The Use of Flexible Fiberoptic Cystoscope for Difficult Endotracheal Intubation in TMJ Ankylosis Patients: A Case Series.

Background: Fiberoptic bronchoscopes might be vital for the safe performance of difficult endotracheal intubations. However, many hospitals in low or middle-income countries are unable to afford the equipment. We describe the use of a flexible fiberoptic cystoscope, as an alternative to a bronchoscope, for difficult nasoendotracheal intubation in patients with temporomandibular joint ankyloses. Methods: Eight Jordanian patients (five females and three males) with severe restriction of mouth opening, due to ankylosis of the temporomandibular joint, underwent awake nasoendotracheal intubation using a flexible fiberoptic cystoscope under local anesthesia. Results: The procedure was successful and well tolerated in all eight patients. Conclusion: A flexible cystoscope can be a successful alternative to a flexible bronchoscope, for difficult nasoendotracheal intubation in hospitals at rural areas in low-or middle-income countries with limited financial resources.

Complicated Spigelian hernia presenting with sigmoid colon strangulation: A unique clinical report.

INTRODUCTION AND IMPORTANCE: Spigelian hernias are rare, constituting about 1-2 % of all abdominal wall hernias. They present clinically significant challenges due to their potential for incarceration and strangulation. This case report highlights a unique presentation of a Spigelian hernia involving sigmoid colon strangulation, emphasizing the critical need for awareness and timely intervention. CASE PRESENTATION: A 60-year-old female with hypertension and diabetes presented with severe left abdominal pain, nausea, and vomiting. Examination revealed leukocytosis, neutrophilia, and signs of acute abdomen. CT imaging showed a complicated left lateral abdominal wall hernia containing the sigmoid colon. Surgical intervention included sigmoidectomy with colorectal anastomosis and hernia repair. Postoperative recovery was successful with subsequent elective ileostomy reversal. CLINICAL DISCUSSION: The rarity of Spigelian hernias and their atypical presentations can complicate diagnosis and management. This case was particularly challenging due to the strangulation of the sigmoid colon within the hernial sac. Surgical management was necessary to address the incarcerated bowel segment and prevent further complications. This case underscores the utility of CT scans in diagnosing complex cases and guiding surgical strategy. CONCLUSION: Despite their rarity, Spigelian hernias carry significant risks of strangulation. Prompt diagnosis and treatment are essential to avoid severe complications. This case highlights the importance of including Spigelian hernia in the differential diagnosis for acute abdominal symptoms, especially when they are nonspecific.

Using a Disposable Flexible Fiberoptic Scope as a Bougie for Difficult Intubation.

In this case report, we describe two difficult intubations in which an endotracheal tube was threaded over a fiberoptic bronchoscope that was acting as a bougie. Our patients initially presented with limited neck extension, narrow mouth opening, and restricted view of the glottic region. A fiberoptic bronchoscope was guided through while the patient was oxygenated through a laryngeal mask. After the scope provided an unrestricted view of the vocal cords, the digital module was removed by cutting the fiberoptic thread, and an endotracheal tube was passed through. After proper confirmation of the endotracheal tube position, the intubation was deemed successful and thereby, we share our experience with the novel technique. This technique may potentially improve critical patient outcomes whether in trauma or an unexpectedly difficult intubation.

Emergency double-J stent insertion following uncomplicated Ureteroscopy: risk-factor analysis and recommendations.

PURPOSE: Emergency double-J (DJ) stenting following ″uncomplicated″ ureteroscopic (UURS) stone treatment is both morbid and costly. Our study aims at identifying those patients who are more likely to require such an extra procedure. Handling of this complication will also be highlighted. MATERIALS AND METHODS: 319 cases of UURS cases were selected out of 903 patients, who were admitted for URS stone treatment at King Abdullah University Hospital during the period from May, 2003 to December, 2010. Thirty-eight of them (11.9%) had emergency post-URS DJ stenting within 24 hours of discharge. The medical records of all UURS cases were retrospectively reviewed. Comparison in demographic and stone-related variables was made using 2-paired t-test with P < 0.05. Operative findings of 38 stented patients were outlined. RESULTS: Significant risk factors for emergency stenting were noted in males with larger (> 1.5 cm) and proximal stones (38 stented vs. 281 unstented). Operative risk factors among the 38 patients were: initial procedure time > 45 minutes (42.1%), ureteral wall edema (21.1%), repeated access for stones > 1.5 cm (21.1%), impacted stone (10.5%) and ignored or missed stones/fragments (4.6%). CONCLUSIONS: The need for emergency DJ stenting following UURS stone treatment is not uncommon. The routine insertion is impractical and weakly-supported. With risk-factor stratification, selective and individualized DJ stenting policy is recommended.

