Postpartum peripheral neuropathy due to vitamin B12 deficiency, potentially precipitated by nitrous oxide use.

Neurological dysfunction which would concern the anaesthetist on labour ward is typically associated with neuraxial blocks. However, an appreciation of other causes is crucial. We present a case of peripheral neuropathy secondary to vitamin B12 deficiency, which highlights the importance of a thorough neurological examination, alongside an understanding of neurological pathophysiology. This is crucial for initiating appropriate referral, subsequent investigations and treatment. Neurological dysfunction secondary to vitamin B12 deficiency may be reversible, following prolonged rehabilitation, so prevention is the best approach, which may require modification of anaesthetic techniques. In addition, at-risk patients should be screened and treated prior to nitrous oxide use, with alternative methods of labour analgesia advised in very high-risk individuals. The incidence of vitamin B12 deficiency may increase in the future potentially linked to a rise in plant-based diets, so this picture may be more commonly seen. Added vigilance by the anaesthetist is imperative.

Surgical solutions for refractory J-pouch inlet obstruction.

AIM: Many surgeons consider total proctectomy with ileal pouch-anal anastomosis as the treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia. However, obstruction occurring at the pouch inlet or involving the afferent limb can be refractory to nonoperative or endoscopic management. Historically, these refractory obstructions have usually required resection of the pouch. There is now increasing evidence to suggest that pouch salvage surgery may be feasible in these patients. METHODS: A retrospective review was performed of all patients of a single surgical practice who underwent a neo ileal-pouch anastomosis for J-pouch inlet obstructions between 2000 and 2017. Data collected included patient demographics, preoperative workup, intra-operative findings, type of surgical intervention and postoperative outcomes. RESULTS: Surgical interventions were performed on eight patients with J-pouch inlet obstructions. Six patients had inlet strictures or acute angulations at the inlet, which were either bypassed or resected and primarily anastomosed. Two patients had internal hernias posterior to the mesentery, with volvulus of the pouch. At a mean follow-up of 36.5 months, all patients retained their pouches and the mean number of daily bowel movements was eight. Two major and two minor complications occurred. DISCUSSION: J-pouch inlet obstructions may take years to develop. In patients with obstruction who are refractory to endoscopic or medical treatment, good functional results may be obtained with pouch salvage procedures. With increasing numbers of J-pouches being performed, awareness of novel surgical techniques is important.

An unusual case of a brain abscess arising from an odontogenic infection.

A brain abscess that originates from an odontogenic infection, although rare, can at times be difficult to diagnose, especially in the context of pain and trismus. We report a rare case of odontogenic infection as a result of an infected maxillary third molar, causing an infratemporal and temporalis collection, resulting in a brain abscess with concurrent cerebritis. This is a clinical case review documenting an uncommon but potentially fatal complication.

Hepatocellular carcinoma metastasis to the maxilla: a rare case.

The manifestation of metastatic malignant disease in the oral cavity can present in a number of ways and may mimic benign conditions. This case reports a rare presentation from a metastasis of a hepatocellular carcinoma that had invaded the attached gingiva of the maxilla and which on initial inspection could have been misdiagnosed as a pyogenic granuloma. With the advent of new classes of drugs to manage this disease it could be expected that this presentation may become more common.

Transnasal K-wire to stabilise a complex zygomatic fracture: a forgotten method of fixation.

Zygomatic complex fractures make up approximately 60% of facial fractures. The vast majority treated surgically use titanium miniplates. These require longer operating times and facial incisions to access the fracture. The use of a K-wire was first described 60 years ago. As a new generation of surgeons emerges, it is important to be aware of the various techniques available to increase their surgical armamentarium. One of its benefits is that it has a significantly reduced operative time and does not require any incisions.

Relationship of endothelial function and atherosclerosis to treatment response in late-life depression.

OBJECTIVE: Treatment response in late-life depression has been linked to cerebrovascular disease notably via the vascular depression hypothesis. This study investigated the relationship between endothelial function and atherosclerosis and treatment response to antidepressant monotherapy. METHODS: Twenty five patients with late-life depression were compared with 21 non-depressed control subjects in a case control study. Nine of the depressed subjects were responders to antidepressant monotherapy and 16 were not. Vascular measures included assessment of carotid intima media thickness (IMT) representing atherosclerosis and biopsied small artery dilatation to acetylcholine to assess endothelial function in a subset of subjects. RESULTS: There were no group differences in vascular risks or sociodemographic variables. There was a significant group difference (responders versus non-responders versus controls) on both IMT and endothelial function (p < 0.01 and p < 0.05, respectively) with a significant difference between controls and non-responders (p < 0.001) on IMT and between controls and responders (p < 0.05) and control versus non-responders (p < 0.05) on endothelial function but no significant difference between responders and non-responders. On both IMT and endothelial function, there was a gradient across groups, with control subjects having best vascular structure or function, non-responders worse and responders in-between. CONCLUSIONS: The results are consistent with a hypothesis that poorer antidepressant response in later life depressive disorder may be linked to an underlying vascular dysfunction and pathology. The study is small, and the results require replication but if confirmed, trials with vasoprotective medication aimed at improving vascular function in order to alter the prognosis of late-life depression would be a rational development.

Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator.

This is a report of adenocarcinoma arising in an ileal pouch after restorative proctocolectomy (RPC) with rectal mucosal stripping performed by Cavitron Ultrasonic Surgical Aspirator (CUSA) for ulcerative colitis. The CUSA was introduced to simplify and optimize ileal pouch-anal anastomosis with mucosectomy and has been shown to shorten the operative time and reduce blood loss. Its use however, may increase the number of pathology specimens made uninterpretable on account of tissue ablation. In the present case, even though preoperative colonoscopy had clearly shown dysplasia, the surgical pathology report could not detect any neoplasia in the specimen; hence, the patient was not surveyed for pouch cancer. Six years later, the patient presented with intestinal obstruction caused by cancer. While protocols for universal pouch surveillance remain somewhat controversial, we conclude on the basis of this case and a review of the literature that in RPC with mucosectomy performed by CUSA, pouch cancer surveillance is particularly important because remnants of rectal epithelium may have been left behind and tissue ablation may have made the surgical pathology report uninterpretable.

Effect of local therapy for the treatment of superficial esophageal cancer in non-operative candidates.

Surgical resection is the current standard treatment for patients with early stage cancer of the esophagus. In a subset of these patients, comorbidities prohibit the operative risks of a potentially curative esophagectomy. Such patients may be candidates for local endoscopic treatment. We sought to look at a large cohort of patients with clinically localized esophagus cancer to determine whether high-risk patients survive significantly longer after endoscopic therapy than those who receive no local treatment. T0 or T1, N0 esophageal cancer (EC) patients who did not receive surgery or radiation were identified from the Surveillance, Epidemiology, and End Results cancer registry (1998-2003). The patients were assigned into two groups: local endoscopic therapy (excisional biopsy, photodynamic, local destruction, thermal laser, polypectomy, electrocautery, or cryoablation) versus no endoscopic therapy. Differences in survival were calculated using the Kaplan-Meier method, and a multivariate Cox regression analysis adjusting for potential confounders was used to analyze the effect of local therapy on survival. The study cohort included 166 T0 or T1, N0 EC patients. (75% male; 50% >70 years old). Tumors were adenocarcinoma (60%), squamous cell carcinoma (24%), and other (16%). The 4-year disease-specific survival rate was 84% for patients receiving local therapy compared with 64% for patients receiving no therapy (P < 0.01). On multivariate analysis, patients receiving local therapy had a significantly lower hazard of EC-related death (P = 0.04). There was no difference in survival curves for deaths secondary to causes other than EC. Local endoscopic therapy significantly prolonged survival in high-risk patients with clinical T0 or T1, N0 EC and is a reasonable alternative for those patients who are not candidates for potentially curative esophagectomy.

Intravenous infusions in hyperbaric chambers: effect of compression on syringe function.

Haemodynamic instability is a recognised phenomenon in critically ill patients undergoing hyperbaric therapy. Instability may result from the effects of ambient pressure on the cardiovascular system, devices involved in infusion of drugs and fluids, or a combination of the two. The effect of hyperbaric pressure on air-containing spaces in syringes has not been previously measured. We connected 60-ml syringes (Terumo Corporation, Tokyo, Japan) containing coloured water to low volume extensions via three-way taps. We examined the effect of pressurisation to 2.4 and 2.8 atmospheres absolute (ATA) on the syringes by measuring the displacement of the coloured water in the low volume extension set. There was compression of air spaces within the syringe causing retrograde flow of fluid within the low volume extension set. The mean (95% CI) change in volume was 154 (141-168) microl at 2.4 ATA, and 197 (183-212) microl at 2.8 ATA (both p < 0.0001). We conclude that hyperbaric exposure may cause clinically significant changes in syringe function at infusion rates < 100 ml. h(-1).

Are consecutive nightly recordings required for valid evaluation of sleep-associated erections?

