Airway management of a patient with linear immunoglobulin A bullous dermatosis: A case report.

BACKGROUND: There is limited literature on managing the airway of patients with linear immunoglobulin A (IgA) bullous dermatosis, a rare mucocutaneous disorder that leads to the development of friable bullae. Careful clinical decision making is necessary when there is a risk of bleeding into the airway, and a multidisciplinary team approach may lead to decreased patient morbidity during these high-risk scenarios, especially when confronted with an unusual cause for bleeding. CASE SUMMARY: A 45-year-old African American female presented to our ambulatory surgical center for right corneal transplantation due to corneal perforation after blunt trauma in the setting of cicatricial conjunctivitis and diffuse corneal neovascularization from linear IgA bullous dermatosis. The diagnosis of IgA dermatosis was recent, and the patient had been lost to follow-up. The severity of the disease and extent of airway involvement was unknown at the time of the surgery. Significant airway bleeding was noticed upon intubation and the otorhinolaryngology team had to be called to the operating room. The patient required transfer to the intensive care unit where a multidisciplinary team was involved in her case. The patient was extubated on postoperative day 4. CONCLUSION: A multidisciplinary approach to treating this disease is the best course of action before a surgical procedure. In our case, key communication between the surgery, anesthesia, and dermatology teams led to the quick and safe treatment of our patient's disease. Ambulatory surgery should not be considered for these cases unless they are in full remission and there is no mucous membrane involvement.

Transradial access for cerebral angiography and neurointerventional procedures: A meta-analysis and systematic review.

PURPOSE: Transradial access (TRA) for diagnostic and interventional neurointerventional procedures has recently gained traction over transfemoral access (TFA) in the neurointerventional community. This meta-analysis aims to assess and summarize the utility of TRA in cerebral angiography and neurointerventional procedures. METHODS: A systematic literature review was performed utilizing Pubmed, Embase, and Scopus databases. Using PRISMA guidelines, records were extracted with the following search terms: transradial approach, transradial access, radial access, cerebral angiogram, cerebral angiography, neurointervention, and neuroendovascular. The primary outcomes assessed were case success rate, complication rate, and crossover rate from TRA to TFA. Secondary analysis was performed on procedure time, fluoroscopy time, fluoroscopy time per vessel (diagnostic procedures only), contrast dose, radial artery diameter, distal radial artery diameter, and patient preference for TRA over TFA. RESULTS: Sixty-two full-text articles were analyzed for this meta-analysis, representing 12,927 diagnostic and interventional TRA access patients. Our analysis revealed a combined diagnostic and interventional case success rate of 95.9% and complication rate of 3.5%, with crossover to TFA occurring in 4.9% of cases. CONCLUSION: This meta-analysis demonstrates that TRA access for diagnostic angiography and neurointerventional procedures is a safe and effective approach, though determining a true complication rate is challenging as the definition of TRA complications has changed in various publications over time.

Academic medicine's glass ceiling: Author's gender in top three medical research journals impacts probability of future publication success.

INTRODUCTION: In December 2017, Lancet called for gender inequality investigations. Holding other factors constant, trends over time for significant author (i.e., first, second, last or any of these authors) publications were examined for the three highest-impact medical research journals (i.e., New England Journal of Medicine [NEJM], Journal of the American Medical Association [JAMA], and Lancet). MATERIALS AND METHODS: Using randomly sampled 2002-2019 MEDLINE original publications (n = 1,080; 20/year/journal), significant author-based and publication-based characteristics were extracted. Gender assignment used internet-based biographies, pronouns, first names, and photographs. Adjusting for author-specific characteristics and multiple publications per author, generalized estimating equations tested for first, second, and last significant author gender disparities. RESULTS: Compared to 37.23% of 2002 - 2019 U.S. medical school full-time faculty that were women, women's first author publication rates (26.82% overall, 15.83% NEJM, 29.38% Lancet, and 35.39% JAMA; all p < 0.0001) were lower. No improvements over time occurred in women first authorship rates. Women first authors had lower Web of Science citation counts and co-authors/collaborating author counts, less frequently held M.D. or multiple doctoral-level degrees, less commonly published clinical trials or cardiovascular-related projects, but more commonly were North American-based and studied North American-based patients (all p < 0.05). Women second and last authors were similarly underrepresented. Compared to men, women first authors had lower multiple publication rates in these top journals (p < 0.001). Same gender first/last authors resulted in higher multiple publication rates within these top three journals (p < 0.001). DISCUSSION: Since 2002, this authorship "gender disparity chasm" has been tolerated across all these top medical research journals. Despite Lancet's 2017 call to arms, furthermore, the author-based gender disparities have not changed for these top medical research journals - even in recent times. Co-author gender alignment may reduce future gender inequities, but this promising strategy requires further investigation.