Lung deflation while placing a subclavian vein catheter: Our experience in minimizing the risk of pneumothorax.

PURPOSE: Lung deflation may reduce the risk of pneumothorax based on the assumption that the distance between the subclavian vein and the lung pleura would increase as well as the diameter of the vein. We aim to provide evidence to support the suggested desideratum of deflation in adults. METHODS: A prospective database was created that included patients who underwent subclavian vein catheterization for monitoring and therapeutic reasons from January 2014 to January 2020. Measurements using ultrasonography of the diameter of the subclavian vein were taken while the patient's breathing was controlled by a ventilator and then repeated after disconnecting the mechanical ventilation and opening the pressure relief valve. RESULTS: A total of 123 patients were enrolled, with an average age of 41.9 years. The subclavian vein diameter was measured during controlled breathing with a mean average of 8.1 ± 0.6mm in males and 7.1 ± 0.5mm in females. The average increase after lung deflation with the pressure relief valve closed was 8.0± 5.1mm in males and 13.9 ± 5.4mm in females. An increase was noticed after opening a pressure valve, and the means were 5.5 ± 2.8mm in males and 5.1 ± 3.3mm in females. The catheter malposition rate was 0.8. CONCLUSION: The benefit of interrupting mechanical ventilation and lung deflation lies within possibly avoiding pneumothorax as a complication of subclavian vein catheterization. These findings support the need for evidence regarding the curtailment of pneumothorax incidence in spontaneously breathing patients and the suggested increase in first-time punctures and success rates.

Persistent Hiccups After Cervical Epidural Steroid Injection.

BACKGROUND Hiccup is a rare complication after a cervical epidural steroid injection used in the treatment of chronic pain. A few studies have reported on the physiological and pharmacological aspects of hiccups after epidural steroid injection and there have been some case reports published. Our presented case report provides insight into the side effect of hiccups that can occur in association with cervical epidural analgesia, and will help inform anesthesiologist about this unpleasant complication. CASE REPORT We present a rare case of persistent hiccups after a cervical epidural steroid injection in a 60-year-old male patient with chronic pain due to disc protrusion in C3-C7. CONCLUSIONS Persistent hiccups after epidural injection is a serious complication. As the exact mechanism of hiccups is not yet known, regardless the level of epidural or the mixture of drugs used, and the incident of hiccups after epidural injection is not well-reported, we think that the etiology and the incident rate must be further evaluated.

Interaction of human defensins with Escherichia coli. Mechanism of bactericidal activity.

Defensins are small, cysteine-rich antimicrobial peptides that are abundant in human, rabbit, and guinea pig neutrophils (PMN). Three defensins (human neutrophil peptide defensin [HNP]-1, HNP-2, and HNP-3) constitute between 30 and 50% of the total protein in azurophil granules of human PMN. We examined the mechanism of HNP-mediated bactericidal activity against Escherichia coli ML-35 (i-, y-, z+) and its pBR322-transformed derivative, E. coli ML-35p. Under conditions that supported bactericidal activity, HNP-1 sequentially permeabilized the outer membrane (OM) and inner membrane (IM) of E. coli. Coincident with these events, bacterial synthesis of DNA, RNA, and protein ceased and the colony count fell. Although these events were closely coupled under standard assay conditions, OM permeabilization was partially dissociated from IM permeabilization when experiments were performed with E. coli that had been plasmolyzed by mannitol. Under such conditions, the rate and extent of bacterial death more closely paralled loss of IM integrity than OM permeabilization. Electron microscopy of E. coli that had been killed by defensins revealed the presence of striking electron-dense deposits in the periplasmic space and affixed to the OM. Overall, these studies show that HNP-mediated bactericidal activity against E. coli ML-35 is associated with sequential permeabilization of the OM and IM, and that inner membrane permeabilization appears to be the lethal event.

