Preliminary evaluation of an indwelling epidural catheter for repeat methylprednisolone administration in canine lumbosacral stenosis.

Objective: To determine the complications, outcomes, and patency of a permanent epidural catheter and subcutaneous access port system (ECAPS) as part of conservative management of degenerative lumbosacral stenosis in dogs. Animals and procedure: Medical records of 11 client-owned dogs that underwent an ECAPS insertion were evaluated retrospectively. Clinical signs, complications related to the procedure, and system patency are reported. Results: All dogs had lumbosacral pain at their initial neurological assessment, with comfort levels adequately controlled following epidural infiltrations. None suffered from complications related to the ECAPS procedure. In 10 dogs, there were no malfunctions for the duration of the study. However, in 1 dog, there was a suspected leak at Day 814. The longest duration of patency reported in this study was 870 d (at the time of writing). Conclusion: Placement of an ECAPS is a feasible technique and a viable option to permit repeated epidural injections of steroids in dogs with degenerative lumbosacral stenosis that is managed conservatively. Further studies are required to evaluate complication rates.

Évaluation préliminaire d'un cathéter épidural permanent (à demeure) pour l'administration répétée de méthylprednisolone lors de sténose lombosacrée dégénérative chez le chien. Objectif: Décrire la technique, les complications, les résultats et la perméabilité d'un système composé d'un cathéter épidural et d'un port d'injection sous-cutanée (ECAPS) pour le traitement médical de la sténose lombosacrée dégénérative chez le chien. Animaux et protocole: Les dossiers médicaux de 11 chiens appartenant à des clients ayant subi l'implantation d'un ECAPS ont été évalués de façon rétrospective. Cette étude décrit les signes cliniques, les complications reliées à la procédure et la perméabilité du système. Résultats: Tous les patients inclus présentaient de la douleur lombosacrée à l'examen initial. Le niveau de confort de tous les patients suite aux injections épidurales fut maitrisé de façon adéquate. Aucun des patients n'a subi de complications reliées à l'implantation du système. Le système n'a pas démontré de dysfonctionnement dans le cas de dix patients. Chez un des patients, une fuite fut suspectée au jour 814. La durée maximale de perméabilité enregistrée dans cette étude est de 870 jours (au moment de la rédaction). Conclusion: L'implantation d'un système ECAPS représente une option faisable et viable pour l'administration additionnelle de stéroïdes pour une gestion conservatrice de sténose lombosacrée dégénérative chez les chiens atteints. Des recherches supplémentaires sont requises pour l'évaluation des taux de complications.(Traduit par les auteurs).

A case of suspected canine multifocal cervical venous sinus thrombosis causing cervical myelopathy.

A 10-year-old spayed female standard poodle was admitted for marked cervical pain. Magnetic resonance imaging (MRI) suggested cervical venous sinus thrombi. An excellent clinical response to clopidogrel and warfarin combination was achieved. Repeat MRI showed partial resolution of the thrombosis. The etiology of the thrombosis is suspected to be due to the previous long-term, chronic use of corticosteroids. To the authors' knowledge, this is the first case report with follow-up imaging of canine venous sinus thrombosis. This clinical case report may help practitioners recognize this condition as a possible differential diagnosis for cervical pain, and it provides important guidelines in the prognosis. This case report highlights the use of anticoagulant therapy for 14 wk leading to complete resolution of clinical signs and to partial resolution of the thrombus 5 wk into the treatment, based on comparative MRI. Key clinical message: To the authors' knowledge, this is the first report of suspected multiple cervical venous sinus thrombi that includes comparative imaging into the course of therapy. The aim of this report is to provide additional information for future guidance on the duration of venous sinus thrombosis therapy.

