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Aim: To determine the intraoperative Ramsay sedation score after dexmedetomidine infusion in patients undergoing perineal surgery. Study design: Descriptive study. Place and duration of study: Department of Anaesthesia, JPMC, Karachi from 13th February 2021 to 13th August 2021. Methodology: One hundred and seventy four patients who met the diagnostic criteria were enrolled. Result(s): The mean age was 46.51 years with the standard deviation of +/-10.87. 66 (37.9%) were male and 108 (62.1%) were female. Whereas, mean duration of surgery, Ramsay sedation score at 5 minutes, 15 minutes, 30 minutes, height, weight and BMI in our study was 1.41+/-0.40 hours, 1.72+/-0.44, 3.51+/-0.60, 4.57+/-0.62, 165.62+/-8.23 cm, 68.34+/-8.23 kg and 24.85+/-3.34 kg/m2 respectively. Conclusion(s): Intraoperative dexmedetomidine proved beneficial in perineal surgeries and could be served as a potent sedative drug.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.
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Background: As a quality service improvement response since elexacaftor/ tezacaftor/ivacaftor (ELX/TEZ/IVA) became available and the yearly average number of cystic fibrosis (CF) pregnancies (n = 7 pre-2020, n = 33 in 2021) increased significantly at an adult CF center (~600 people with CF), a monthly multidisciplinary CF-maternal health virtual clinic was established with antenatal virtual CF exercise classes dedicated to providing adaptive, specialist support to this cohort, aswell as outreach guidance and education to local obstetric teams. Method(s): This was a single-center retrospective reviewof Royal Brompton Hospital CF-Maternal Health multidisciplinary team clinic records and a patient survey from March 2020 to March 2022. Result(s): Of 47 pregnancies in 41 women (median age 30;) eligible for ELX/ TEZ/IVA at start of pregnancy, 40% (n = 19) were unplanned, and 19% (n = 9) used assisted conception. Three women with a history of infertility conceived naturally, having required assisted conception for previous pregnancies, and five women had multiple pregnancies during the study period. ELX/TEZ/IVA was continued in 60% (n = 28), delayed in 28% (n = 13), and stopped in 13% (n = 6) of pregnancies through maternal choice and careful clinical counselling. Pre-pregnancy pulmonary status was poorer in women who continued than in those who delayed or stopped (Table 1). Of those who stopped, 85% (n = 5) restarted because of pulmonary deterioration by the third trimester. Prenatal CF complications included at least one episode of minor hemoptysis in 21% (n = 9/41) of women, at least one infective exacerbation in 55% of pregnancies (n = 26/47), and noninvasive ventilation in one woman. Other pregnancy-associated complications included one case of ovarian hyperstimulation syndrome, one case of sub-segmental pulmonary embolism, and two cases of pregnancy-induced hypertension. Excluding 10 first trimester terminations, 10 current pregnancies, and one patient relocation, obstetric outcomes available for 26 pregnancies confirmed a live birth rate of 85% (n = 22/26) and a 15% first-trimester miscarriage rate (n = 4). Obstetric complications included preterm delivery rate of 23% (n = 6/26), including two cases of COVID infection resulting in two neonatal intensive care unit admissions, one case of endometritis after cesarean section, and a fourthdegree perineal tear. There were no ectopic pregnancies, maternal or neonatal deaths, or reports of infant cataracts or congenital malformations. Median gestational age was 37/40 weeks (range 29-40). Mode of delivery was via cesarean section in 45% (n = 10/22, of which twowere emergency) and vaginal in 55% (n = 12/22), of which 83% (n = 10/12) were via induction of labor for diabetes (CF or gestational) indication. Deliveries were supported and occurred equally at local obstetric units and in tertiarycare obstetric hospital settings (50%, n = 11/22). Patient-experience survey responses cited high levels of confidence in health optimization and prioritization during pregnancy and praised excellent inter-health care provider communication and peer-to-peer emotional support provided among expectant mothers in the virtual prenatal exercise groups. Table 1. Baseline demographic and clinical characteristics of elexacaftor/tezacaftor/ivacaftoreligible expectant mothers according to therapeutic decision (Table Presented) Conclusion(s): In the absence of clinical trial safety data, the novel approach of a dedicated CF-maternal health multidisciplinary team clinic with local obstetric outreach support has ensured regular specialist clinical and emotional peer-to-peer support for this cohort of women eligible for ELX/ TEZ/IVA to ensure optimal outcomes and experiences of their pregnancies, where appropriate, close to home.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
