Cryptococcal laryngitis in an immunocompetent asthmatic patient using inhaled corticosteroids.

We present a case of laryngeal cryptococcosis caused by cryptococcosis neoformans var. grubii affecting a patient using excessive inhaled corticosteroids. The patient experienced symptoms for several months prior to specialist review and the visualization of a mass lesion by nasopharyngoscopy. Fortunately a biopsy was performed and through histopathology & microbiological assessment a diagnosis of cryptococcal laryngitis was made. Treatment with 6 months of fluconazole resulted in clinical cure and resolution of symptoms. It is important to raise awareness of the risk of non-Candida fungal infections in patients on high dose corticosteroids, especially in the post covid era were steroids are more commonly prescribed.

Post-Spinal Anesthesia Intradural Extramedullary Arachnoid Cyst Formation: A Case Report.

The formation of an intradural extramedullary arachnoid cyst is a rare complication of spinal anesthesia. We present a case of a 34-year-old female patient who developed neurological symptoms including a bilateral reduction in sensation and strength in the lower limbs following a C-section under spinal anesthesia. MRI of the thoracic spine revealed a lesion at the level of T11/T12 and the upper limit of the L1 vertebral body, which was pushing the cord to the side, and a diagnosis of the intradural extramedullary arachnoid cyst was established. The prognosis for this condition is good and surgical excision leads to resolution of the symptoms. Proper and prompt diagnosis is crucial to rule out other differentials and prevent permanent neurological damage in these patients.

Association of the Depth of Invasion With Recurrence Rates of Basal Cell Carcinoma in a Tertiary Health Care Facility: A Retrospective Study Over a Period of Six Years.

Background Basal cell carcinoma (BCC) is one of the most common types of cutaneous malignancies and the most frequently occurring form of cancer worldwide. The incidence of basal cell carcinoma is difficult to determine due to its wide geographic variations; however, it has been increasing worldwide with an annual increase of 7% in the number of reported cases. Although BCC is more prevalent in the aging population, diagnosis in younger individuals is steadily increasing. BCC has overall low mortality, however, it leads to significant economic and physical impact on patients and their families along with adding burden to the healthcare system. The primary risk factor for the development of BCC is increased cumulative sun exposure, particularly to UV radiation. The UV index of Karachi averages around 12 (extremely high) during summer months, putting the population at a significantly higher risk of developing BCC in the long term. Objectives This audit was undertaken with the following primary objectives: to use the data collected to determine possible prognostic factors for BCC, to measure the rate of recurrence and the number of new primary tumors detected, to study the completeness of follow-up by patients, and to co-relate histopathological findings with the recurrence rate of basal cell carcinoma. Methods A retrospective analysis was performed for all patients with BCC who had undergone surgical resection over a six-year time period. Patient charts were reviewed for demographic information, tumor size, onset-to-diagnosis, anatomic location, clinical subtype, histologic differentiation, method of surgical treatment, and recurrence. Data were entered and analyzed in SPSS version 23 (IBM Corp., Armonk, NY). Results The review identified cases of BCC in 99 patients. Of the 99 patients, 60.39% were men and 38.38% were women. The most frequent age group was 65-85-year-olds (42 patients, 42.85%) for BCC. Based on the aesthetic units of the face, the most common location was the nasal unit (30 cases, 30.30%) for BCC. Most of the lesions were closed primarily; however; local flaps were used in the case of surgical defects. The recurrence rate was 19.19% for BCC in this study. Our study included 1.0% of patients who were classified as Clark classification level 2 of BCC, 6.1% as Clark level 3, 23.4% as Clark level 4, and 0.16% as Clark level 5. Recurrence rates were seen to increase with increasing Clark classification level in this study. Conclusion In our study, many characteristics of BCC were compared to previously published reports and the results were seen to be generally similar. This study correlates the recurrence of BCC with Clark's classification, showing that depth of invasion is a significant factor in predicting recurrence. There is a paucity of literature regarding the depth of invasion of BCC along with its' Clarks classification and recurrence. Further studies can help explore and establish the characteristics of BCC.

Indigenous Bacillus paramycoides spp. and Alcaligenes faecalis: sustainable solution for bioremediation of hospital wastewater.

