Life-threatening macroglossia after posterior fossa surgery: a surgical positioning problem?

A 55-year-old woman was operated in the lateral park bench position with significant neck flexion and oral packing. Macroglossia was noticed immediately postoperatively after endotracheal extubation. The patient was reintubated for 13 days and subsequently required a tracheostoma. After the placement of the tracheostoma and the removal of the endotracheal tube, the congestion of the tongue decreased markedly within 24 hours. Macroglossia is a rare complication following posterior fossa procedures with few cases reported so far. It can cause airway obstruction, which could be a life-threatening complication, and it therefore requires prompt treatment. The aetiology of postoperative macroglossia remains uncertain and has been attributed to arterial, venous and lymphatic compression, mechanical compression, or neurogenic causes. This article describes new insights into aetiology and also describes preventive measures and possible treatment.

Differential diagnosis of mediastinal cysts: a case series.

BACKGROUND: Mediastinal cysts are common mediastinal lesions in which diagnostic and therapeutic choices are not always unambiguously presented. Usually, these cysts are asymptomatic and detected by coincidence. The question remains whether, if symptoms are present, the cyst is responsible and whether it should be treated. Unfortunately, there is a lack of standardised guidelines concerning diagnostic, therapeutic management and follow-up. CASE SUMMARY: In this case series we reported five patients with mediastinal cysts. All patients received a thoracic CT during the initial diagnostic assessment. Four out of five patients were symptomatic and were surgically treated during a uniportal video-assisted thoracoscopy. One patient was asymptomatic and receives a biennial follow-up. Most often, histopathological examination confirmed the already presumed type of non-neoplastic mediastinal cyst based on anatomical location and tissue characteristics (one thymic cyst, one bronchogenic cyst and two pericardial cysts). Except for one patient, all surgically treated patients experienced improvement in symptoms. CONCLUSION: Regarding diagnosis and treatment of this entity, a systematic approach in accordance with the most recent literature is important. The diagnosis can only be confirmed on histopathological examination, but several imaging techniques, with contrast-enhanced CT as the first-choice technique, could guide the differential diagnosis. In large, symptomatic cysts or present potential malignant features, surgical removal is indicated. This case series encourages further substantial research concerning the selection and timing of therapy.

Granulomatous peritoneal disease associated with oxaliplatin-based chemotherapy for ampullary adenocarcinoma: a case report.

Adenocarcinomas of the ampulla of Vater represent only 0.2% of all gastrointestinal cancers. Due to the low incidence no large clinical trials evaluating efficacy of treatments are available. Adjuvant therapy is often administered in patients with stage IB or higher. Oxaliplatin is considered as an effective and well tolerated therapeutic option. Adverse events associated with this therapy include cardio-, neuro-, nephrotoxicity and myelosuppression. Previously granulomatous pulmonary and liver manifestations have been described in oxaliplatin-based chemotherapy. In this report peritoneal manifestation of granulomatous disease associated with oxaliplatin is described for the first time. Sarcoidlike reactions may be misinterpreted as tumour progression or metastatic disease, and may consequently result in over-treatment.

Recurrent Miller Fisher syndrome with vestibular involvement.

We describe a patient who had four relapses of Miller Fisher syndrome over a period of 20 years. The classical triad - ophthalmoparesis, ataxia and areflexia - was present during the first two attacks; ataxia was not observed during the third episode. The final recurrence was characterized by signs suggestive of a central involvement of the oculomotor pathways, subclinical slowing of the visual-evoked potentials, and peripheral vestibular hyporeactivity. Brain imaging was normal, but high levels of anti-GQ1b IgG antibodies were detectable during the second relapse and persisted after the fourth recurrence despite complete clinical recovery.

An unexpected cause of persistent bacteraemia and portomesenteric venous gas.

