Critical Lower-Limb Ischemia and Arterial Thrombosis Following Intraarticular Corticosteroid Injection of the Knee.

ABSTRACT: We present a case of acute lower-limb arterial thrombosis following intra-articular steroid injection into the knee of a previously fit and active 41-year-old man. Symptoms of acute limb ischemia developed within 24 hours of treatment. Objective assessment with ultrasound arterial duplex and CT angiogram of the lower limb confirmed acute thrombosis of the popliteal artery in the treated leg. Although there is documented evidence of the association between steroid therapy and venous thromboembolic phenomena, there are no cases of arterial thrombosis in the literature. The temporal series of events that we report strongly suggest an association between the corticosteroid injection and the acute thrombotic event, the mechanism of which remains unclear. The patient underwent successful revascularization. It is important to document and disseminate this seemingly rare complication of a commonly associated procedure to increase awareness, invoke caution, and invite others to share similar cases.

Implication of Peripheral Neuropathy on Unplanned Readmissions in Patients Hospitalized for Complicated Diabetic Foot Disease.

Introduction. Unplanned readmissions are common following discharge in patients after hospitalization for diabetic foot disease (DFD) complications. The aim of this study was to identify factors associated with readmissions in these high-risk patients, treated in a multidisciplinary setting and the implication of measures that could effectively reduce readmission rates. Methods. Patients presenting with DFDs admitted between 2015 and 2017 were studied retrospectively in a single-centre patient database. The demographics and clinical comorbidities were analyzed and comparison was made between 2 groups: patients readmitted within 30 days of discharge and those who did not require readmission. Multivariate analysis was performed to identify risk factors associated with readmissions. Results. In total, 340 patients were included. The unplanned readmission rate was 10.9%. More than half of readmissions (71%) were related to wound deterioration and infection. In the readmission group, the patients had lower body mass index, higher rate of osteomyelitis, lower rate of debridement, and evidence of peripheral vascular disease below the knee in the index admissions but these were not significant. In the multivariate analysis, peripheral neuropathy was the only significant risk associated with unplanned readmissions (odds ratio: 2.78, 95% confidence interval: 1.23-6.29, P = .014). Conclusion. This study demonstrates a significant association between peripheral neuropathy and unplanned readmissions. The implications of this nonmodifiable risk factor in reducing readmissions include all levels of patient care delivery such as adequate preparation for discharge and transition back into the community. Recognition and education in successful long-term offloading of insensate diabetic feet may help reduce rates of unplanned readmission.

Development of a novel nomogram to predict the risk of severe compensatory sweating following endoscopic thoracic sympathectomy.

BACKGROUNDS: Endoscopic thoracic sympathectomy (ETS) is a permanent and effective treatment for primary hyperhidrosis and facial blushing; however, severe compensatory sweating (SCS) remains a devastating complication. We aimed to (i) construct a nomogram to predict the risk of SCS, and (ii) investigate factors associated with the level of satisfaction. METHODS: From Jan 2014 to Mar 2020, 347 patients underwent ETS by a single surgeon. These patients were asked to complete an online questionnaire regarding primary symptom resolution, level of satisfaction, and development of compensatory sweating. Multivariable analysis was conducted via logistic regression and ordinal regression to predict SCS and satisfaction level respectively. Nomogram was developed based on significant predictors. RESULTS: In total, 298 (85.9%) patients responded to the questionnaire with a mean follow up of 4.9 ± 1.8 years. Significant factors associated with SCS in the nomogram included older age (OR 1.05, 95% CI 1.02-1.09, P = 0.001), primary indication other than palmar hyperhidrosis (OR 2.30, 95% CI 1.03-5.12, P = 0.04), and current smoking (OR 5.91, 95% CI 2.46-14.20, P < 0.001). The area under receiver operating characteristic curve was 0.713. Multivariable analysis revealed that longer follow up (ß = -0.201 ± 0.078, P = 0.01), gustatory hyperhidrosis (ß = -0.781 ± 0.267, P = 0.003), primary indication other than palmar hyperhidrosis (ß = -1.524 ± 0.292, P < 0.001), and SCS (ß = -3.061 ± 0.404, P < 0.001) were independently associated with a lower degree of patient satisfaction. CONCLUSION: The novel nomogram can provide a personalized numerical risk estimate to assist both the clinician and patient weigh the pros and cons as part of the decision-making process, mitigating the chance of patient dissatisfaction.

Changes in membrane properties of rat deep cerebellar nuclear projection neurons during acquisition of eyeblink conditioning.

Previous studies have shown changes in membrane properties of neurons in rat deep cerebellar nuclei (DCN) as a function of development, but due to technical difficulties in obtaining viable DCN slices from adult animals, it remains unclear whether there are learning-related alterations in the membrane properties of DCN neurons in adult rats. This study was designed to record from identified DCN cells in cerebellar slices from postnatal day 25-26 (P25-26) rats that had a relatively mature sensory nervous system and were able to acquire learning as a result of tone-shock eyeblink conditioning (EBC) and to document resulting changes in electrophysiological properties. After electromyographic electrode implantation at P21 and inoculation with a fluorescent pseudorabies virus (PRV-152) at P22-23, rats received either four sessions of paired delay EBC or unpaired stimulus presentations with a tone conditioned stimulus and a shock unconditioned stimulus or sat in the training chamber without stimulus presentations. Compared with rats given unpaired stimuli or no stimulus presentations, rats given paired EBC showed an increase in conditioned responses across sessions. Whole-cell recordings of both fluorescent and nonfluorescent DCN projection neurons showed that delay EBC induced significant changes in membrane properties of evoked DCN action potentials including a reduced after-hyperpolarization amplitude and shortened latency. Similar findings were obtained in hyperpolarization-induced rebound spikes of DCN neurons. In sum, delay EBC produced significant changes in the membrane properties of juvenile rat DCN projection neurons. These learning-specific changes in DCN excitability have not previously been reported in any species or task.

