Brain injury due to anaphylactic shock: broadening manifestations of Kounis syndrome.

Anaphylactic shock is a real and life threatening medical emergency which is encountered in every field of medicine. The coronary arteries seem to be the primary target of anaphylaxis resulting in the development of Kounis syndrome. Kounis syndrome is a pan-arterial anaphylaxis -associated syndrome affecting patients of any age, involving numerous and continuously increasing causes, with broadening clinical manifestations and covering a wide spectrum of mast cell activation disorders. Recently, Kounis-like syndrome affecting the cerebral arteries was found to be associated with mast cell activation disorders. In anaphylactic shock, the decrease of cerebral blood flow is more than what would be expected from severe arterial hypotension. This is attributed to the early and direct action of anaphylactic mediators on cerebral vessels. While adrenaline is a life saving agent in the treatment of anaphylactic shock, it contains sodium betabisulfite as preservative and should be avoided in sulfite allergic patients. Potential allergens encountered in endodotic practice include formocresol, zinc compounds thiurams, sodium dimethyldithiocarbamade, and mercaptobenzothiazole that might have synergistic action. All these agents together with analgesics, antibiotics, antiseptics, formaldehyde, latex, local anaesthetics and metals used in dental practice, in general, can induce anaphylactic shock. Practitioners should be aware of these consequences. A careful history of previous atopy and reactions is of paramount importance for safe and effective management.

University faculty on student motivation to use medical education apps and barriers to their usage.

OBJECTIVE: University teachers, who primarily provide guidance and advice to their students, can play a significant role in educational process transformation. As there is no particular e-learning framework, it is important to understand the factors and variables that may impact both its effective usage and further successful implementation. The current study aims to outline the influence of university faculty, and possible barriers preventing medical students from using apps for learning purposes. SUBJECTS AND METHODS: Α cross-sectional study was conducted with an online survey questionnaire. The population of the study included 1,458 students from all the seven Greek schools of medicine. RESULTS: University faculty (51.7%), followed by fellow students and friends (55.6%), constitute the second most common source of information on adopting apps for medical education. 45.8% of students rated their educational guidance as insufficient/inadequate, 33.0% as moderate, 18.6% as quite good, and only 2.7% as sufficient/complete. University professors have proposed certain apps to 25.5% of students. PubMed (41.7%), Medscape (20.9%), and Complete Anatomy (12.2%) were the leading suggestions. The main barriers to app usage were the lack of knowledge of apps' benefits (28.8%), insufficient updates of their content (21.9%), their cost-effectiveness (19.2%), and financial reasons (16.2%). Most students preferred using free apps (51.4%) and 76.7% preferred universities to cover apps' expenses. CONCLUSIONS: University faculty represent the main source of information regarding the adaptation of medical apps in the educational process. However, students need improved and enhanced guidance. The main barriers are ignorance about apps and financial reasons. The majority prefer free apps and universities to cover their cost.

Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy. / Síndrome de Kounis del tipo II inducido por amoxicilina-ácido clavulánico complicado con encefalopatía hipóxico-isquémica durante anestesia general.

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called 'Kounis-like' syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.

Trace elements and the carotid plaque: the GOOD (Mg, Zn, Se), the UGLY (Fe, Cu), and the BAD (P, Ca)?

