Immunohistochemistry with C4d, SV 40, CD3, CD20, CD138, kappa and lambda light chain was performed. Total 210 allograft biopsies were performed in the study period of which seven biopsies (3.3%) were diagnosed as PCAR with ABMR. All these were late ABMRs (more than 6 months) with median posttransplant duration of 17 months. The allograft biopsy showed features of PCAR along with glomerulitis, peritubular capillaritis, and positive C4d. DSA was positive in six patients. All the patients were treated with standard therapeutic measures of acute cellular rejection (ACR) and ABMR including steroids, plasma exchange, rituximab and intravenous immunoglobulins. All the patients had persistent graft dysfunction or graft loss on follow-up.

Микроциркуляторные нарушения и их коррекция ингибитором ангиотензинпревращающего фермента лизиноприлом у больных ишемической болезнью сердца в сочетании с сахарным диабетом 2 типа

A coronary heart disease and diabetes mellitus type 2 are the most complicated and urgent problem of medical science and public health. The standard therapeutic measures in some cases do not provide significant clinical improvement of patients with a stable course of the disease. This requires further study of the pathogenesis of the heart and vessels lesions in patients with combined pathology and the search for new medicines. In this work, the authors studied the state of microcirculation with the morphological assessment of the microvascular bed, considering the effectiveness of therapeutic effects of angiotensin-converting enzyme inhibitor lisinopril a daily dose of 5 mg in patients with ischemic heart disease (IHD), stable angina ΠΙ FC in combination with type 2 diabetes. Baseline, after 1 and 6 months of treatment, the authors conducted a conjunctival biomicroscopy of the eye vessels with a caliber measurement and mor-phometric analysis. The results of the study were the following: the combination of IHD and type 2 diabetes forms the gross disorders of microcirculation. This is reflected in the development of widespread perivascular edema, multiple hemorrhages, sudden depletion of the vascular bed with nonvascular lesions, intravascular aggregation of erythrocytes -&amp;#34;sludge-phenomenon&amp;#34;. The prolonged complex use of lisinopril caused the positive dynamics of microcirculatory disorders, in particular, intravascular link with increasing flow velocity and decreasing the aggregation of erythrocytes. This is the basis for recommendations to the widespread use of this drug in this combined pathology.

Severe Hypertriglyceridemia‐Related Acute Pancreatitis

Acute pancreatitis is a potentially life-threatening complication of severe hypertriglyceridemia. In some cases, inborn errors of metabolism such as lipoprotein lipase deficiency, apoprotein C-II deficiency, and familial hypertriglyceridemia have been reported as causes of severe hypertriglyceridemia. More often, severe hypertriglyceridemia describes various clinical conditions characterized by high plasma levels of triglycerides (>1000 mg/dL), chylomicron remnants, or intermediate density lipoprotein like particles, and/or chylomicrons. International guidelines on the management of acute pancreatitis are currently available. Standard therapeutic measures are based on the use of lipid-lowering agents (fenofibrate, gemfibrozil, niacin, Ω-3 fatty acids), low molecular weight heparin, and insulin in diabetic patients. However, when standard medical therapies have failed, non-pharmacological approaches based upon the removal of triglycerides with therapeutic plasma exchange can also provide benefit to patients with severe hypertriglyceridemia and acute pancreatitis. Plasma exchange could be very helpful in reducing triglycerides levels during the acute phase of hyperlipidemic pancreatitis, and in the prevention of recurrence. The current evidence on management of acute pancreatitis and severe hypertriglyceridemia, focusing on symptoms, treatment and potential complications is reviewed herein.