We report the case of a 59-year old man with portomesenteric venous gas (PMVG) due to inferior mesenteric vein fistulization caused by sigmoid diverticulitis with an unusual evolution. The patient initially presented with classic symptoms of lower abdominal pain and fever. Diagnosis of uncomplicated sigmoid diverticulitis was confirmed on computed tomography (CT) for which intravenous antibiotics were initiated. Hemocultures were positive for omnisensitive Escherichia Coli, but despite adequate intravenous antibiotic therapy, episodes of bacteraemia persisted and hemocultures remained positive. Repeat CT scan demonstrated regression of inflammation without signs of abcedation or perforation consistent with clinical findings. Endocarditis was excluded with a normal transoesophageal echocardiography. Finally, positron emission tomography-computed tomography (PET-CT) suspected a colovenous fistula and the presence of PMVG. The patient was successfully treated with laparoscopic sigmoidectomy. This case report summarises the diagnostic pathway and aims for higher awareness of non-ischemic PMVG causes.

1H-NMR analysis of trimethylamine in urine for the diagnosis of fish-odour syndrome.

This paper reports the use of proton NMR spectroscopy for the analysis of trimethylamine in the urine of a patient with trimethylaminuria. Analysis of this compound was also performed for other members of his family. Qualitative and quantitative determination of trimethylamine and trimethylamine-N-oxide was simultaneously performed on untreated urine within a few minutes. The application of the method is discussed.

NMR structural and kinetic assignment of fluoro-3H-naphthopyran photomerocyanines.

The kinetic and structural behavior of a photochromic compound, 3-(2-fluorophenyl)-3-phenyl-3H-naphtho[2,1-b]pyran (F-Py), was investigated using 1H and 19F nuclear magnetic resonance (NMR) spectroscopy. Upon irradiation, the four theoretically predicted photomerocyanines appear along with a fifth form X, whose final structure has not been elucidated. This last form and two of the photomerocyanines are thermally labile, whereas the other two do not show any signs of decay. The system has been analyzed by NMR spectroscopy. This led to the structural assignment of each photomerocyanine. The kinetics of the thermal bleaching were monitored by directly and separately measuring the concentrations of each species at regular time intervals using 19F NMR spectroscopy. We therefore propose a plausible reaction mechanism. On the basis of this mechanism, the mathematical treatment and the study of the effects of temperature led to the determination of the kinetic and thermodynamic parameters (rate coefficients, enthalpy and entropy of activation) of this photochromic system. The leading role of the labile intermediate X on the formation of trans-transoid-cis (TTC) and cis-transoid-cis (CTC) photomerocyanines is pointed out.

Type I and type II photosensitization by the antibacterial drug nalidixic acid. A laser flash photolysis study.

The 355 nm laser flash photolysis of nalidixic acid at pH 9.2 leads to the formation of the nalidixate anion triplet state (absorption lambda max = 620 nm; 5700 less than or equal to epsilon T less than or equal to 9000 M-1cm-1; 0.6 less than or equal to phi T less than or equal to 1). The first order triplet state decay (kT = 7.7 x 10(3) s-1) is accompanied by a diffusion controlled triplet-triplet annihilation. Oxygen efficiently quenches the triplet state (k = 3.2 x 10(9) M-1s-1). The nalidixate radical dianion (absorption lambda max = 650 nm; epsilon = 3000 M-1cm-1) is produced by the diffusion controlled reductive quenching of the triplet state by tryptophan and tyrosine. The superoxide anion (O2-.) is produced by diffusion controlled reaction of the radical dianion with oxygen. The O2-. is characterized by its reactions with ferricytochrome c and superoxide dismutase. The physiological form of nalidixic acid is thus a good Type I and Type II photosensitizer.

Poisoning with methanol and ethylene glycol:1H NMR spectroscopy as an effective clinical tool for diagnosis and quantification.

Analysis of serum and urine samples from three patients in a metabolic acidotic state was performed using biochemical methods and proton nuclear magnetic resonance (1H NMR). Methanol and ethylene glycol were identified by their singlet peaks in the 1H NMR spectra recorded directly from 0.5 ml of the collected samples. Quantification of these compounds was obtained simultaneously with that of their metabolites, formate and glycolate respectively and of lactate and ethanol, the latter being used as an antidote. The NMR results were found to be very similar to the biochemical findings. The results presented here suggest that 1H NMR can be clinically useful since it quickly provides information on the onset of metabolic acidosis and on the biotransformation of xenobiotics.