We questioned the need for more than one RigiScan recording for accurate assessment of sleep-associated penile erections and determine the necessity of consecutive nightly recordings for valid evaluation of sleep-associated erections. Men complaining of erectile dysfunction (ED) and referred to RigiScan evaluation for the first time participated. Recordings were performed at the patient's home during two consecutive nights, and data on test time, number of erections, erection duration, minimal and maximal base and tip tumescence and rigidity were retrieved for both nights. Normal erectile function was defined with the recording of at least one erection (70 out of 100% tip rigidity lasting for at least 10 min during either night). The main outcome measures were RigiScan recordings. Group 1 consisted of 29 men (mean age 42.4+/-13.8 years, range 22-71) who had normal erections, all during the first night. Group 2 consisted of 26 men (mean age 48.6+/-13.5 years, range 25-70) who failed to fulfill both criteria for normal erection. In Group 2, only the values for penile base rigidity and erection duration were normal during the first night: the parameters of maximal base tumescence, tip rigidity, number of effective erections and duration of effective erections that were impaired during the first night were significantly worse (P<0.01) during the second night. The required information for the diagnosis of psychogenic ED was obtained during the first night in >50% of the participants. Men with normal erections during the first night can be spared the inconvenience and cost of re-testing. Consecutive night recording should be reserved for patients whose recorded data during the first night did not fulfill the criteria for normal erection.

Early rheumatoid arthritis is associated with a deficit in the CD4+CD25high regulatory T cell population in peripheral blood.

OBJECTIVE: Our aim was to test the hypothesis that there is a deficit in the CD4+CD25high regulatory T-cell population in early rheumatoid arthritis (RA), either in size or functional activity. METHODS: Peripheral blood mononuclear cells were examined from subjects with early active RA who had received no previous disease-modifying therapy (n = 43), from individuals with self-limiting reactive arthritis (n = 14), from subjects with stable, well-controlled RA (n = 82) and from healthy controls (n = 72). The frequencies of CD4+CD25high T-cells were quantified using flow cytometry, and function was assessed by the ability to suppress proliferation of CD4+CD25- T-cells. Paired blood and synovial fluid was analysed from a small number of RA and reactive arthritis patients. RESULTS: There was a smaller proportion of CD4+CD25high T-cells in the peripheral blood of early active RA patients (mean 4.25%) than in patients with reactive arthritis or in controls (mean 5.90 and 5.30%, respectively, P = 0.001 in each case). Frequencies in stable, well-controlled RA (mean 4.63%) were not significantly different from early active RA or controls. There were no differences in suppressor function between groups. Higher frequencies of CD4+CD25high T-cells were found in synovial fluid than blood in both RA and reactive arthritis. CONCLUSIONS: These data demonstrate a smaller CD4+CD25high regulatory T-cell population in peripheral blood of individuals with early active RA prior to disease-modifying treatment. This may be a contributory factor in the susceptibility to RA and suggests novel approaches to therapy.

Sexual dysfunction in women partners of men with erectile dysfunction.

We evaluated 113 female partners of men with erectile dysfunction (ED) attending a sexual dysfunction clinic in order to define sexual dysfunction among these women. In all, 51 (45%) women denied having any sexual dysfunction. The other 62 (55%) responded to questions classifying their complaint(s) according to the international classification of female sexual dysfunction (FSD) in the following topics (40/62, 65%, reported having more than one problem): decreased sexual desire (n=35, 56%), sexual aversion (none), arousal (n=23, 37%) and orgasmic disorders (n=39, 63%), dyspareunia (n=19, 31%), vaginismus (n=3, 5%), and noncoital sexual pain (none). Many female partners of men with ED report having some form of sexual disorder, mostly orgasmic problems and decreased sexual desire. Therefore, for optimal outcome of ED treatment, evaluation and treatment of male and FSD should be addressed as one unit within the context of the couple, and be incorporated into one clinic of sexual medicine.

Anti-CCP antibodies measured at disease onset help identify seronegative rheumatoid arthritis and predict radiological and functional outcome.