Methohexital zur Therapie des erhöhten intrakraniellen Drucks

Barbiturate coma therapy is a useful method to control increased intracranial pressure (ICP) in patients with severe brain damage if standard measures have failed to lower ICP. Pentobarbital (not available in Germany) and thiopental (in Germany only approved for induction of anesthesia) have frequently been used in patients with intracranial hypertension and the effects and side-effects are well-described. However, little is known about the effect of methohexital (the only barbiturate in Germany approved for maintaining anesthesia) in lowering increased ICP. Therefore, the effect of methohexital on ICP was studied in patients where standard measures had failed to control intracranial hypertension. A retrospective observational study was carried out with the inclusion criteria of patient age ≥18 years and methohexital therapy for 12h or more with ICP monitoring in place. Methohexital was administered following a standardized algorithm to patients for whom standard measures, such as deep anesthesia, normoventilation, cerebral perfusion pressure (CPP) >65mmHg, osmotherapy, neurosurgical evacuation of mass lesions, had failed to lower ICP. Methohexital was used if the ICP had risen above 20-25mmHg for more the 20-30min and otherwise manageable causes for the ICP increase had been ruled out. Methohexital was given continuously in addition to standard analgesia and sedation in doses of 2-4-6mg/kg body weight (BW), depending on the ICP lowering effect. The records of the patient data management system from the years 2008/2009 were used to compare the ICP and CPP before and during methohexital administration. For statistical analyses Student's t-test was applied for measured values and the χ(2)-test was applied for percentage values whereby p<0.05 was defined as being statistically significant. During the study period 36 patients required methohexital therapy and 30 fulfilled the inclusion criteria. In 26 out of 30 patients the data were complete and these 26 patients were included in the data analyses. Of the patients 6 (23%) died due to elevated intracranial hypertension and 20 patients (77%) survived. In all patients methohexital lowered the ICP from 25.2mmHg (standard deviation, SD ±4.3mmHg) to 19.8mmHg (SD ±12.5mmHg) within the first 24h, this result closely failed to reach a level of significance. In the 20 survivors methohexital lowered the ICP from 25.88mmHg (SD ±4.8mmHg) to 14.25mmHg (SD ±6.9mmHg) within the first 24h, which is statistically highly significant. In non-survivors the ICP had risen from 24mmHg (SD ±2.6mmHg) to 32mmHg (SD ±16.3mmHg) within the first 24h despite all efforts. Due to the CPP driven volume and vasopressor therapy no significant changes in the CPP during methohexital administration were observed. No significant changes in brain temperature (as possible cause for the decrease of the ICP) were observed. Non-survivors received significantly more methohexital due to increased ICP and required significantly more vasopressor therapy to maintain a sufficient CPP. Methohexital showed a clear trend for decreasing ICP in patients with intracranial hypertension refractory to standard therapeutic measures. In survivors the effect was highly significant. Patients not responding to methohexital therapy seemed to have an unfavorable outcome.

Anti-Factor V inhibitor in patients with autoimmune diseases: case report and literature review

Acquired anti-Factor V deficiency caused by inhibitor production is a rare coagulation disorder. Although this is a well known entity in the literature, choice of optimal treatment for an individual patient is difficult, given that no standard therapeutic measures are available because of rare incidence and various underlying diseases occurring in the elderly. An 88 year-old man treated for Hashimoto’s disease was found to exhibit prolongation of both prothrombin time and activated partial thromboplastin time. Detailed study of coagulation factors revealed a deficiency of Factor V. Our patient’s coagulation disorder resolved in two weeks with intravenous administration of prednisolone 20 mg/day. Clinical features of autoimmune disease-related Factor V deficiency are discussed, along with eight previously reported cases over the past 20 years.

European Physicians and Botanists, Indigenous Herbal Medicine in the Dutch East Indies, and Colonial Networks of Mediation

During the nineteenth and the early twentieth century, European physicians and botanists working in the Dutch East Indies displayed an eager interest in Indonesian indigenous herbal medicine or jamu, the investigation of which required them to establish contacts with local informers and mediators who could make indigenous medicine understandable to researchers. In the Dutch East Indies, these mediators were Indo-European women who had built up a medical lore with both European and Indigenous elements. The diminishing trust in the standard therapeutic measures created a window of opportunity for the investigation of Indonesian indigenous herbal medicine. The way medical knowledge circulated in the Dutch East Indies, the intermediaries who aided this circulation and the factors which impeded or facilitated it, and the ways in which European physicians and botanists legitimized indigenous herbal medicine are analyzed.