183W NMR Study of Peroxotungstates Involved in the Disproportionation of Hydrogen Peroxide into Singlet Oxygen ((1)O(2), (1)Delta(g)) Catalyzed by Sodium Tungstate in Neutral and Alkaline Water.

The disproportionation of aqueous hydrogen peroxide catalyzed by sodium tungstate has been investigated with regard to the multiplicity of the oxygen molecules released. Trapping experiments and detection of the IR luminescence of (1)O(2) have shown that the yield of (1)O(2) is virtually quantitative. The mono-, di-, and tetraperoxotungstate intermediates W(O(2))(n)()O(4)(-)(n)()(2)(-) (n = 1, 2, 4) have been characterized by UV and (183)W NMR spectroscopies. The diperoxo species is proposed as the precursor of (1)O(2).

Identification and quantitation of xenobiotics by 1H NMR spectroscopy in poisoning cases.

In order to analyse a wide range of xenobiotics and their metabolites present in biological fluids, NMR spectroscopy can be used. A large variety of xenobiotics (therapeutic agents, pesticides, solvents, alcohols) can be characterized and quantitated directly, without sample preparation. NMR investigations were applied to acute poisoning cases, involving drugs such as salicylates and valproic acid (VPA). In a salicylate poisoning case, the three major metabolites of acetylsalicylic acid have been detected in crude urine, and rapid identification of lysine revealed the origin of the intoxication, namely lysine acetylsalicylate (Aspegic). Valproic acid as its glucuronide was identified in urine samples from two poisoned patients. 1H NMR was also used to identify and quantitate paraquat (Gramoxone) in urine owing to its two aromatic signals at 8.49 and 9.02 ppm, in two acutely poisoned patients (183 and 93 mg/l). An intentional poisoning case with tetrahydrofuran (THF) was also investigated. Serum and urine samples were collected. THF was characterized by its resonances at 1.90 and 3.76 ppm, and quantified at 813 and 850 mg/l in the two biological fluids, respectively. Moreover, two other compounds were detected: lactate and gamma-hydroxybutyric acid (GHB). 1H NMR spectroscopic analysis of serum samples from three poisoned patients revealed methanol in one case and ethylene glycol in the two others. Moreover, in the same spectrum, the corresponding metabolites formate and glycolate were found. Compared with the reference chromatographic or spectrophotometric methods, requiring time-consuming extraction and/or derivatization steps, NMR spectroscopy allows the determination of many exogenous and endogenous compounds, without any pre-selection of the analytes.

Determination of glyphosate in biological fluids by 1H and 31P NMR spectroscopy.

Identification of glyphosate in four cases of poisoning, using nuclear magnetic resonance spectroscopy of biological fluids is reported. It has been performed by using a combination of 1H and 31P NMR analyses. Characterization of the N-(phosphonomethyl) glycine herbicide was achieved by chemical shift considerations and coupling constant patterns: CH2-(P) presents specific resonance at 3.12 ppm and appears as a doublet with a H-P characteristic coupling constant of 12.3 Hz. Moreover, resonances due to isopropylamine were present, confirming the ingestion of the considered trade formulation. After a calibration step, quantitation was performed by 1H and 31P NMR spectroscopy. The benefit and reliability of NMR investigations of biological fluids are discussed, particularly when the clinical picture is quite confusing.

1H NMR spectroscopic investigation of serum and urine in a case of acute tetrahydrofuran poisoning.