OBJECTIVE: Anti-cyclic citrullinated peptide (anti-CCP) antibodies have been identified as highly specific for rheumatoid arthritis (RA). Studies suggest an association with radiographic outcome. The aims of this study were to assess the diagnostic and prognostic utility of the second-generation anti-CCP(2) test in a large cohort of early RA patients compared with connective tissue disease (CTD) controls. METHODS: One hundred and eighty-two patients with RA and 121 patients with CTD were recruited. All RA patients had less than 24 months of symptoms and had CRP, rheumatoid factor (RF), HLA typing (SE) and anti-CCP(2) antibodies measured at baseline. Function was assessed using the Health Assessment Questionnaire (HAQ) and X-rays performed at 0, 12 and 24 months. RESULTS: The anti-CCP(2) antibody test demonstrated a specificity of 91% and sensitivity of 81% for RA when compared with controls. In RF-negative patients, specificity was 92% and sensitivity 60%. Baseline demographics of the RA cohort showed mean age 57 yr, mean symptom duration 7 months, 63% RF-positive patients, 72% SE-positive, 81% CCP-positive and 21% erosive. The only predictor of change in Larsen score from 0 to 24 months in the cohort was the presence of the shared epitope (P<0.05) and in the RF-negative subgroup it was CCP(2) antibody titre >100 (P<0.05). Baseline HAQ was the only significant predictor of HAQ at 24 months, but in the RF-negative subgroup CCP(2) antibody titre >100 predicted a poor functional response at 24 months (P<0.05). CONCLUSIONS: This study confirms the diagnostic utility of anti-CCP(2) antibodies in early RA, particularly in seronegative patients, in whom anti-CCP(2) positivity also conferred prognostic utility for radiographic and functional outcomes.

Infliximab in combination with methotrexate in active ankylosing spondylitis: a clinical and imaging study.

OBJECTIVE: To examine the efficacy and safety of infliximab combined with methotrexate compared with methotrexate alone in the treatment of ankylosing spondylitis (AS) using MRI and DXA to monitor its impact on bone. METHODS: In this single centre study 42 subjects with active AS were treated with methotrexate and were randomly assigned, in a ratio of 2:1, to receive five infusions of either 5 mg/kg infliximab or placebo over 30 weeks. The primary outcome was improvement in disease activity as shown by the BASDAI at week 30. MRI was used to assess the effect of treatments on sacroiliac and spinal enthesitis/osteitis and DXA to monitor bone mineral density. RESULTS: Both therapeutic agents were well tolerated with no dropouts due to adverse events. A significantly greater improvement in mean BASDAI score was seen in the infliximab arm at week 10 (p = 0.017) than in the placebo arm, but this was not maintained by week 30 (p = 0.195), 8 weeks after the last infusion, at which stage disease flares were reported by some subjects. MRI showed that the mean number of lesions resolving for each subject from week 0 to week 30 was significantly greater in the combination group than in the methotrexate monotherapy group (p = 0.016). CONCLUSIONS: Infliximab in combination with methotrexate was a safe and efficacious treatment in AS over 6 months and was associated with significant regression in enthesitis/osteitis as determined by MRI. However, disease flares were reported 8 weeks after the last infusion, indicating that addition of methotrexate failed to extend the infliximab dosing interval.

Per urethra insertion of a through-and-through safety guide wire using a dual-lumen ureteral catheter during percutaneous nephrolithotripsy.

BACKGROUND: The second ("safety") of two guide wires is commonly inserted antegradely in percutaneous nephrolithotripsy (PCNL). We describe the retrograde insertion of a through-and-through safety guide wire during PCNL. METHODS: After inserting a percutaneous nephrostomy 1 day earlier, a guide wire was introduced through the nephrostomy tube to the bladder and pulled out through the urethral meatus via a cystoscope and grasper. The tube was removed, leaving the wire positioned from the flank to the meatus. A dual-lumen catheter was introduced retrogradely through the urethra over the wire, up to the nephrostomy incision. The safety guide wire was introduced retrogradely through the catheter's other port. RESULTS: This procedure succeeded in 9 of 10 patients: the exception was very obese and the catheter was too short to reach the incision in the flank. CONCLUSION: Using a dual-lumen catheter allows quick and simple retrograde insertion of a safety guide wire during PCNL.

Surgery for late-onset ulcerative colitis: predictors of short-term outcome.

BACKGROUND: Onset of ulcerative colitis and Crohn disease after the age of 65 (late-onset disease) is not common, and is usually associated with a worse prognosis. We review our experience with late-onset ulcerative colitis and define the predictors of short-term outcome. METHODS: A retrospective analysis of our surgical experience with 33 patients suffering from late-onset ulcerative colitis. The medical records of 17 women and 16 men who had surgery between 1984 and 1999 were reviewed for age at surgery, sex, duration of disease, extent of disease, indications for surgery, surgical procedures and outcome. Additionally, we identified predictors of outcome. RESULTS: The median age at surgery was 74 years (range 65-83). The most common indication for surgery was refractoriness to medical treatment. There were 4 deaths for a mortality rate of 12%, and 7 major complications. There was no mortality for elective procedures. On univariate analysis, albumin levels of 2.8 g/dl or less and urgent surgery were predictors of poor outcome. Disease of short duration (3 years or less from onset of disease to surgery) was also associated with a poor outcome, but this did not reach statistical significance. CONCLUSIONS: We conclude that in the elderly population suffering from late-onset ulcerative colitis and requiring an operation, urgent surgery and hypoalbuminemia are predictors of adverse outcome. Age at surgery, sex and the extent of colonic involvement did not influence outcome. Low complication and death rates should be expected for elective procedures in the elderly.