Retrograde Intubation Over a Flexible Fiber-Optic Bronchoscope.

Traditional retrograde intubation consists of tracheal intubation performed over a guide wire inserted into the trachea inferior to the vocal cords and then passed transorally or transnasally. This intubation technique is reserved for patients with a difficult airway when other methods such as blind nasal intubation or video laryngoscopy fail. A guide wire passed blindly in a retrograde fashion, however, is not without its own constraints. This case report presents the anesthetic management of a 23-year-old Duchenne muscular dystrophy patient with substantial scarring from a previous tracheostomy stoma and limited mouth opening. The patient underwent a retrograde fiber-optic transnasal intubation without the use of a guide wire for a tracheostomy revision procedure, followed by a second tracheostomy revision and retrograde fiber-optic transoral intubation 7.5 months later. This report demonstrates a novel technique for intubating patients with difficult airways. The use of a flexible fiber-optic bronchoscope for a retrograde intubation mitigates complications that can arise using traditional retrograde intubation over a guide wire and increases the likelihood of successful intubation.

Evaluation of contrast sensitivity in non-high-risk proliferative diabetic retinopathy treated with panretinal photocoagulation with and without intravitreal injections of ranibizumab / Avaliação da sensibilidade ao contraste em retinopatia diabética proliferativa de não alto risco tratada com panfotocoagulação retiniana com ou sem injeções intravítrea de ranibizumabe

ABSTRACT Purpose: To evaluate contrast sensitivity in non-high-risk, treatment-naïve proliferative diabetic retinopathy patients treated with panretinal photocoagulation and intravitreal injections of ranibizumab) versus panretinal photocoagulation alone. Methods: Sixty eyes of 30 patients with bilateral proliferative diabetic retinopathy were randomized into two groups: one received panretinal photocoagulation and ranibizumab injections (study group), while the other received panretinal photocoagulation alone (control group). All eyes were treated with panretinal photocoagulation in three sessions according to the Early Treatment Diabetic Retinopathy Study guidelines. Contrast sensitivity measurements were performed under photopic conditions (85 cd/m2) with the Visual Contrast Test Sensitivity 6500 chart, allowing for the evaluation of five spatial frequencies with sine wave grating charts: 1.5, 3.0, 6.0, 12.0, and 18.0 cycles per degree (cpd). Outcomes were measured in contrast sensitivity threshold scores among and within groups, from baseline to 1, 3, and 6 months. Results: Fifty-eight eyes (28 in the study group and 30 in the control group) reached the study endpoint. A comparative analysis of changes in contrast sensitivity between the groups showed significant differences mainly in low frequencies as follows: at month 1 in 1.5 cpd (p=0.001) and 3.0 cpd (p=0.04); at month 3 in 1.5 cpd (p=0.016), and at month 6 in 1.5 cpd (p=0.001) and 3.0 cpd (p=0.026) in favor of the study group. Conclusions: In eyes of patients with non-high-risk proliferative diabetic retinopathy, panretinal photocoagulation treatment with ranibizumab appears to cause less damage to contrast sensitivity compared with panretinal photocoagulation treatment alone. Thus, our evaluation of contrast sensitivity may support the use of ranabizumab as an adjuvant to panretinal photocoagulation for the treatment of proliferative diabetic retinopathy.