This article reports the investigation by 1H nuclear magnetic resonance (1H NMR) spectroscopy of biological fluids in a case of intentional poisoning with tetrahydrofuran (THF). Occupational exposures to this solvent are well documented, but acute poisoning cases are extremely rare, and the one presented here is the second known case of this kind. Urine and serum samples were collected. Without any pretreatment, the presence of THF was confirmed by characteristic resonances at 1.90 and 3.76 ppm; high lactate levels were also observed. The presence of gamma-hydroxybutyric acid (GHB) was noted. Quantitative analysis was performed by relative integration of peak areas. THF concentrations were 813 and 850 mg/L (11.3 and 11.8 mmol/L), and GHB concentrations 239 and 2,977 mg/L (2.3 and 28.6 mmol/L) in serum and urine, respectively. A gas chromatographic-mass spectrometric method confirmed 1H NMR observations. The origin of GHB detected in serum and urine is also discussed.

Determination by 1H NMR spectroscopy of paraquat in urine from acutely poisoned patients. Comparison with second-derivative spectroscopy method.

The application of 1H nuclear magnetic resonance (NMR) spectroscopy to characterize and quantitate paraquat in urine is described. Characterization was performed taking advantage of two NMR spectroscopy parameters: chemical shifts and coupling patterns. Without any pretreatment of the biological samples, herbicide was detected by its aromatic doublets at 8.49 and 9.02 ppm. Quantitation of the xenobiotic was realized by relative integration of the dipyridyl protons to an internal standard. After a validation step using control urine samples, quantitation was performed in urine obtained from two poisoned patients. On admission, mean paraquat concentrations were 985 (patient 1) and 500 (patient 2) micromol/L. Results are compared and found to be in good agreement, using a second-derivative spectroscopy method.

[Photophysical evaluation of photosensitization by various quinolones]. / Evaluation photophysique du pouvoir photosensibilisant de diverses quinolones.

An original physicochemical method is proposed for the evaluation of the photosensitizing activity of drugs in vitro. A Nuclear Magnetic Resonance (NMR) spectrum is recorded during light irradiation of drug solutions. The change in the intensity of the NMR lines under such conditions is termed the Photochemically Induced Dynamic Nuclear Polarization (Photo-CIDNP) effect. It is related to the formation of radical intermediates which may be involved in the in vivo photosensitization reactions (the so-called type-I photoreactions). Nine commercial quinolones were tested by this method: nalidixic, oxolinic, pipemidic and piromidic acids, rosoxacin, flumequine, enoxacin, pefloxacin and norfloxacin. Each quinolone was irradiated in alcoholic solutions in its UV absorption band (300-350 nm) in the absence or in the presence of a biological target chosen as a model: the amino-acid N-acetyltyrosine. The quinolones were classified in two groups in relation to the intensities of the observed CIDNP effects. Nalidixic and oxolinic acids, rosoxacin and flumequine are among the most potent photosensitizers.

A radiological comparison of anterior fusion rates in anterior lumbar interbody fusion.

Aim To compare anterior fusion in standalone anterior lumbar interbody fusion (ALIF) using cage and screw constructs and anterior cage-alone constructs with posterior pedicle screw supplementation but without posterior fusion. Methods Eighty-five patients underwent single- or two-level ALIF procedure for degenerative disk disease or lytic spondylolisthesis (SPL). Posterior instrumentation was performed without posterior fusion in all cases of lytic SPL and when the anterior cage used did not have anterior screw through cage fixation. Results Seventy (82%) patients had adequate radiological follow-up at a mean of 19 months. Forty patients had anterior surgery alone (24 single level and 16 two levels) and 30 had front-back surgery (15 single level and 15 two levels). Anterior locked pseudarthrosis was only seen in the anterior surgery-alone group when using the STALIF cage (Surgicraft, Worcestershire, UK) (37 patients). This occurred in five of the single-level surgeries (5/22) and nine of the two-level surgeries (9/15). Fusion was achieved in 100% of the front-back group and only 65% (26/40) of the anterior surgery-alone group. Conclusion Posterior pedicle screw supplementation without posterolateral fusion improves the fusion rate of ALIF when using anterior cage and screw constructs. We would recommend supplementary posterior fixation especially in cases where more than one level is being operated.