Farmers near towns and cities are using a wide range of highly polluted wastewaters for crop irrigation in Pakistan due to severe freshwater shortage. The present study aimed to promote indigenous bacterial strains isolated from domestic, hospital, textile, pharmaceutical and mixed wastewaters to remove contaminants and colour and render these wastewaters safer for irrigation. Thirty seven bacterial strains were isolated from five wastewater samples collected from different sites in Lahore, Pakistan. Under optimal growth conditions, three isolates (D6, D7 and P1) showed >93% decolourisation potential in the treatment of hospital wastewater. 16S rDNA sequencing identified two of these isolates (D6 and D7) as showing 100% and 99.86% homology to Bacillus paramycoides spp. - novel strains from B. cereus group. Isolate P1 showed 97.47% homology to Alcaligenes faecalis. GCMS analysis of the untreated hospital wastewater revealed the presence of pharmaceutic pollutants, i.e. Phenol (876 µg/L), Salicylic acid (48 µg/L), Caffeine (7 µg/L), Naproxen (23 µg/L), Octadecene (185 µg/L) and Diazepam (14 µg/L). The analysis of treated hospital wastewaters showed percentage degradation of pharmaceutic pollutants (100%-43%) and significant reduction in the BOD5 (91%-68%), COD (89%-52%) and heavy metals concentrations. These strains therefore can represent a low-cost and low-tech alternative to bioremediate complex matrices of hospital wastewater prior to crop irrigation to support the achievement of clean re-usable water in developing countries like Pakistan.

Hospital wastewater treated with a novel bacterial consortium (Alcaligenes faecalis and Bacillus paramycoides spp.) for phytotoxicity reduction in Berseem clover and tomato crops.

Hospital wastewaters are produced in large volumes in Pakistan (∼362-745 L/bed.day) and are discharged without proper treatment. They are widely used by farmers for crop irrigation and induce a phytotoxic effect on plant growth. The study was conducted to evaluate the effect of untreated and treated hospital wastewater on seed germination of a fodder crop Trifolium alexandrinum (Berseem clover) and a food crop Solanum lycopersicum (tomato). A bacterial consortium was formed with three bacterial strains, i.e., Alcaligenes faecalis and Bacillus paramycoides spp., which were individually proven efficient in previous studies. The concentrations of untreated and treated hospital wastewater (25, 50, 75 and 100%) were used to irrigate these crop seeds. To assess the efficiency of treatment, the germination percentage, delay index, germination index, stress tolerance indices, seedling vigour index and phytotoxicity index were calculated and were statistically proven significant. The seeds grown in treated wastewater concentrations showed negative values of phytotoxicity indices (tomato: -0.36, -0.47, -0.78 and -1.11; Berseem clover: -0.23) which indicate a stimulatory or non-toxic effect on seedling growth. Our work proposes that this bacterial consortium is efficient for hospital wastewater treatment before crop irrigation.

Differential Diagnosis of Common Acute Toxicologic Versus Nontoxicologic Illness.

This article provides a display table laying out the differential diagnosis of common acute toxicologic versus nontoxicologic illnesses in small animals. Major clinical abnormalities are listed, along with common toxicologic rule outs and nontoxicologic rule outs. Further readings are also provided.

Common Reversal Agents/Antidotes in Small Animal Poisoning.

This article provides a quick source of information for practicing veterinarians for using various antidotes in small animal poisoning cases. For easy access, this information is included in the form of a table. The first column includes common names and/or brand names of different antidotes. In the second column, names of different toxicants or indications for which these antidotes can be used are described. The third column is the comment section that briefly describes salient points or cautions for using these antidotes.

Toxicology of Frequently Encountered Nonsteroidal Anti-inflammatory Drugs in Dogs and Cats: An Update.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for their antipyretic, anti-inflammatory, and analgesic properties. Although most NSAIDs consist of a range of pharmacologically active agents with diverse chemical structures and properties, they have similar therapeutic and adverse effects associated with their use. Each year, the American Society for the Prevention of Cruelty to Animals Animal Poison Control Center (APCC) receives hundreds of cases involving acute accidental ingestion/overdose of NSAIDs in dogs and cats. This article provides an overview on the classification, uses, pharmacokinetics, mechanisms of action, and treatment of the most commonly encountered NSAIDs in dogs and cats.

Do demographics and tumour-related factors affect nodal yield at neck dissection? A retrospective cohort study.