RESUMO Objetivos: Avaliar a sensibilidade ao contraste em pacientes virgens de tratamento com retinopatia diabética proliferativa de não alto risco, submetidos a panfotocoagulação retiniana com injeções intravítreas de ranibizumabe versus pan­fotocoagulação isolada. Métodos: Sessenta olhos de 30 pa­cientes foram randomizados em dois grupos: um submetido a panfotocoagulação com injeções de ranibizumabe (grupo estudo), e o outro submetimedo a panfotocoagulação isolada (grupo controle). Todos olhos foram tratados em 3 sessões de laser, seguindo recomendação do Early Treatment Diabetic Retinopathy Study (ETDRS). Avaliação da sensibilidade ao contraste foi realizada sob condições fotópicas (85 cd/m2) com tabela Visual Contrast Test Sensitivity 6500, permitindo avaliação de cinco frequências espaciais medidas com redes senoidais: 1.5, 3.0, 6.0, 12.0 e 18.0 ciclos por grau de ângulo visual (cpd). Foram realizadas medidas dos limiares de sensibilidade ao contraste intra e entre grupos na visita inicial, no 1º, 3º, e 6º mês de seguimento. Resultados: Cinquenta e oito olhos, 28 do grupo estudo e 30 do grupo controle, atingiram o término do estudo. Análise comparativa da SC entre os grupos mostrou diferença estatisticamente significante, nas baixas frequências espaciais, no 1º mês em 1.5 cpd (p=0,001) e 3.0 cpd (p=0,04), no 3º mês em 1.5 cpd (p=0,016) e no 6º mês em 3.0 cpd (p=0,026) a favor do grupo estudo. Conclusão: O tratamento com panfotocoagulação associada a injeção de ranibizumabe parece causar menos danos a sensibilidade ao contraste quando comparada com panfotocoagulação isolada em olhos com retinopatia diabética proliferativa de não alto risco. Dessa forma, os resultados apresentados podem justificar a associação do ranibizumabe à panfotocoagulação nestes pacientes.

Evaluation of contrast sensitivity in non-high-risk proliferative diabetic retinopathy treated with panretinal photocoagulation with and without intravitreal injections of ranibizumab.

PURPOSE: To evaluate contrast sensitivity in non-high-risk, treatment-naïve proliferative diabetic retinopathy patients treated with panretinal photocoagulation and intravitreal injections of ranibizumab) versus panretinal photocoagulation alone. METHODS: Sixty eyes of 30 patients with bilateral proliferative diabetic retinopathy were randomized into two groups: one received panretinal photocoagulation and ranibizumab injections (study group), while the other received panretinal photocoagulation alone (control group). All eyes were treated with panretinal photocoagulation in three sessions according to the Early Treatment Diabetic Retinopathy Study guidelines. Contrast sensitivity measurements were performed under photopic conditions (85 cd/m2) with the Visual Contrast Test Sensitivity 6500 chart, allowing for the evaluation of five spatial frequencies with sine wave grating charts: 1.5, 3.0, 6.0, 12.0, and 18.0 cycles per degree (cpd). Outcomes were measured in contrast sensitivity threshold scores among and within groups, from baseline to 1, 3, and 6 months. RESULTS: Fifty-eight eyes (28 in the study group and 30 in the control group) reached the study endpoint. A comparative analysis of changes in contrast sensitivity between the groups showed significant differences mainly in low frequencies as follows: at month 1 in 1.5 cpd (p=0.001) and 3.0 cpd (p=0.04); at month 3 in 1.5 cpd (p=0.016), and at month 6 in 1.5 cpd (p=0.001) and 3.0 cpd (p=0.026) in favor of the study group. CONCLUSIONS: In eyes of patients with non-high-risk proliferative diabetic retinopathy, panretinal photocoagulation treatment with ranibizumab appears to cause less damage to contrast sensitivity compared with panretinal photocoagulation treatment alone. Thus, our evaluation of contrast sensitivity may support the use of ranabizumab as an adjuvant to panretinal photocoagulation for the treatment of proliferative diabetic retinopathy.

Unexpected blunt neck trauma resulting in laryngeal fracture, the case of the dangerous wooden box: A case report.