European Physicians and Botanists, Indigenous Herbal Medicine in the Dutch East Indies, and Colonial Networks of Mediation

During the nineteenth and the early twentieth century, European physicians and botanists working in the Dutch East Indies displayed an eager interest in Indonesian indigenous herbal medicine or jamu, the investigation of which required them to establish contacts with local informers and mediators who could make indigenous medicine understandable to researchers. In the Dutch East Indies, these mediators were Indo-European women who had built up a medical lore with both European and Indigenous elements. The diminishing trust in the standard therapeutic measures created a window of opportunity for the investigation of Indonesian indigenous herbal medicine. The way medical knowledge circulated in the Dutch East Indies, the intermediaries who aided this circulation and the factors which impeded or facilitated it, and the ways in which European physicians and botanists legitimized indigenous herbal medicine are analyzed.

The prevalence of hyper- and hypothyroidism in patients with ulcerative colitis

Background The association between ulcerative colitis and thyroid disorders has been previously reported. However, most reports consist of single case description, and a systematic assessment of this relationship has only sporadically been investigated. Aims To study a cohort of patients with ulcerative colitis to establish the prevalence of hyper- and hypothyroidism. Material and methods During a four-year period, we studied thyroid function in 162 ulcerative colitis patients (62 men, 100 women, age range 18–78 years). Results Thyroid dysfunction was present in 4 patients (2.5%) of the overall population and was represented by both hypo- (3 patients) and hyperthyroidism (1 patient). The incidence of this kind of thyroid dysfunction was significantly ( p = 0.03) lower than that found in a large (more than 5000 subjects) control group. Conclusions We conclude that the prevalence of hyper-/hypothyroidism is relatively low in patients with ulcerative colitis, at least in our country, and does not justify a systematic investigation of the thyroid function, except in selected cases, probably those with scarce or no response to standard therapeutic measures.

Editorial Comment

No sooner is a “miracle drug” introduced that seemingly cures an ailment resistant to traditional therapy, than a troubling side effect becomes apparent that potentially dampers the enthusiasm for the new drug. This is the case with topiramate, a neuruomodulatory agent initially approved for use as an antiepileptic drug but increasingly used to prevent migraine headaches, often in patients for whom standard therapeutic measures have failed. Perhaps it might have been anticipated that topiramate, a carbonic anhydrase inhibitor, would promote stone formation similar to acetazolamide, which has long been known to pose a risk of stones.

Cisatracurium in ???weakening doses??? assists in weaning from sedation and withdrawal following extended use of inhaled isoflurane

Isoflurane was used to treat a patient with status asthmaticus refractive to standard therapeutic measures. The patient developed a significant withdrawal syndrome when the isoflurane was weaned. A case is reported here where this withdrawal syndrome was treated successfully by using a weakening dose neuromuscular blockade with cisatracurium. Case report. Pediatric critical care unit. A 4-yr-old girl with severe reactive airways disease. The use of weakening doses of cisatracurium to assist in weaning from mechanical ventilation in the setting of withdrawal symptoms following the extended use of inhaled isoflurane. Despite treatment with mechanical ventilation, intravenous corticosteroids, and bronchodilators for status asthmaticus, the patient required inhaled isoflurane. She became tolerant to isoflurane over an extended period of time; her tolerance was associated with a specific withdrawal syndrome, with the development of choreoathetoid movements resulting in poor pulmonary coordination and agitation. Conventional medical treatment of withdrawal failed. Finally, by using an infusion of cisatracurium at weakening doses to assist in the control of these choreoathetoid movements, the isoflurane and ventilator support were weaned. Weakening doses of cisatracurium may be used safely to control unpleasant motor symptoms secondary to tolerance of isoflurane. This may have a use in other circumstances where agitation in mechanically ventilated patients is not due to pain or anxiety.