BACKGROUND: Nodal metastasis is an important prognostic factor in head and neck squamous cell carcinoma. This study aimed to determine the average nodal basin yield per level of neck dissection, and to investigate if age, gender, body mass index, tumour size, depth of tumour invasion and p16 status influence nodal yield. METHOD: A retrospective review of 185 patients with head and neck squamous cell carcinoma generated 240 neck dissection specimens. RESULTS: The respective mean nodal yields for levels I, II, III, IV and V were 5.27, 9.43, 8.49, 7.43 and 9.02 in non-cutaneous squamous cell carcinoma patients, and 4.2, 7.57, 9.65, 4.33 and 12.29 in cutaneous squamous cell carcinoma patients. Multiple regression analysis revealed that p16-positive patients with mucosal squamous cell carcinoma yielded, on average, 2.4 more nodes than their p16-negative peers (p = 0.04, 95 per cent confidence interval = 0.116 to 4.693). This figure was 3.84 (p = 0.008, 95 per cent confidence interval = 1.070 to 6.605) for p16-positive patients with oral cavity squamous cell carcinoma. CONCLUSION: In mucosal squamous cell carcinoma, p16-positive status significantly influenced nodal yield, with the impact being more pronounced in oral cavity squamous cell carcinoma patients.

Fetal lower urinary tract obstruction: proposal for standardized multidisciplinary prenatal management based on disease severity.

OBJECTIVE: To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity. METHODS: This was a retrospective cohort study of 25 consecutive fetal patients with prenatal diagnosis of primary LUTO. Fetal intervention was offered after evaluation by a multidisciplinary team. Analyses were conducted using Bayesian methodology to determine predictors of survival at 6 months postpartum. Odds ratios (ORs) with 95% credibility intervals are reported. RESULTS: Fifteen (60.0%) of the 25 patients referred for assessment survived to postnatal evaluation. Fetal vesicoamniotic shunt was placed in 14 (56.0%) patients with 12 survivors. Multivariable analysis suggested that fetal intervention (OR, 6.97 (0.88-70.16), Pr(OR > 1) = 96.7%), anhydramnios (OR, 0.12 (0.04-0.35), Pr(OR < 1) = 99.9%), favorable fetal urine analysis (OR, 3.98 (0.63-25.15), Pr(OR > 1) = 92.7%) and absence of renal cortical cysts (OR, 3.9 (0.66-24.2), Pr(OR > 1) = 93.3%) were predictors of survival. CONCLUSIONS: Fetal intervention and fetal renal function were independently associated with postnatal survival of fetuses with LUTO. A classification based on the severity of disease is proposed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Therapeutic hypothermia for status epilepticus: A report, historical perspective, and review.

Refractory status epilepticus is a disease associated with high morbidity and mortality, which does not always respond to standard treatments, and when they fail, alternative modalities become crucial. Therapeutic hypothermia slows nerve conduction in vitro, and has been shown to abort seizures in animal models. Therapeutic hypothermia has been experimentally used in humans since 1963 for a variety of intracranial pathologies. More recently there have been multiple reports demonstrating the effectiveness of therapeutic hypothermia in treating refractory status epilepticus. We report a case of super-refractory status epilepticus successfully treated with therapeutic hypothermia, complimented by a historical and literature review of this modality. While there is limited evidence, and some risks associated with therapeutic hypothermia, it should be considered as a reasonable and potentially effective treatment option for refractory status epilepticus.

Concentrated tea tree oil toxicosis in dogs and cats: 443 cases (2002-2012).

OBJECTIVE: To determine the frequency, types, and severity of clinical signs; geographic distribution; and treatment information associated with toxicosis caused by 100% tea tree oil (TTO) in dogs and cats in the United States and Canada. DESIGN: Retrospective case series. ANIMALS: 337 dogs and 106 cats with evidence of exposure to 100% TTO. PROCEDURES: 10-year incident data were retrieved from the ASPCA Animal Poison Control Center database from January 2002 to December 2012. Only evidenced or witnessed incidents assessed as toxicosis or suspected toxicosis were included. Signalment, amount of TTO used, intention of use, and outcome information were evaluated. Severity of illness and correlations with breed, sex, age, and weight were determined. RESULTS: TTO was intentionally used in 395 of 443 (89%) animals. The amount used ranged from 0.1 to 85 mL. Incidents were reported from 41 states, the District of Columbia, and 4 Canadian provinces. Exposure route was cutaneous in 221 (50%) animals, cutaneous and oral in 133 (30%), and oral in 67 (15%). Clinical signs developed within 2 to 12 hours and lasted up to 72 hours. The most common signs were increased salivation or drooling, signs of CNS depression or lethargy, paresis, ataxia, and tremors. A significant association with severity of illness was found for age and weight, with higher prevalence of major illness in younger and smaller cats. CONCLUSIONS AND CLINICAL RELEVANCE: Intentional or accidental use of 100% TTO in dogs or cats caused serious signs of CNS depression, paresis, ataxia, or tremors within hours after exposure and lasting up to 3 days. Younger cats and those with lighter body weight were at greater risk of developing major illness.

The effect of endurance exercise on both skeletal muscle and systemic oxidative stress in previously sedentary obese men.