BACKGROUND: Laryngeal fracture is a rare condition but is potentially lethal. These injuries are usually caused by major blunt trauma from motor vehicle accidents, physical assaults, or sports injuries. The high mortality associated with these injuries requires prompt recognition and treatment. CASE REPORT: We present a case of laryngeal fracture caused by falling from standing height and landing onto the edge of a wooden box- a seemingly minor blunt trauma. The patient fractured her thyroid lamina and had a comminuted fracture of the cricoid cartilage. The patient was able to be decannulated and required injection augmentation for return of normal voice. CONCLUSION: This case highlights the importance of maintaining a high level of suspicion for laryngeal fracture in a patient that falls and strikes the anterior neck. Early identification of laryngeal fractures not only allows for airway protection but helps ensure the preservation of voice, swallowing and airway functions.

Laryngopharyngeal reflux: Comparing improvements in reflux symptom index with reflux finding score.

PURPOSE: The objective of this study was to determine the correlation of reported symptom improvement in laryngopharyngeal reflux (LPR) with physical findings on laryngoscopic examination following medical therapy. MATERIALS AND METHODS: This IRB-approved, retrospective, single-institution study included all patients who were diagnosed and medically treated for LPR from Jan. 1, 2015-October 21st, 2019. Only patients who received at least six weeks of treatment with a proton pump inhibitor and those with pre- and post-treatment Reflux Symptom Index; RSI (n = 91) and Reflux Finding Score; RFS (n = 33) were included in the study. RESULTS: A total of 91 patients were included in the analysis (61.54% female). There was a 19.99% improvement in total RSI (p = 0.0034) and a 25.20% improvement in total RFS (p = 0.0011) following at least six weeks of treatment (average = 253 ± 213 SD days). RSI symptoms were significantly decreased between pre- and post-treatment for hoarseness (p = 0.0005), clearing of the throat (p = 0.0066), excess throat mucus or postnasal drip (p = 0.0004), troublesome cough (p = 0.0231), and heartburn/chest pain (p = 0.0053). RFS demonstrated a statistically significant decrease in only subglottic edema (p < 0.0001) and ventricular obliteration (p = 0.0295). Pearson's correlation test did not demonstrate a relationship between RSI and RFS in the pre- and post-treatment analyses alone, but did demonstrate a statistically significant relationship when analyzed across all captured pre and post data (r = 0.265, p = 0.006). CONCLUSIONS: RSI and RFS are complimentary to one another when assessing for treatment response, but improvement in RSI does not correlate with that in RFS.

The Pathophysiology and Clinical Manifestations of Spinocerebellar Ataxia Type 6.

Spinocerebellar ataxias (SCA) constitute of a group of degenerative and progressive disorders that can be identified on a molecular and cellular basis. Along with histological changes, the clinical presentation of SCA differs between subtypes. In addition to basic cerebellar dysfunction symptoms, patients with SCA develop gait ataxia, dysphagia, dysarthria, oculomotor disturbances, pyramidal and extrapyramidal disease signs, rigidity, bradycardia, sensory deficits, and mild cognitive and executive function decline. MRI scans have confirmed reduction in mass of frontal, temporal, and parietal portions of the brain along with the cerebellar peduncles, brainstem, and cranial nerve III. Clinically, these damages manifest as decline in cognition and problems with speech, contemplation, and vision. This review article compares the most prevalent subtypes of SCA based on genetic background, pathogenesis, neurological manifestations, other presenting symptoms, and diagnostic workup. Further goals of research in this field should be directed towards a cure for SCA, which currently does not exist.

A solitary supraglottic neurofibroma presenting with obstructive sleep apnea in an adolescent.

None: Obstructive sleep apnea (OSA) is commonly encountered in the pediatric population and has a large differential diagnosis. As clinicians, we must determine who needs to undergo flexible laryngoscopy to rule out potential obstructing lesions causing OSA. This report presents a 16-year-old female who presented with snoring, "asthma," dysphagia, and OSA. Flexible laryngoscopy and computed tomography revealed a neurofibroma of the aryepiglottic fold without associated neurofibromatosis type 1. The patient underwent microlaryngoscopy and the lesion was excised using cold steel and a carbon dioxide laser. At 6 months' follow-up, the patient was breathing without difficulty and had no evidence of recurrence. Solitary laryngeal neurofibromas are extremely rare, and this is the first case of an adolescent with OSA caused by a solitary supraglottic neurofibroma. A supraglottic mass needs to be considered in the differential diagnosis of patients with OSA who fail conservative treatment, even a diagnosis as rare as a solitary laryngeal neurofibroma.