A novel veno-arteriovenous extracorporeal membrane oxygenation with double pump for the treatment of Harlequin syndrome.

OBJECTIVES: The Harlequin syndrome is a complication observed in patients receiving peripheral venoarterial extracorporeal membrane oxygenation. This condition is defined as a critical variation in the oxygen saturation between the upper and the lower part of the body deriving from a poor lung function. METHODS: Between July 2018 and November 2019, a total of 60 patients (42 men and 18 women; mean age 57.4 ± 10.0 years; range = 28-71 years) underwent peripheral venoarterial extracorporeal membrane oxygenation in our center. Harlequin syndrome was identified in eight cases (six men and two women; 13.3%) of the 60 venoarterial extracorporeal membrane oxygenation-supported patients. As a result of the Harlequin syndrome, all these patients required conversion to veno-arteriovenous extracorporeal membrane oxygenation. Control and monitoring of the blood flows of the return cannulae were performed using two centrifugal pumps, one for each inlet line, according to the patient requirements to achieve optimum hemodynamic and oxygenation. RESULTS: Mean duration of veno-arteriovenous extracorporeal membrane oxygenation support was 5.3 ± 1.4 days. Seven patients (87.5%) were switched to venovenous extracorporeal membrane oxygenation, and after 13.5 ± 2.7 days, those patients were totally weaned from extracorporeal membrane oxygenation support. One patient (12.5%) had an improvement in the pulmonary function, but the cardiac function was poor. This patient was switched to venoarterial extracorporeal membrane oxygenation, and after 10 days, the patient was completely weaned from extracorporeal membrane oxygenation support. CONCLUSION: The use of a secondary centrifugal pump to manage the blood flow directed to the internal jugular vein, in the veno-arteriovenous extracorporeal membrane oxygenation setup, allows the reduction in the risk of blood clot formation, clotting factor consumption, and pulmonary embolism when compared to the use of an external clamp.

Child Neurology: An infant with episodic facial flushing: A rare case and review of congenital harlequin syndrome.

Congenital harlequin syndrome is rare dysautonomia of the face most often reported in adults and rarely in infants and children. It is a diagnosis of exclusion and a seemingly benign condition. We report a case of a 6-month-old girl with episodic unilateral and bilateral facial flushing provoked upon awakening and resolved with sleeping with associated autonomic features consistent with harlequin syndrome. This is followed by a review of cases identified regarding this condition in infants and children.

MANAGEMENT OF ENDOCRINE DISEASE: Flushing: current concepts.

OBJECTIVE: Flushing can be defined as a sensation of warmth accompanied by erythema that most commonly is seen on the face and which occurs in episodic attacks. Such a problem can be clinically problematic, since many conditions and drugs can be related to flushing, and while often there appears to be no underlying organic disease, it is important to exclude disorders since they may be life-threatening conditions. DESIGN AND METHODS: We performed a search in MEDLINE using the terms 'flushing' in combination with 'carcinoid syndrome', 'pheochromocytoma', 'mastocytosis', 'menopausal hot flush' and 'treatment'. European and American guidelines relating to neuroendocrine tumours, mastocytosis and menopause were reviewed. RESULTS: In this review, we discuss the main causes of flushing and propose an algorithm based on pathogenesis, which can be used to guide the clinical evaluation process. We also review recent significant developments in the assessment and treatment of the carcinoid syndrome and menopausal hot flushes, which should guide the clinical practice regarding this common but sometimes confusing condition. CONCLUSIONS: When evaluating flushing, a precise systematic approach is needed to exclude potentially serious underlying causes, although despite this, the cause of the disorder is not always found. If symptoms are not progressive, the patient should be advised about its apparently benign nature in order to avoid unnecessary studies or initiating treatments of minimal benefit.

Venous Cannula Positioning in Arterial Deoxygenation During Veno-Arterial Extracorporeal Membrane Oxygenation-A Simulation Study and Case Report.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is indicated in reversible life-threatening circulatory failure with or without respiratory failure. Arterial desaturation in the upper body is frequently seen in patients with peripheral arterial cannulation and severe respiratory failure. The importance of venous cannula positioning was explored in a computer simulation model and a clinical case was described. A closed-loop real-time simulation model has been developed including vascular segments, the heart with valves and pericardium. ECMO was simulated with a fixed flow pump and a selection of clinically relevant venous cannulation sites. A clinical case with no tidal volumes due to pneumonia and an arterial saturation of below 60% in the right hand despite VA-ECMO flow of 4 L/min was described. The case was compared with simulation data. Changing the venous cannulation site from the inferior to the superior caval vein increased arterial saturation in the right arm from below 60% to above 80% in the patient and from 64 to 81% in the simulation model without changing ECMO flow. The patient survived, was extubated and showed no signs of hypoxic damage. We conclude that venous drainage from the superior caval vein improves upper body arterial saturation during veno-arterial ECMO as compared with drainage solely from the inferior caval vein in patients with respiratory failure. The results from the simulation model are in agreement with the clinical scenario.