The use of temozolomide in recurrent malignant gliomas.

Gliomas are the most common primary intracerebral tumours and over 60% of these are malignant. Standard treatment in the UK for patients with a good performance status consists of surgery and postoperative radiotherapy, however, recurrence is almost inevitable. Treatment of recurrent malignant gliomas (MG) is limited to further surgery, chemotherapy and novel biological therapies. The response rate to standard chemotherapy protocols for recurrent MG is less than 30%. Temozolomide (Temodar-US, Temodal-Rest of World) is an oral alkylating agent with a similar chemical structure to dacarbazine, and has recently been licensed in the UK for second line treatment of recurrent MG. Several phase II studies and one randomised trial suggest that Temozolomide improves time to progression and quality of life but not overall survival. The drug is well tolerated with dose limiting myelosuppression and thrombocytopenia occurring in less than 10% of patients at current dosage schedules. A randomised trial comparing Temozolomide with best first line adjuvant chemotherapy (PCV) is about to start recruiting patients. Further clinical studies investigating its role in neoadjuvant treatment or in combination with radiotherapy or other chemotherapeutic approaches are ongoing.

Does local hyperthermia affect metastasis of a human prostate carcinoma grown in athymic nude mice?

PRIMARY OBJECTIVE: This study investigated whether local hyperthermia increases metastasis of prostate carcinoma xenografts in athymic nude mice. RESEARCH DESIGN AND METHODS: Human prostate carcinoma cells (1-LN-PC-3-1A) were injected into the animal's thigh. Mice were randomly divided into those treated with local hyperthermia (43 degrees C for 45 min, tumour volume 100 or 200 mm(3)) and untreated controls, and sacrificed when the tumour volume reached 500 mm(3). MAIN OUTCOMES AND RESULTS: Histological evaluation (hematoxylin and eosin staining) of lymph nodes showed metastases in 20/21 hyperthermia-treated and 17/21 control mice. Lymph node involvement, tumour weight at sacrifice, and tumour growth rate were not significantly different between groups. CONCLUSION: Single local hyperthermia treatment had no effect on lymph node metastatic spread in this model.

Surgery for ulcerative colitis in elderly persons: changes in indications for surgery and outcome over time.

HYPOTHESIS: Medical therapy has changed the indications for surgery over the last 4 decades. Advances in perioperative care have significantly improved the outcome. DESIGN: The medical records of all patients 65 years and older who underwent surgery for ulcerative colitis during a 40-year period were analyzed retrospectively. SETTING: Tertiary referral center. PATIENTS: One hundred thirteen consecutive patients 65 years and older who underwent surgery for ulcerative colitis between January 1, 1960, and June 30, 1999. MAIN OUTCOME MEASURES: Changes in elective and urgent indications for surgery. Changes over time in outcome and the factors that brought about these changes. Predictors of poor outcome in an elderly population with ulcerative colitis. RESULTS: One hundred thirteen patients were divided into 3 cohorts of 38, 38, and 37 consecutive patients admitted to the hospital during the periods 1960 through 1984, 1985 through 1993, and 1994 through 1999, respectively. Indications for surgery and morbidity and mortality rates have changed with time. Dysplasia has replaced carcinoma as a major indication for elective surgery (P =.001). Toxic megacolon has become significantly less common as an indication for urgent surgery (P =.001). Surgery-associated adverse outcomes have decreased significantly from 50% (13% deaths, 37% major complications) to 27% (3% deaths, 24% major complications) (P =.04). Male sex, an albumin level of 2.8 g/dL or less, and urgent surgery were found to be independent predictors of poor outcome. CONCLUSIONS: In our referral center, the indications for urgent and elective surgery have changed during the past 4 decades from toxic megacolon and carcinoma, to disease refractory, to medical therapy and dysplasia, respectively. Morbidity and mortality have decreased dramatically over time. Urgent procedures, low levels of albumin, and male sex are all predictors of poor outcome.