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The 2022 mpox outbreak affected 84,318 individuals in 110 countries. Mpox is transmitted by multiple modalities, including direct contact, respiratory droplets, and fomites among others. Identifying skin lesions aids prompt diagnosis. Variation in initial skin lesion location is not well understood;it is hypothesized that mode of transmission may determine primary inoculation site and subsequent clinical presentation. This study sourced healthcare provider-reported data from the AAD/ILDS Dermatology COVID-19, Mpox, and Emerging Infections Registry to explore factors related to the location of the first skin lesion in mpox cases. Out 119 mpox cases,115 had primary lesion location data. 97% were male with a median age of 37. Most (83/115, 72%) patients had first skin lesions in the genito-anal area, and 32/115 (27%) had lesions elsewhere or had morbilliform rash. 74% of males had the first lesion in the genito-anal region compared to females (25%, p=0.03). Males in same-sex relationships had ano-genital lesions more often than men in other relationships (77% vs. 44%, p=0.03). The type of mpox exposure was also associated with first lesion location: 83% of patients who contracted mpox from a spouse or other sexual contact had ano-genital lesions as compared to a non-sexual contact (0%, p=<0.01). This analysis characterized factors associated with the first mpox skin lesion location, which can aid healthcare providers in diagnosis and shed light on transmission. This data suggests that type of exposure and mode of transmission may be associated with primary lesion location;patients who contracted mpox from sexual contact were more likely to have ano-genital lesions.Copyright © 2023
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Invasive aspergillosis is a rapidly progressive, fatal infection that usually occurs in immunocompromised patients. The spectrum of clinical presentation ranges from non-invasive, invasive, destructive and allergic aspergillosis. It is rare to see overwhelming aspergillosis in an immunocompetent host. Nevertheless, certain risk factors such as underlying fibrotic lung disease, suppurative infection, long-term corticosteroid use and uncontrolled diabetes mellitus (DM) have been described. We hereby present a case of invasive pulmonary aspergillosis in a patient with uncontrolled DM. A 60-year-old man with a history of heavy smoking (50- pack-year), poorly controlled DM presented to the hospital with a large area of erythema with eschar over his left posterior thigh. Clinical examination and CT abdomen pelvis confirmed necrotizing fasciitis involving his perineum and left thigh. Admission CT abdomen showed a small left lower lobe infiltrate (Day 1, Panel A). He underwent urgent debridement and intraoperative tissue cultures grew coagulase-negative staphylococcus, Proteus Vulgaris and anaerobic gram-positive rods. He received piperacillintazobactam, vancomycin, and clindamycin for 16 days which was subsequently narrowed to ceftriaxone and metronidazole. He had worsening leukocytosis but all his blood cultures have been negative. Tracheal aspirate gram stain on day 5 showed moderate yeast, and cultures grew Candida albicans and Aspergillus fumigatus. CT scan of his chest showed bilateral reticulonodular opacities with a new loculated right pleural effusion (Day 16, Panel B). Trans-esophageal echocardiogram did not show any right-sided heart valve vegetation. He received intravenous voriconazole for disseminated aspergillosis. Despite of new prophylactic antifungal strategies, more sensitive and rapid diagnostic tests, as well as various efficacious treatments, survival of invasive disseminated aspergillosis remains poor. High clinical suspicion with a proactive investigation approach is the key to minimizing mortality. Various risk factors such as hematopoietic-cell transplantation, neutropenia, solid-organ transplantation, chemotherapy, prolonged ICU stay, structural lung disease, impaired mucociliary clearance after a recent pulmonary infection (including SARS-CoV-2) have been well described. Our case highlights the importance of recognizing uncontrolled DM as a crucial risk factor for disseminated aspergillosis. (Figure Presented).