Urotherapy for tear production with painless urination.

We report a rare case of a 4-year-old girl with involuntary watering of eyes and facial redness during painless voiding since early infancy. Here, we describe her response to urotherapy with improvement of involuntary tearing during micturition, which although neither life threatening nor debilitating, may be quite bothersome for children and their parents, leading to anxiety, emotional burden, or embarrassment. We hypothesize that the lacrimal glands and the bladder and bowel have common central nervous system pathways and that bladder retraining and bowel management might be a potential treatment for this rare condition.

Practical guide to supportive care of patients with functional neuroendocrine tumors.

Supportive care of patients with functional neuroendocrine tumors (NETs) has evolved to include the use of multiple targeted agents to control paraneoplastic states and newer surgical and interventional radiologic techniques to reduce tumor bulk. Challenges encountered by the clinician are the recognition of specific symptom complexes, selecting the relevant laboratory tests and radiologic/scintigraphic scans, and the timing of intervention(s). Individual variables such as the severity of symptoms in the context of primary and metastatic disease sites, tumor bulk, comorbidities, and previous treatment are factors determining the prioritization of specific treatment regimens for patients with functional NETs. Symptoms such as flushing, secretory diarrhea, hypercalcemia, hyper /hypoglycemia, hypercortisolism, and peptic ulcers should improve with decreasing the elevated amino acid and/or peptide levels produced by NETs. These paraneoplastic symptoms may be accompanied by complaints related to tumor burden such as fatigue, pain, early satiety, anorexia, weight loss, night sweats, and/or symptoms secondary to adverse drug effects such as mucositis, dysgeusia, diarrhea, rash, hypertension, and myelosuppression. Developing a comprehensive continuum of care plan early in disease management assists in controlling the presenting signs and symptoms, and in minimizing disease- and/or treatment-related side effects. This guide serves as a framework to manage the signs and symptoms of metastatic functional neuroendocrine tumors.

Topical niacin cream-assisted 595-nm pulsed-dye laser treatment for facial flushing: retrospective analysis of 25 Korean patients.

BACKGROUND: Flushing is defined clinically as a transient reddening of the face and other areas. Due to the transient nature of flushing, a patient may not show signs of flushing during laser treatment. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of 595-nm pulsed-dye laser treatment of flushing or erythema after provocation of flushing by topical niacin cream. METHODS: We retrospectively reviewed a total of 25 Korean patients with facial flushing who were treated with three sessions of 595-nm pulsed-dye laser after the application of topical niacin cream. RESULTS: Follow-up results revealed that 12 of the 25 patients demonstrated marked (51-75%) clinical improvement of baseline facial erythema. Eight patients had moderate (26-50%) improvement and three demonstrated near total (≥ 75%) improvement. Two patients showed minimal to no (0-25%) improvement. We observed that the reactivity to topical niacin cream was markedly reduced in 64% of our patients after 595-nm pulsed-dye laser treatments. Minimal post-therapy facial oedema was noted in most of the patients, which usually resolved spontaneously within 2 days. Pronounced facial swelling was observed in four patients. CONCLUSION: We suggest that 595-nm pulsed-dye laser treatment after provocation of flushing by topical niacin cream may provide a new treatment algorithm for facial flushing in Asians.

Niacin-a critical component to the management of atherosclerosis: contemporary management of dyslipidemia to prevent, reduce, or reverse atherosclerotic cardiovascular disease.

Niacin (nicotinic acid) is the most effective agent for raising high-density lipoprotein cholesterol levels and can improve the entire lipid panel in patients with dyslipidemia. Niacin-containing regimens are among the few treatments studied for dyslipidemia that have both elicited significant reductions in atherosclerotic progression (by angiography or imaging) and also significantly reduced (by approximately 90% vs control) the incidence of cardiovascular events in a single clinical trial. However, cutaneous flushing-an uncomfortable but typically transient adverse effect of niacin-often results in patient nonadherence with this potentially life-saving therapy. Effective counseling regarding the highly favorable benefit-risk ratio for niacin and management strategies such as careful dose escalation, follow-up monitoring, regimen adjustments, and the use of treatment adjuncts (eg, aspirin) can improve patient adherence with niacin therapy. Clinicians are uniquely positioned to provide such counseling to appropriate patients for niacin treatment and hence encourage wider use of this important and necessary cardioprotective medication.