Defensins. Natural peptide antibiotics of human neutrophils.

We extracted a granule-rich sediment from normal human neutrophils and subjected it to chromatographic, electrophoretic, and functional analysis. The extract contained three small (molecular weight less than 3,500) antibiotic peptides that were named human neutrophil peptide (HNP)-1, HNP-2, and HNP-3, and which will be referred to as "defensins." HNP 1-3, a mixture of the three defensins, killed Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli effectively in vitro when tested in 10 mM phosphate buffer containing certain nutrients, but it had little or no bactericidal activity in nutrient-free buffer. In contrast, the nutrient-free buffer supported a high degree of activity by HNP 1-3 against Cryptococcus neoformans. In addition to its antibacterial and antifungal properties, HNP 1-3 directly inactivated herpes simplex virus, Type 1. Two of the individual purified defensins, HNP-1 and HNP-2, were as microbicidal as the mixture HNP 1-3. HNP-3 was less active than the other defensins against most but not all of the microbes tested. Immunoperoxidase stains revealed HNP 1-3 to have a granular localization in the neutrophil's cytoplasm by light microscopy. Frozen thin section immunogold transmission electron microscopy showed HNP 1-3 to be localized in azurophil granules. These studies define a broad-spectrum antimicrobial system in human neutrophils. The defensin system may operate in conjunction with or independently from oxygen-dependent microbicidal processes to enable human neutrophils to inactivate and destroy potential pathogens.

Emergency double-J stent insertion following uncomplicated Ureteroscopy: risk-factor analysis and recommendations

Purpose Emergency double-J (DJ) stenting following “uncomplicated” ureteroscopic (UURS) stone treatment is both morbid and costly. Our study aims at identifying those patients who are more likely to require such an extra procedure. Handling of this complication will also be highlighted. Materials and Methods 319 cases of UURS cases were selected out of 903 patients, who were admitted for URS stone treatment at King Abdullah University Hospital during the period from May, 2003 to December, 2010. Thirty-eight of them (11.9%) had emergency post-URS DJ stenting within 24 hours of discharge. The medical records of all UURS cases were retrospectively reviewed. Comparison in demographic and stone-related variables was made using 2-paired t-test with P < 0.05. Operative findings of 38 stented patients were outlined. Results Significant risk factors for emergency stenting were noted in males with larger (>1.5 cm) and proximal stones (38 stented vs. 281 unstented). Operative risk factors among the 38 patients were: initial procedure time > 45 minutes (42.1%), ureteral wall edema (21.1%), repeated access for stones > 1.5 cm (21.1%), impacted stone (10.5%) and ignored or missed stones/fragments (4.6%). Conclusions The need for emergency DJ stenting following UURS stone treatment is not uncommon. The routine insertion is impractical and weakly-supported. With risk-factor stratification, selective and individualized DJ stenting policy is recommended. .

Sigmoid volvulus in the Middle East.

Little is known about sigmoid volvulus in the Middle East despite textbooks referring to the region as part of the "volvulus belt." Our objectives were to assess the prevalence, clinical presentations, radiological findings, operative treatments, and postoperative outcomes of patients managed for sigmoid volvulus in Jordan as a model for the region. The medical records of patients with large bowel obstruction who were managed at King Abdullah University Hospital and its affiliated institutes, northern Jordan, over a 6-year period between January 2001 and January 2007 were retrospectively reviewed to identify patients with a confirmed diagnosis of sigmoid volvulus. Sigmoid volvulus was responsible for 9.2% of all cases of large bowel obstruction seen during the study period. There were 32 patients with sigmoid volvulus, 24 (75%) of whom were men. The median age of the patients was 59 years (range 21-83 years). Abdominal pain and distention were the main presentations. Colonoscopic detorsion was applied in 25 patients, which was achieved in 17 (68%) of them after the first attempt. Six patients had a gangrenous sigmoid colon, four of which required resection and a Hartmann procedure. Sigmoid resection with primary anastomosis was performed in 28 patients, including 2 with a gangrenous colon. Postoperative complications were observed in five patients, including one patient with viable colon who develop an anastomotic leak. Two patients died, making the mortality rate 6%. Sigmoid volvulus is uncommon in Jordan. Resection of the sigmoid colon with primary anastomosis appears to be the preferred procedure.