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Objective: This case report describes a longitudinally-extensive transverse myelitis after Moderna SARS-CoV-2 vaccination. Background: Transverse myelitis (TM) is an inflammatory spinal cord syndrome presenting with acute-to-subacute neurological deficits. A lesion spanning three or more vertebral segments on imaging is considered “longitudinally-extensive.” The TM differential is broad-- among these etiologies, vaccination is a rare but recognized entity. Design/Methods: 60-year-old, right-handed man with chronic right hemisphere stroke with residual left hemiparesis admitted for four days of bilateral lower extremity numbness progressing to weakness and urinary and bowel incontinence 10 days after receiving his second Moderna SARS-CoV-2 vaccination. Examination showed hypotonic lower extremities, proximal greater than distal weakness, a T9 dermatome sensory level, perineal numbness, mildly-reduced rectal tone, and preserved reflexes. MRI spine revealed a longitudinallyextensive, non-enhancing T2-hyperintense lesion spanning T8-T12. CSF analysis demonstrated 5 white blood cells, 1271 red blood cells, 124 glucose, and 55 protein. Aside from mildly elevated ESR and CRP, extensive serum and CSF work-up for other causes of myelopathy, including nutritional/toxic (copper, zinc, heavy metals), infectious (RPR/VDRL, HIV, HTLV, HSV, VZV, West Nile), and rheumatologic (anti-Jo, anti-Mi-2, anti-Ro/La, anti-smith, anti-Scleroderma, anti-dsDNA, anti-ribosomal P, anti-RNP), were unremarkable. Anti-NMO and anti-MOG antibodies were negative. He improved with methylprednisolone 1000 mg daily for five days suggesting an autoimmune etiology. Results: NA Conclusions: Transverse myelitis has a broad presentation and differential, requiring detailed history-taking to determine the cause as management differs between etiologies. SARS-CoV-2 and post-vaccination are known etiologies for TM. Given the timing of our patient's symptom onset after vaccination and thorough exclusion of other causes, we postulate a potentially novel case of TM associated with the Moderna SARS-CoV-2 vaccine. Though post-vaccination myelopathy is potentially debilitating if untreated, it is rare, and the benefits of vaccination appear to outweigh the risks.
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Background: Acute Transverse Myelitis (ATM) is a very uncommon neurological syndrome, characterized by acute or subacute spinal cord dysfunction that can lead to paresthesias, sensory/autonomic impairment and paralysis. The aetiology is often unclear, but infectious, para-infectious, systemic autoimmune diseases, paraneoplastic, ischemic diseases and drugs are potential causes. Vaccine administration can also trigger an immune response and induce an autoimmune response;however, ATM has rarely been reported as a complication of COVID-19 infections or vaccination. The treatment mainly consists of steroids and plasmapheresis, which often reverses any neurologic symptoms. The therapeutic plasmapheresis is a highly complex procedure. It separates the patient's blood components replacing the plasma removed by solution that can be fresh frozen plasma or albumin, allowing the removal of the autoantibody, immune complex, lipoprotein or endotoxin that's causing the pathology. Aims: Clinical case report. Methods: A 46-year-old male patient, with personal history of hypertension and obesity, 3 weeks after COVID-19 vaccination, presented to the emergency department due to urinary complaints (urgency and pollakiuria), progressive numbness, paresthesias and decreased muscle strength in the lower limbs and decreased sensibility in the perineal region. Physical examination revealed total gait disability, decreased sensation and strength in the right lower limb, loss of sensation and plegia in the left lower limb and urinary incontinence. Initial laboratory workup and CT imaging of the brain, cervical, dorsal and lumbar spine were normal. The patient was admitted to Neurology internment for further study and treatment. During hospitalization, lumbar puncture and MRI of the dorsal and lumbosacral neuraxis were performed, but only allowed us to exclude infectious and compressive etiologies. The inflammatory aetiology was assumed as the most probable, so acute therapy with pulses of methylprednisolone was initiated. In the remaining study, weakly positive anti-MOG (Myelin Oligodendrocyte Glycoprotein) antibodies were detected in the serum. Therapeutic plasmapheresis using a cell separator (which use centrifugal force to separate components according to their density) was proposed as additional therapy. Seven sessions were performed without intercurrences. Results: During acute therapy, there was a partial improvement in sensitivity and strength in lower limbs. The patient started a rehabilitation program with favourable neurological recovery. At the time of hospital discharge, he still needed crutch support for walking and had muscle strength grade 4-/5 bilaterally. Summary/Conclusions: Although the patient maintained some functional limitation and there was not a complete resolution of the neurological symptoms, he showed a good response to acute therapy. The plasmapheresis, by permitting the antibody to be removed faster than would occur by its endogenous clearance, proved to be fundamental in the clinical recovery of the patient. No relationship between COVID-19 vaccination and the event was established.