Un cas de thrombose multifocale du sinus veineux cervical causant une myélopathie cervicale. Une femelle caniche standard stérilisée âgée de 10 ans a été présentée pour une douleur aigüe marquée au cou. L'imagerie par résonance magnétique (IRM) était évocatrice de thrombose du sinus veineux cervical. Une excellente réponse au traitement combinant Warfarine et Clopidogrel a été notée. L'étiologie suspectée d'être à l'origine de la thrombose est l'administration prolongée de corticostéroïdes. Jusqu'à maintenant, il s'agit du premier rapport de cas avec imagerie de suivi de thrombose du sinus veineux cervical. Il pourrait aider à reconnaître cette condition comme l'un des diagnostics différentiels lors de douleur cervicale et il fournit des indications importantes reliées au pronostic. Ce rapport met en évidence l'utilisation d'un anticoagulant pendant quatorze semaines conduisant à la disparition complète des signes cliniques reliés à la thrombose et à une résolution partielle de la thrombose notée sur l'IRM comparative 5 semaines suivant l'introduction du traitement.Message clinique clé :À la connaissance des auteurs, il s'agit du premier rapport de cas de multiples thromboses du sinus veineux cervical suspectées incluant une imagerie comparative au cours du traitement. L'objectif de ce rapport est de fournir de l'information supplémentaire à la formation de lignes directrices futures sur la durée de traitement de la thrombose veineuse cervicale.(Traduit par les auteurs).

What is the optimal outcome after endoscopic sinus surgery in the treatment of chronic rhinosinusitis? A consultation of Canadian experts.

OBJECTIVES: Many experts feel that in the absence of well-defined goals for success, they have an easier time identifying failure. As success ought to not be defined only by absence of failure, we aimed to define optimal outcomes for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) by obtaining expert surgeon perspectives. METHODS: A total of 12 surgeons participated in this targeted consultation. Face to face semi-structured interviews were performed with expert surgeons in the field of CRS and ESS. General impressions and personal definitions of acceptable operative success and optimal operative outcomes were compiled and summarized. RESULTS: According to an expert survey, patients' main objectives are an improvement in their chief complain, a general improvement in quality of life (QoL), and a better overall symptomatic control. The most important aspects of endoscopy for defining a successful intervention were an adequate mucus circulation, a healthy mucosa, minimal edema, and patency of all explored cavities or ostia. In the assessment of surgical outcomes, it was determined that both objective and patient reported data must be carefully examined, with more attention given to subjective outcomes. CONCLUSIONS: According to data gathered from a Canadian expert consultation, a definition of success must be based on both subjective data and nasal endoscopy. We propose to define an acceptable outcome as either a subjective improvement of at least the minimal clinically improvement difference of a validated patient reported outcome questionnaire, along with a satisfactory endoscopic result (1) or a complete subjective resolution with a sub-optimal endoscopy (2).

Respiratory activity of the cricopharyngeus muscle in the neonatal period.

While phasic electrical activity of the cricopharyngeus muscle (EAcp)-the main component of the upper esophageal sphincter-occurs with inspiration and forceful expiration in adults, no such data is available for newborns. In addition, the effect of nasal respiratory support commonly used in newborns is unknown. We aimed to describe the phasic respiratory EAcp and to assess the potential effect of nasal CPAP (nCPAP, 6 cmH2O) or high-flow nasal cannula (HFNC, 7 L/min) in newborn lambs during 6-h recordings. Phasic EAcp was present in 11/17 lambs, including in 32 % (25, 81) [(median (Q1, Q3)] of respiratory cycles in wakefulness, 40 % (27, 70) in NREM sleep, and 10 % (0, 23) in REM sleep. In addition, EAcp was observed only during post-inspiration and/or expiration. Nasal CPAP or HFNC assessed in 7 of the 17 lambs did not have any effect. We conclude that phasic respiratory EAcp occurs in post-inspiration and expiration in newborn lambs.

Pathological investigation of placentas in preeclampsia (the PEARL study).