BACKGROUND: Obesity is associated with low-grade systemic inflammation, in part because of secretion of proinflammatory cytokines, resulting into peripheral insulin resistance (IR). Increased oxidative stress is proposed to link adiposity and chronic inflammation. The effects of endurance exercise in modulating these outcomes in insulin-resistant obese adults remain unclear. We investigated the effect of endurance exercise on markers of oxidative damage (4-hydroxy-2-nonenal (4-HNE), protein carbonyls (PCs)) and antioxidant enzymes (superoxide dismutase (SOD), catalase) in skeletal muscle; urinary markers of oxidative stress (8-hydroxy-2-deoxyguanosine (8-OHdG), 8-isoprostane); and plasma cytokines (C-reactive protein (CRP), interleukin-6 (IL-6), leptin, adiponectin). METHODS: Age- and fitness-matched sedentary obese and lean men (n=9 per group) underwent 3 months of moderate-intensity endurance cycling training with a vastus lateralis biopsy, 24-h urine sample and venous blood samples taken before and after the intervention. RESULTS: Obese subjects had increased levels of oxidative damage: 4-HNE (+37%; P0.03) and PC (+63%; P0.02); evidence of increased adaptive response to oxidative stress because of elevated levels of copper/zinc SOD (Cu/ZnSOD) protein content (+84%; P0.01); increased markers of inflammation: CRP (+737%; P0.0001) and IL-6 (+85%; P0.03), and these correlated with increased markers of obesity; and increased leptin (+262%; P0.0001) with lower adiponectin (-27%; P0.01) levels vs lean controls. Training reduced 4-HNE (-10%; P0.04), PC (-21%; P0.05), 8-isoprostane (-26%; P0.02) and leptin levels (-33%; P0.01); had a tendency to decrease IL-6 levels (-21%; P=0.07) and IR (-17%; P=0.10); and increased manganese SOD (MnSOD) levels (+47%; P0.01). CONCLUSION: Endurance exercise reduced skeletal muscle-specific and systemic oxidative damage while improving IR and cytokine profile associated with obesity, independent of weight loss. Hence, exercise is a useful therapeutic modality to reduce risk factors associated with the pathogenesis of IR in obesity.

Effectiveness and adverse effects of the use of apomorphine and 3% hydrogen peroxide solution to induce emesis in dogs.

OBJECTIVE: To determine the effectiveness and adverse effects of apomorphine and 3% hydrogen peroxide solution used for emesis in dogs. DESIGN: Prospective observational study. ANIMALS: 147 dogs that received apomorphine (IV or placed in the conjunctival sac) or 3% hydrogen peroxide solution (PO) to induce emesis after exposure to toxic agents. PROCEDURES: Data regarding signalment; agent information; type, dose, route, and number of emetic administrations; whether emesis was successful; number of times emesis occurred; percentage of ingested agent recovered; and adverse effects were collected via telephone during American Society for the Prevention of Cruelty to Animals Animal Poison Control Center operations and stored in a database for analysis. Mann-Whitney and Fisher exact tests were used to evaluate emetic success rates. RESULTS: Apomorphine and 3% hydrogen peroxide solution successfully induced emesis in 59 of 63 (94%) and 76 of 84 (90%) of dogs, respectively. Mean time to onset of emesis after the first dose of emetic was 14.5 and 18.6 minutes when hydrogen peroxide (n = 37) and apomorphine (31) were used, respectively, with mean durations of 42 and 27 minutes, respectively. Mean estimates for recovery of ingested agents were 48% for hydrogen peroxide and 52% for apomorphine. Adverse effects were reported in 16 of 112 (14%) dogs for which information was available. CONCLUSIONS AND CLINICAL RELEVANCE: 3% hydrogen peroxide solution and apomorphine effectively induced emesis in dogs when used as directed. Emesis occurred within minutes after administration and helped recover substantial amounts of ingested agents. Adverse effects of both emetics were considered mild and self-limiting.

Adverse reactions from essential oil-containing natural flea products exempted from Environmental Protection Agency regulations in dogs and cats.