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Introduction & Objectives: Adrien Proust was a French epidemiologist and hygienist in Paris. He is acknowledged as one of the pioneers of social distancing, quarantine, the modern cordon sanitaire (a barrier to stop the spread of infectious diseases) and confinement, which he called “sequestration“. Materials & Methods: Moreover Adrien Proust was the father of two world famous sons. One is the author Marcel Proust (1871-1922), who wrote one of the most iconic books in French literature “À la recherche du temps perdu”. The younger son was Robert Proust (1873-1935), a well-known urologist in his time, who pioneered perineal prostatectomy after 1900, a procedure therefore nicknamed “proustatectomie” in France. Results: Already as a young doctor Adrien Proust travelled many countries to conduct research on cholera and other infectious diseases and to understand how pandemics are transmitted. He became Professor of Hygiene at the Faculty of Medicine in Paris and was appointed Inspector General of International Health Services from 1974 to 1903. Conclusions: Highlights of his career were public appearances at international conferences in Venice to fight against cholera and plague (“La défense de l'Europe contre le choléra et la peste”) in 1892 and 1897. Adrien Proust addressed the duality of economy and health in the time of pandemics and his pioneering ideas are of high interest for us today in the time of COVID 19.
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[...]we have the historic task of engendering and delivering a socialism that is not only anti-capitalist, anti-imperialist but, most of all, anti-patriarchal.] To be Venezuelan during the Bolivarian Revolution (referring to the reimagination initiated in 1999 of the Venezuelan Republic as a socialist nation), however, has also meant contending with an increasingly aggressive US and neoliberal world order. The state of Zulia, for example, is home to the largest Indigenous population in the country and reported the highest number of maternal deaths that year.5 The incomplete, fractured, and often dated nature of available information, notwithstanding feminist analysis and synthesis of existing reports, official information sporadically released to the media, and information from agencies with treaties and conventions signed by the state, indicates that conditions that originate during the perinatal period are among the top five causes of death of Venezuelan women.6 Nancy Bello, a feminist doctor and psychiatrist who has led sexual and reproductive health services for Caracas and the Ministry of Popular Power and currently serves as the spokesperson for the women's human rights group Movimiento Mujeres por los Derechos, states that the rise in maternal mortality is rooted in a system that has long been patriarchal.7 She notes that although far fewer women died from causes related to maternity in the 1980s and 1990s, they were overmedicalized and, as a result, young women at the time routinely sustained harms also connected to a lack of patient-centered care such as hysterectomies, damage to the perineum due to badly done episiotomies, alterations to genital anatomy, and other harmful consequences to their sexual lives. While sterilization can serve as a legitimate elective contraceptive method, it is arguably coercive when offered without available alternative contraceptive methods. [...]given that the Plan does not include vasectomies, it is "a biased and discriminatory measure that confirms that, in Venezuela, reproductive matters are the purview of women and not men. The authors note that in Venezuela, gender-based violence caused fifty deaths compared to none due to COVID-19 in the sixty days preceding the statement. [...]they called for additional measures to the state's plan to address the pandemic including a hotline to report and collect data on gender-based violence during the pandemic;pandemic-specific and -responsive protective and security measures, including emergency shelter for women and children who report gender-based violence;and a public awareness campaign about gender-based violence.