INTRODUCTION: Preeclampsia (PE), but mainly preterm PE, is associated with deep placentation disorders. We aimed to compare placental pathologies in pregnancies affected by term and preterm PE compared to normal pregnancies. METHODS: We performed a prospective case-cohort study. Low-risk nulliparous women were recruited in the first trimester and women who developed PE were recruited at diagnosis. Placental pathologies were reported according to the Amsterdam Placental Workshop Group Consensus Statement and were compared between cases and controls. PE cases stratified as term (≥37 weeks) and preterm PE (<37 weeks). Our primary outcome was maternal vascular malperfusion (MVM). RESULTS: Twenty-four women who developed preterm PE were compared to 10 women who developed term PE and 41 women without PE. Preterm PE (92%) was associated with more MVM than term PE (10%, p < 0.01) and controls (4%, p < 0.01), but the rate of MVM was similar between term PE and controls (p = 0.56). Preterm PE was also associated with more placental infarcts (65% vs. 20% vs. 15%); advanced villous maturation (91% vs. 30% vs. 1%); and hypoplastic villous maturation (70% vs. 10% vs. 3%); and moderate to severe decidual vasculopathy (56% vs. 10% vs. 3%) than term PE and controls (all p < 0.05). CONCLUSION: Most cases of preterm PE are associated with MVM, placental infarcts, advanced and/or hypoplastic villous maturation, and moderate to severe decidual vasculopathy, while it is infrequent in term PE and pregnancies without PE. Preterm and term preeclampsia have a different pathologic process that should be considered for their prevention and clinical management.

Cervicofacial and mediastinal emphysema following minor dental procedure: a case report and review of the literature.

BACKGROUND: Subcutaneous cervical emphysema is a clinical sign associated with many conditions, including laryngotracheal trauma, pneumothorax and necrotizing deep tissue infections. CASE PRESENTATION: We discuss a case of a 76-year-old man presenting with extensive cervical emphysema a few hours after a minor dental filling procedure. The CT-scan revealed a significant amount of air within the cervical and mediastinal spaces, reaching lobar bronchi. Vitals were within normal values Bloodwork demonstrated an elevation of creatinine kinase (3718; normal < 150) and mild leukocytosis (WBC = 11.6). We decided to proceed to an urgent cervical exploration to exclude necrotizing fasciitis. This revealed air but no tissue necrosis nor abnormal fluid. The patient improved clinically and was discharged two days later with oral antibiotics. Although cervicofacial subcutaneous emphysema following dental procedures has been reported, it is usually less extensive and involving more invasive procedures using air-driven handpieces. CONCLUSION: As an otolaryngologist confronted with extensive subcutaneous emphysema following a potential entry route for an aggressive infection, given the seriousness of this diagnosis, the decision of whether or not to perform a diagnostic surgical exploration should remain.

Placental Growth Factor and Soluble, Fms-Like Tyrosine Kinase-1 in Preeclampsia: A Case-Cohort (PEARL) Study.

OBJECTIVE: Preeclampsia is associated with a higher maternal blood levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and lower levels of placental growth factor (PlGF) that appear before clinical onset. We aimed to estimate the normal progression of these biomarkers in normal pregnancies and in those affected by preeclampsia. METHODS: We conducted a case-cohort study including low-risk nulliparous women recruited at 11-13 weeks gestation (cohort) and women with preeclampsia (cases). Maternal blood was collected at different points during pregnancy including at the time of diagnosis of preeclampsia for cases. Maternal serum PlGF and sFlt-1 concentrations and the sFlt-1/PlGF ratio were measured using B•R•A•H•M•S plus KRYPTOR automated assays and were compared between patients in both groups matched for gestational age. Cases were stratified as early- (≤34 weeks), intermediate- (35-37 weeks) and late-onset (>37 weeks) preeclampsia. RESULTS: The cohort consisted of 45 women whose results were compared with those of 31 women who developed preeclampsia, diagnosed at a median gestational age of 32 weeks (range 25-38 weeks). We observed that sFlt-1, PlGF and their ratio fluctuated during pregnancy in both groups, with a significant correlation with gestational age after 28 weeks (P < 0.05). We observed a significant difference between cases and controls, with a median ratio 100 times higher in early preeclampsia (P < 0.001), 13 times higher in intermediate preeclampsia (P < 0.001), but no significant difference between groups in late-onset preeclampsia with matched controls. CONCLUSION: PlGF, sFlt-1, and their ratio may be useful in the prediction and diagnosis of early- and intermediate-onset preeclampsia but are not useful for late-onset preeclampsia.