A study to look at the effects of a hydrolat spray on hot flushes in women being treated for breast cancer.

Women undergoing treatment for breast cancer may experience hot flushes, which greatly impact on quality of life. The use of water sprays or moist wipes to lower skin temperature is often recommended. A peppermint and neroli hydrolat spray was compared to a plain water spray to assess which was preferred, in a single-blind randomised control crossover trial. Only 18 of the 44 patients (41%) preferred the hydrolat spray to a plain water spray, which was less than the 80% required to offer this spray as a standard suggestion for hot flush management. However a small number of those choosing it found it extremely helpful. Both sprays appeared to lessen hot flush annoyance. Previous chemotherapy appeared to be a factor influencing the choice of spray.

Diagnosing, treating and managing carcinoid tumours.

Carcinoid tumours are slow-developing, rare, malignant, hormone-secreting tumours. This article discusses their diagnosis, treatment and symptom management and highlights the need for a multidisciplinary approach to patient care.

The homeopathic approach to symptom control in the cancer patient: a prospective observational study.

The aims of this study were to describe a population of patients with cancer referred for complementary therapies to an NHS homeopathic hospital, and to explore the homeopathic approach to symptom control and its impact on mood disturbance and quality of life. One hundred consecutive patients attending a designated research cancer clinic were seen for a consultation, lasting up to 60 min, and prescription of a homeopathic remedy. A maximum of three symptoms were identified and rated by the patient as a problem, using a numerical self-rating scale. The effect these symptoms have on daily life and overall sense of well being were recorded using similar scales. Patients completed the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment in Cancer--Quality of Life Questionnaire--Core 30 (EORTC QLQ-30) at the initial consultation and at four to six consultations later. After this time, the patients completed a final assessment questionnaire asking about satisfaction with the homeopathic approach, how helpful they had found the approach for the targeted symptoms and what factors they felt may have contributed to the changes perceived. One hundred patients were entered into the study. Thirty-nine patients had metastatic disease. Nine patients were refusing conventional cancer treatments. The most common symptoms were pain, fatigue and hot flushes. Symptom scores for fatigue and hot flushes improved significantly over the study period but not for pain scores. Side effects included a transient worsening of symptoms in a few cases, which settled on stopping the remedy. Fifty-two patients completed the study, and in those patients satisfaction was high, and 75% (n=38) rated the approach as helpful or very helpful for their symptoms. Results suggest that further research is warranted to explore the management of hot flushes in women with breast cancer and fatigue in the cancer diagnosis.

Integration of acupuncture into the oncology clinic.

PURPOSE/OBJECTIVE: Patients with cancer or symptoms referable to cancer therapy were offered acupuncture as potential palliation of their symptoms. This paper describes the physical integration of the discipline into the Oncology Clinic, and patient perspectives on its availability and efficacy. PATIENTS AND METHODS: Between August 1999 and May 2000, 123 patients with varying symptoms received acupuncture in our Center's Radiation and Medical Oncology Clinics and Breast Health Center. These patients had 823 visits during this time period. A practice outcome analysis was performed on patients receiving therapy between 1 January 2000 and 30 April 2000. The 89 patients treated during this interval had 444 total visits. In June and July 2000, a questionnaire was administered by phone to 79 of these patients (89%). Standard allopathic care continued while patients were receiving acupuncture. RESULTS: Major reasons for referral included pain (53%), xerostomia (32%), hot flashes (6%) and nausea/loss of appetite (6%). Patients had a mean of five acupuncture visits (range 1-9). Most patients (60%) showed at least 30% improvement in their symptoms. About one-third of patients had no change in severity of symptoms. There were no untoward effects reported related to the acupuncture. When analysed by diagnosis, these values persist. Irrespective of response to therapy, 86% of respondents considered it 'very important' that we continue to provide acupuncture services. CONCLUSION: Acupuncture may contribute to control of symptoms for cancer patients. Expansion of providers, continued patient follow-up, optimization of techniques and prospective objective measurement of response continue in our clinic.