Predictors of outcome following endoscopic thoracic sympathectomy.

BACKGROUND: Endoscopic thoracic sympathectomy (ETS) provides definitive management for primary focal hyperhidrosis and facial blushing. These conditions are debilitating and not uncommon, but many clinicians avoid ETS due to the risk of complications, particularly compensatory sweating (CS). This retrospective cohort study aimed to evaluate the degree of symptom resolution, patient satisfaction and adverse reactions after ETS and to identify subgroups of patients more likely to achieve a satisfactory outcome. METHODS: From 2004 to 2010, 210 patients underwent ETS performed by a single surgeon. These patients responded to a questionnaire regarding levels of satisfaction, symptom resolution and complications encountered, particularly CS. RESULTS: Palmar hyperhidrosis (97%) and scalp/facial hyperhidrosis (93%) demonstrated greater degrees of symptom resolution than axillary hyperhidrosis (71%) and facial blushing (71%) (P < 0.001). Rates of severe CS were lowest in patients with palmar hyperhidrosis (8%) and highest in patients with axillary (26%) and scalp/facial (44.5%) hyperhidrosis (P = 0.0003). The probability of experiencing no CS was highest at young ages and decreased with age (P = 0.0006). Satisfaction rates also fell as age increased (P = 0.004). Satisfaction rates were highest in patients with palmar (90%) and lowest in patients with scalp/facial (52%) hyperhidrosis (P < 0.02). DISCUSSION: Patient satisfaction following ETS is highest among younger patients and those undergoing the procedure for palmar hyperhidrosis. Dissatisfaction arises from failure to achieve the desired aim as well as the development of severe CS, which is more common in older patients and those undergoing ETS for axillary and scalp/facial hyperhidrosis.

Dietary Cholesterol Concentration and Duration Degrade Long-Term Memory of Classical Conditioning of the Rabbit's Nictitating Membrane Response.

A rabbit model of Alzheimer's disease based on feeding a cholesterol diet for eight weeks shows sixteen hallmarks of the disease, including learning and memory changes. Although we have shown 2% cholesterol and copper in water can retard learning, other studies show feeding dietary cholesterol before learning can improve acquisition whereas feeding cholesterol after learning can degrade long-term memory. We explored this issue by manipulating cholesterol concentration and duration following classical trace conditioning of the rabbit's nictitating membrane response and assessed conditioned responding after eight weeks on cholesterol. First, rabbits given trace classical conditioning followed by 0.5%, 1%, or 2% cholesterol for eight weeks showed body weight and serum cholesterol levels that were a function of dietary cholesterol. Although all concentrations of cholesterol showed some sign of retarding long-term memory, the level of memory retardation was correlated with serum cholesterol levels. Second, rabbits given trace conditioning followed by different durations of a 2% cholesterol diet combined with different durations of a 0% control diet for 8 weeks showed duration and timing of a 2% cholesterol diet were important in affecting recall. The data support the idea that dietary cholesterol may retard long-term memory.

Initial Australasian experience with portal-enteric drainage in simultaneous pancreas-kidney transplantation.

BACKGROUND: Pancreas-kidney transplantation is currently the most effective method to re-establish euglycaemia in insulin-dependent diabetics with associated renal failure. The standard technique employed has been bladder drainage of exocrine secretions coupled with systemic venous drainage ('systemic-bladder' (SB) drainage). The more physiological technique, enteric exocrine with portal venous drainage ('portal-enteric' (PE) drainage), has been utilized sparingly in the past as a result of fears of technical complications. This paper compares the Monash Medical Centre experience with both techniques. METHODS: A total of 68 simultaneous pancreas-kidney transplantations were performed at Monash Medical Centre from 1991 until 2004. The first 37 received SB drainage. Since March 2001, 27 have received PE drainage. This retrospective study compared the SB group (n= 37) with the PE group (n= 27), with a 2-year follow-up, examining a number of surgical outcomes. RESULTS: Two-year patient (94.3 versus 96.0%), kidney (89.2 versus 85.2%), pancreas (77.9 versus 71.4%) and event-free (73.0 versus 67.7%) survivals were all similar between the SB and PE groups, respectively. Although surgery took longer in PE subjects (4 h : 47 min ± 0:48 versus 5 h : 16 min ± 1:00; P= 0.045), less intraoperative transfusions were required (1.3 ± 1.43 versus 0.52 ± 0.90; P= 0.024). Length of hospital stay and time to insulin independence were similar. Pancreas graft thrombosis rates were similar (10.8% SB versus 7.4% PE, P= 0.497). CONCLUSIONS: PE drainage is a safe and viable method for pancreas transplantation, which can be performed with excellent outcomes. An increased rate of complications with PE drainage has not been demonstrated in this series.