OBJECTIVE: To describe adverse effects in dogs and cats exposed to Environmental Protection Agency exempted plant-derived flea preventatives containing mixtures of essential oils. DESIGN: Retrospective study from 2006 to 2008. SETTING: Records of dog and cat cases were reviewed from the American Society for the Prevention of Cruelty to Animals, Animal Poison Control Center database. ANIMALS: Thirty-nine cats and 9 dogs with history of exposure to natural flea preventatives. MEASUREMENTS AND MAIN RESULTS: The following information was retrieved from each incident: number of animals, species involved, frequency, types, onset time, duration of clinical signs, exposure appropriateness, final outcome, and treatment information. Ninety-two percent of animals (n = 44) showed presence of one or more adverse effects. The frequency of adverse effects in dogs (n = 8; 89%) and cats (n = 36; 92%) was similar. Onset time of adverse effects in 39 of 44 animals occurred within 24 hours. The duration of signs in 24 animals ranged from 30 minutes to 149 hours. The products were used as per label in 77% animals (n = 37). Of 28 animals with known outcome, 50% (n = 14) recovered with bathing alone while others received intravenous fluids, muscle relaxants, and anticonvulsive medications. Death (1 cat; n = 1/28; 4%) or euthanasia (1 cat and 1 dog; n = 2/28; 7%) was reported in 3 animals. CONCLUSION: Dogs and cats can experience significant adverse effects when exposed to plant-derived flea preventatives even when used according to label directions. The number of reports of exposure in cats was higher than dogs, but the frequency of reported adverse effects was similar between the 2 species. Agitation and hypersalivation were common in cats, whereas lethargy and vomiting were common in dogs.

Laryngeal paraganglioma in an irradiated neck.

OBJECTIVE: We present the first reported case of a paraganglioma of the larynx occurring concurrently with squamous cell carcinoma in an irradiated neck. METHOD: We present a case report and a literature review of paraganglioma of the larynx. CASE REPORT: A 78-year-old woman was found to have a mass on the laryngeal surface of the epiglottis and non-functioning larynx, four months after radical radiotherapy for biopsy-proven squamous cell carcinoma. Repeated positron emission tomography computed tomography was highly suggestive of residual malignancy. Given these findings, and the fact that the patient was aspirating, she was treated with total laryngectomy, and was found to have a paraganglioma of the larynx. CONCLUSION: This is the first report of such a case. Its importance is three-fold in that it demonstrates: the coexistence of paraganglioma and squamous cell carcinoma; the difficulties that can be encountered in the diagnosis; and the use of radiotherapy in the treatment of paraganglioma.

Toxicology of frequently encountered nonsteroidal anti-inflammatory drugs in dogs and cats.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of heterogeneous compounds extensively used in both human and veterinary medicine for their antipyretic, anti-inflammation, and analgesic properties. NSAIDs consist of a wide range of pharmacologically active agents with different chemical structures, with similar therapeutic and adverse effects. The ASPCA Animal Poison Control Center received 22,206 NSAID incidents in dogs and cats (3% of total cases; dogs [15,823] and cats [1244]) during 2005 to 2010. This is roughly equivalent to 4% NSAID incidents reported in humans. The most common NSAID involved was ibuprofen, followed by aspirin, naproxen, deracoxib, meloxicam, diclofenac, piroxicam, indomethacin, nabumetone, and etodolac. This article provides a brief overview of classification, mechanism of action, pharmacologic and toxicologic properties, and treatment information involving frequently encountered human and veterinary NSAIDs in dogs and cats.

Differential diagnosis of common acute toxicologic versus nontoxicologic illness.

This table outlines common toxicologic versus nontoxicologic rule outs based on clinical abnormalities seen in an acutely ill animal. The purpose is to provide an initial guideline for considering toxicologic versus nontoxicologic rule outs when a patient is presented to a practicing veterinarian. Major clinical abnormalities followed by common toxicologic rule outs and non-toxicologic rule outs have been listed so that practicing veterinarians can narrow down an etiology quickly. Based on history, physical examination findings, and blood work changes, once a reasonable etiology has been narrowed down or established, the reader is encouraged to review a more detailed discussion on management of the particular poisoning or disease listed in this or other references.

Common reversal agents/antidotes in small animal poisoning.

Different antidotes counteract the effect of a toxicant in several different ways. Antidotes can reverse, decrease, or prevent action of a toxicant. They can also help in achieving stabilization of vital signs, directly or indirectly, and promote excretion of a toxicant. However, overreliance on an antidote can be unrealistic and dangerous. While expectations of rapid recovery from antidotes are usually high, in a real life situation, there are many impediments in achieving this goal. The timing of its use, availability, cost, and sometimes adverse effects from the antidote itself can influence the results and outcome of a case. The majority of toxicants do not have a specific antidote therapy indicated and patients in these cases equally benefit from supportive care. In this chapter, commonly used antidotes and reversal agents in small animals are listed in a table form. The table lists generic name along with brand name of an antidote/reversal agent whenever available, main indications for their use, and provides comments or cautions in their use as needed. After stabilizing the patient and establishing the etiology, the clinicians must review more detailed management of that particular toxicant discussed here or in other references.