Life Threatening Delayed Complication of Botulinum Toxin Injection for Treatment of Spasmodic Dysphonia.

Spasmodic dysphonia is a primary task specific focal dystonia affecting the laryngeal muscles during speech. Most medical and surgical approaches to treatment of spasmodic dysphonia are aimed at the denervation of the laryngeal muscles to block symptom expression in the voice. The standard of care for the adductor form of spasmodic dysphonia is botulinum toxin chemodenervation. The common side effects of treatment with Botox are excessive breathiness and aspiration of fluids. We present the report of a delayed presentation of upper airway obstruction due to a complete vocal cords adduction requiring intubation ten days post Botox injection for the adductor form of spasmodic dysphonia. This presentation may be preceded by a change in voice, productive cough, shortness of breath, or odynophagia. We would recommend supportive treatment in an Intensive Care Unit and close liaison with the otolaryngology team for the management of this complication. Acute upper airway obstruction requiring tracheal intubation is a delayed complication of botulinum toxin administration in the adductor form of spasmodic dysphonia.

Evaluating the safety and efficacy of regional citrate compared to systemic heparin as anticoagulation for continuous renal replacement therapy in critically ill patients: A service evaluation following a change in practice.

Following the implementation of citrate anticoagulation for continuous renal replacement therapy, we evaluate its first year of use and compare it to the previously used heparin, to assess whether our patients benefit from the recently reported advantages of citrate. We retrospectively analysed 2 years of data to compare the safety and efficacy of citrate versus heparin. The results have shown that 43 patients received continuous renal replacement therapy with heparin, 37 patients with citrate. We found no significant difference in metabolic control of pH, urea and creatinine after 72 h. Filters anticoagulated with citrate had significantly longer median lifespan (33 h vs 17 h; p = 0.001), shorter downtime (0 h vs 5 h; p = 0.015) and less filter sets per patient day (0.37 vs 0.67; p = 0.002). Filters anticoagulated with heparin were commonly interrupted due to clotting (50% vs 16.4%), whereas filters anticoagulated with citrate were often stopped electively (53.4% vs 24.6%). Patients on heparin filters had significantly higher APPTs, some at potentially dangerous levels (>180 s), whilst patients on citrate filters had significantly higher levels of bicarbonate. Therefore, we conclude that citrate is superior in terms of safety and efficacy, with longer filter lifespan. It has become our first line anticoagulant for continuous renal replacement therapy.

Smoke on the water: A case report of chronic renal failure resulting from the ingestion of smoke machine fluid.

We report the case of an 18-year-old male admitted to the Intensive Care Unit in Basingstoke and North Hampshire Hospital, who developed chronic kidney disease following the ingestion of smoke machine fluid. Smoke machine fluid may contain ethylene glycol, and a diagnosis of ethylene glycol toxicity with calcium oxalate nephropathy was made. This case resulted in a National Poisons Information Service internal review of the subject and a new TOXBASE entry for smoke machine fluid ingestion.

Primary malignant melanoma of the nose: a rare cause of epistaxis in the elderly.

We report the case of a primary nasal malignant melanoma in an elderly woman, illustrating the dilemmas involved in clinical decision making with non-specific symptoms, and the treatment of cancer in elderly patients. We also discuss the incidence, clinical presentation, diagnosis, principles of management and outcome.