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Introduction: Objectives: Methods: Results: A four-months old infant was referred for fever for two days and dyspnea. He had bilateral conjunctival hyperemia;bilateral cervical lymphadenopathy;truncal exanthem;perineal erythema;dry cough;normal cardiac, thoracic, and abdominal examination. Nasopharyngeal swab was negative for SARS-CoV-2. His routine analysis showed: Hb 9,9 g/dl;leukocytes 12000/mm3 (neutrophils 60%;lymphocytes 13%);platelets 430000/mm3;CRP 19 mg/dl (normal values < 0,5 mg/dl);ESR 94;Serum Amyloid A 1430 mg/l;ferritin 883 ng/ml. His chest X-ray showed an interstitial pattern. His first echocardiographic evaluation only showed a minimal pericardial effusion, and normal coronary arteries. The patient received two consecutive intravenous infusions of immunoglobulins (2 g/kg), associated with 2 mg/kg/day methylprednisolone, with consequent apyrexia and reduction of CRP (4,5 mg/dl). He also started 3 mg/kg/day aspirin. After two days from the second infusion, fever reappeared together with coronary dilatation: diameter was 2,4 mm for LCA (z-score 3,16);2,4 mm for LAD (z-score 4,49);2,5 mm for RCA (z-score 4,13). Exams showed CRP 6,57 mg/dl;leukocytes 62860/mm3 (73% neutrophils);platelets 1532000/mm3. The child then received Intravenous pulses of 30 mg/kg/day methylprednisolone in three consecutive days, and started 4 mg/kg/day anakinra. The pulses were followed by apyrexia, with CRP 6,54 mg/dl. Four days later CRP was 8,96 mg/dl, so anakinra was interrupted, and 5 mg/kg infliximab was started. Echocardiogram showed rapidly evolving giant coronary aneurysms: diameter was 6 mm for LCA (z-score 15,79);6,5 mm for LAD (z-score 16,41);5 mm for RCA (z-score 11,72). Due to the rapid evolution of aneurysms and an elevated z-score (> 10), 1 mg/kg/dose enoxaparin was started, according to the Kawasaki disease guidelines of the American Heart Association (AHA) (Circulation, 2017). The patient also started ECG, troponin and BNP monitoring. Three days later, the coronary arteries showed further dilatation. Seven days after infliximab infusion, RCA developed a rosary bead - like pattern. There was a gradual improvement of general clinical conditions with reduction of inflammatory markers (negative CRP, ESR 22, leukocytes 28580/mm3, platelets 800000/mm3 after ten days from infliximab infusion), so steroid tapering was started. Because of an increased thromboembolic risk (due to thrombocytosis and to the accelerated blood flow in stenotic coronary traits), clopidogrel 0,5 mg/kg/day was added, according to AHA guidelines. Thirty days after symptom onset, also LDA developed a rosary bead - like pattern. CRP was 1,27 mg/dl and ESR was 37. The patient was then transferred to Pediatric Cardiac Surgery, started 5 mg/kg/day cyclosporin and, after further coronary dilatation (LDA 11 mm;RCA 9 mm), 3 mg/kg/day propranolol and warfarin. A CT angiogram confirmed the aneurysms, and excluded any aortic dilatations. Epiaortic vessels were spared. An increase of cyclosporin dose to 8 mg/kg/day was followed by stabilization of coronary aneurysms. Conclusion: The extreme refractariety of coronary disease, despite aggressive therapy and biologics, is rather clear. The rapid evolution could be explained, though only in part, by a few risk factors such as age below 12 months and elevated CRP. These factors are well known, even though they are not mentioned in guidelines. ed.