Uso de antibióticoterapia posoperatoria en pacientes con apendicitis aguda en fase flegmonosa / Postoperative antibiotic use in patients with acute appendicitis flegmonous phase

Con la finalidad de determinar si existen beneficios al utilizar antibióticoterapia posoperatoria en pacientes con apendicitis aguda en fase flegmonosa, se realizó un estudio prospectivo y aleatorio evaluando 63 pacientes con dicho diagnóstico. Los pacientes se incluyeron aleatoriamente en 2 grupos y en todos los casos se administró una dosis preoperatoria de antibióticos (amikacina más metronidazol). En el grupo 1, de 32 pacientes, se administró antibióticoterapia posoperatoria. Se excluyeron los pacientes con diagnóstico intraoperatorio distinto a apendicitis aguda flegmonosa, así como aquellos que presentaron enfermedades debilitantes del sistema inmunológico. Se evaluó la evolución posoperatoria y sus complicaciones con seguimiento de 1 mes. Servicio de Cirugía IV. Hospital Universitario de Caracas. Predominó el sexo masculino con un 65,4 por ciento de los casos, y el grupo etario entre los 10 y 30 años correspondió al 79,3 por ciento de los pacientes. Se presentaron complicaciones infecciosas relacionadas con la herida operatoria en dos casos, un paciente para cada grupo, lo que equivale al 3,1 por ciento, con una mortalidad de 0 por ciento. El uso de antibióticoterapia posoperatoria en pacientes con apendicitis aguda en fase flegmonosa no disminuyó el índice de complicaciones infecciosas, por lo tanto recomendamos que la antibióticoterapia en estos pacientes se limite al preoperatorio.

Nonhormonal alternatives for the management of early menopause in younger women with breast cancer.

Current medical practice recommends the use of alternatives to estrogen-replacement therapy for the treatment of menopausal sequelae in younger women with breast cancer, although this clinical recommendation is undergoing reappraisal. Until prospective randomized studies addressing hormone use in this population are available, estrogen use in breast cancer patients will remain controversial. Because estrogen-replacement therapy is not the standard of practice and there is limited information available on nonestrogen therapies, women with breast cancer who are menopausal may not be prescribed or counseled about nonestrogen options. The efficacy, safety, and extent of use of most nonestrogen treatment modalities (other hormonal preparations, nonhormonal drugs, homeopathic preparations, and non-drug treatments) are not well documented and, unlike estrogen, many are selective in their benefit and do not share estrogen's universal impact. The use of several nonestrogen approaches for the prevention and treatment of osteoporosis has been promising. Traditional recommendations to maintain skeletal integrity, such as weight-bearing exercise; a diet rich in calcium and limited in caffeine, alcohol, and protein; avoidance of smoking; and measures to minimize trauma have been expanded to include the use or investigation of drugs (either alone or in combination). These drugs include progestins, vitamin D metabolites, injectable and intranasal synthetic salmon calcitonin, bisphosphonates, sodium fluoride, parathyroid hormone, growth factors, tamoxifen, etc. Strict control of the known risk factors, such as smoking, dyslipidemia, and hypertension as well as exercise, weight control, and the use of tamoxifen, are employed for the prevention and treatment of cardiovascular complications.(ABSTRACT TRUNCATED AT 250 WORDS)

A clinicopathologic study of ten patients with recurrent unexplained flushing.

We describe the clinicopathologic features of 10 patients with recurrent unexplained flushing. These patients were referred to the National Institutes of Health with a diagnosis of mastocytosis or idiopathic anaphylaxis. Both diagnoses were eliminated after evaluation. Patients reported attacks of flushing lasting 15 minutes to 2 days and associated with such symptoms as anxiety, chest tightness, paresthesia, slurred speech, weakness, and pruritus. Abdominal pain was a constant feature, often associated with cramping and an increase in stool frequency. Attacks witnessed by physicians consisted of an exaggerated blush response of the face and upper part of the chest, and were sometimes associated with tachycardia, mild hypertension, and tachypnea. Hives, angioedema, wheezing, and hypotension were not observed. Routine laboratory studies and 5-hydroxyindoleacetic acid, vanillylmandelic acid, and plasma histamine levels were normal. Plasma histamine levels did not elevate during attacks. When performed, results of bone marrow examinations, skin biopsies, and bone scans were normal. Psychiatric examinations frequently revealed somatization disorders. Patients had often been prescribed a wide variety of medications including antihistamines, nonsteroidal anti-inflammatory drugs, and steroids, with little or no benefit. Despite the benign nature of the clinical and laboratory findings, patients had undergone repeated, often invasive, examinations for several years. Whether such patients have a prominent flush response exaggerated through a somatization disorder or a relatively benign flushing disorder associated with putative mediator release remains to be determined. Recognition of this category of patients with unexplained flushing will avoid subjecting such patients to unwarranted repeated examinations, procedures, and inappropriate therapy.

Flushing and rosacea: overview and nursing interventions.

Rosacea is a dynamic facial dermatosis characterized by exacerbations and remissions which affects middle-aged men and women, most of whom flush easily. It is a conspicuous, yet treatable condition. Oral and topical antibiotics, as well as changes in lifestyle and elimination of aggravating factors, are necessary for control. Nurses facilitate compliance with the treatment regimen and optimize patient self-esteem.