Direct inactivation of viruses by human granulocyte defensins.

Human neutrophils contain a family of microbicidal peptides known as defensins. One of these defensins, human neutrophil peptide (HNP)-1, was purified, and its ability to directly inactivate several viruses was extensively tested. Herpes simplex virus (HSV) types 1 and 2, cytomegalovirus, vesicular stomatitis virus, and influenza virus A/WSN were inactivated by incubation with HNP-1. Two nonenveloped viruses, echovirus type 11 and reovirus type 3, were resistant to inactivation. Purified homologous peptides HNP-2 and HNP-3 were found to have HSV-1-neutralizing activities approximately equal to that of HNP-1. Inactivation of HSV-1 by HNP-1 depended on the time, temperature, and pH of incubation. Antiviral activity was abrogated by low temperature or prior reduction and alkylation of the defensins. Addition of serum or serum albumin to the incubation mixtures inhibited neutralization of HSV-1 by HNP-1. We used density gradient sedimentation techniques to demonstrate that HNP-1 bound to HSV-1 in a temperature-dependent manner. We speculate that binding of defensin peptides to certain viruses may impair their ability to infect cells.

Direct inactivation of viruses by MCP-1 and MCP-2, natural peptide antibiotics from rabbit leukocytes.

Six homologous peptides were purified to homogeneity from rabbit granulocytes or alveolar macrophages and tested for their ability to inactivate herpes simplex virus type 1 (HSV-1). Two of the peptides, MCP-1 and MCP-2, showed considerable in vitro neutralizing activity, whereas four structurally homologous peptides (NP-3a, NP-3b, NP-4, and NP-5) were relatively ineffective. Inactivation of HSV-1 by MCP-1 or MCP-2 depended on peptide concentration and on the time, temperature, and pH of the incubation. HSV-2, vesicular stomatitis virus, and influenza virus A/WSN were also susceptible to direct neutralization by MCP-1 or MCP-2, whereas cytomegalovirus, echovirus type 11, and reovirus type 3 were not. We speculate that MCP-1 and MCP-2, peptides that are abundant in rabbit granulocytes and lung macrophages, may contribute to antiviral defenses by mediating the direct inactivation of HSV-1 and selected other viruses.

Isolation and characterization of human defensin cDNA clones.

Four clones that encode defensins, a group of microbicidal and cytotoxic peptides made by neutrophils, were isolated from an HL-60 human promyelocytic leukemia cDNA library. Analysis of these clones indicated that the defensins are made as precursor proteins, which must be cleaved to yield the mature peptides. Defensin mRNA was detected in normal bone marrow cells, but not in normal peripheral blood leukocytes. Defensin transcripts were also found in the peripheral leukocytes of some leukemia patients and in some lung and intestine tissues. Defensin mRNA content was augmented by treatment of HL-60 cells with dimethyl sulfoxide. These results define important aspects of the mechanism of synthesis and the tissue-specific expression of a major group of neutrophil granule proteins.

Assignment of defensin gene(s) to human chromosome 8p23.

A relatively abundant component of the polymorphonuclear leukocyte granulocytes has been recently isolated and called defensin. Defensins have antimicrobial activity against gram-positive and gram-negative bacteria and enveloped viruses. A cDNA insert for defensin HNP-1 (DEF1) has been used to map the gene(s) to human chromosome 8p23 using a mouse/human somatic cell hybrid panel and in situ hybridization to normal human metaphase chromosomes. Because of the similarity of HNP-1 defensin to other defensins, it is likely that two of these genes map to this region.