Resection versus preservation of the middle turbinate in surgery for chronic rhinosinusitis with nasal polyposis: a randomized controlled trial.

BACKGROUND: Chronic rhinosinusitis (CRS) affects up to 16% of the population. When medical treatment fails, endoscopic sinus surgery (ESS) is considered. The value of resecting the middle turbinate to optimize surgical outcomes has been hypothesized but remains controversial and unproven. Whether the middle turbinate should be left in place or resected is controversial. Our objective is to determine if middle turbinectomy improves objective surgical outcomes after ESS. METHODS: Sixteen patients (15 men, 15 primary surgery) undergoing bilateral complete ESS for CRS with nasal polyposis were recruited. Nasal cavities were randomized so that middle turbinectomy was performed on one side while the middle turbinate was preserved on the other. Each participant acted as their own control. Nasal cavities were compared using Perioperative Sinus Endoscopy (POSE) and Lund-Kennedy (LKES) scores pre-operatively, and at 1, 3 and 6 months after ESS. Results were analyzed using Wilcoxon signed-rank test. RESULTS: Pre-operatively, the POSE (12.4 ± 2.9 vs 12.8 ± 2.6, p = 0.33, for the preserved side and the resected side, respectively) and LKES (5.0 ± 1.0 vs 4.8 ± 1.2, p = 0.33) scores were similar between sides. During follow up, resection was associated with more crusting at 1 month following ESS (1.0 ± 0.7 vs 0.4 ± 0.6, p = 0.02). There was a small, but statistically significant, difference between the nasal cavities at 3 months, where the resected side showed better endoscopic appearance (2.0 ± 2.2 vs 3.4 ± 2.8, p = 0.01). No difference was found at 6 months. Frontal sinus scores were similar between sides at 6 months (0.7 ± 0.5 vs 0.7 ± 0.5, p = 1.00). CONCLUSION: Our results show no sustained objective endoscopic benefit of routine middle turbinectomy, at least within the first six postoperative months, in patients undergoing primary ESS for CRS with polyposis. TRIAL REGISTRATION: NCT, NCT02855931 . Registered 16 August 2016.

Absence of inspiratory laryngeal constrictor muscle activity during nasal neurally adjusted ventilatory assist in newborn lambs.

In nonsedated newborn lambs, nasal pressure support ventilation (nPSV) can lead to an active glottal closure in early inspiration, which can limit lung ventilation and divert air into the digestive system, with potentially deleterious consequences. During volume control ventilation (nVC), glottal closure is delayed to the end of inspiration, suggesting that it is reflexly linked to the maximum value of inspiratory pressure. Accordingly, the aim of the present study was to test whether inspiratory glottal closure develops at the end of inspiration during nasal neurally adjusted ventilatory assist (nNAVA), an increasingly used ventilatory mode where maximal pressure is also reached at the end of inspiration. Polysomnographic recordings were performed in eight nonsedated, chronically instrumented lambs, which were ventilated with progressively increasing levels of nPSV and nNAVA in random order. States of alertness, diaphragm, and glottal muscle electrical activity, tracheal pressure, Spo(2), tracheal Pet(CO(2)), and respiratory inductive plethysmography were continuously recorded. Although phasic inspiratory glottal constrictor electrical activity appeared during nPSV in 5 of 8 lambs, it was never observed at any nNAVA level in any lamb, even at maximal achievable nNAVA levels. In addition, a decrease in Pco(2) was neither necessary nor sufficient for the development of inspiratory glottal constrictor activity. In conclusion, nNAVA does not induce active inspiratory glottal closure, in contrast to nPSV and nVC. We hypothesize that this absence of inspiratory activity is related to the more physiological airway pressurization during nNAVA, which tightly follows diaphragm electrical activity throughout inspiration.