Multiple epidemiological studies have suggested that industrialization and progressive urbanization should be considered one of the main factors responsible for the rising of atherosclerosis in the developing world. In this scenario, the role of trace metals in the insurgence and progression of atherosclerosis has not been clarified yet. In this paper, the specific role of selected trace elements (magnesium, zinc, selenium, iron, copper, phosphorus, and calcium) is described by focusing on the atherosclerotic prevention and pathogenesis plaque. For each element, the following data are reported: daily intake, serum levels, intra/extracellular distribution, major roles in physiology, main effects of high and low levels, specific roles in atherosclerosis, possible interactions with other trace elements, and possible influences on plaque development. For each trace element, the correlations between its levels and clinical severity and outcome of COVID-19 are discussed. Moreover, the role of matrix metalloproteinases, a family of zinc-dependent endopeptidases, as a new medical therapeutical approach to atherosclerosis is discussed. Data suggest that trace element status may influence both atherosclerosis insurgence and plaque evolution toward a stable or an unstable status. However, significant variability in the action of these traces is evident: some - including magnesium, zinc, and selenium - may have a protective role, whereas others, including iron and copper, probably have a multi-faceted and more complex role in the pathogenesis of the atherosclerotic plaque. Finally, calcium and phosphorus are implicated in the calcification of atherosclerotic plaques and in the progression of the plaque toward rupture and severe clinical complications. In particular, the role of calcium is debated. Focusing on the COVID-19 pandemia, optimized magnesium and zinc levels are indicated as important protective tools against a severe clinical course of the disease, often related to the ability of SARS-CoV-2 to cause a systemic inflammatory response, able to transform a stable plaque into an unstable one, with severe clinical complications.

WITHDRAWN: Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.redar.2019.06.002. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

A joint allergist/cardiologist classification for thienopyridines hypersensitivity reactions based on their symptomatic patterns and its impact on the management strategies.

The role and importance of thienopyridines such as ticlopidine, clopidogrel, and prasugrel is well-established for several indications, ranging from prevention of acute coronary syndromes to percutaneous coronary interventions, where the dual antiplatelet therapy represents the gold standard to avoid denovo coronary stenosis. However, there is a significant cohort of patients with coronary artery disease who may manifest hypersensitivity reactions to thienopyridines. The examination of the various case reports from medical literature leads to identify mainly four clinical patterns of hypersensitivity to thienopyridines which involves more frequently cutaneous, hematologic, and articular tissues, therefore the kind and predominance of clinical symptoms may determine a different clinical approach to overcome or neutralize thienopyridines hypersensitivity.

Ascites and other extracardiac manifestations associated with right atrial myxoma: a case report.

Right atrial myxomas are rare intracardiac tumors that often pose difficulties in diagnosis. Right ventricular failure and ascites ensuing from tricuspid valve orifice obstruction are potentially dangerous complications. Early diagnosis of cardiac myxoma is important since surgical treatment leads to disappearance of all symptoms with a low rate of recurrence and good long-term survival. Nonspecific extracardiac symptoms, signs, complications, and laboratory findings may be the initial manifestations contributing to misdiagnosis of these rare but totally treatable atrial tumors.

Electrocardiographic changes in elderly patients during small bowel enema.

RATIONALE AND OBJECTIVES: Enteroclysis (small-bowel enema) involves the introduction of a large amount of fluid into the small bowel, through a tube, producing small bowel distention. A study was done to determine the incidence of any electrocardiographic changes during enteroclysis with Holter monitoring. METHODS: Continuous electrocardiographic monitoring and 12-lead electrocardiograms were performed in 30 elderly patients undergoing enteroclysis and in 30 control subjects undergoing routine chest, bone, and upper gastrointestinal small bowel follow-up studies. Two channel qualitative and quantitative electrocardiographic analysis was performed by a computerized nontriggered template system. Arrhythmias, change in cardiac axis, conduction defects, pauses, ST segment changes, and ectopics were sought. RESULTS: Increased sympathetic tone resulting in increased heart rate and transient atrial and ventricular ectopics was frequent during enteroclysis compared with the control group. In one patient ventricular tachycardia developed, and two patients had diminished heart rate, but this was attributed to preexisting heart disease and concurrent medication. CONCLUSION: Transient, nonhazardous cardiac arrhythmias are encountered during enteroclysis in elderly patients. These arrhythmias may be attributed to the preexisting heart disease, fear, and anxiety during intubation, or increased sympathetic tone from the enteric loop distention.

Brainstem auditory evoked potentials in patients with ischemic heart disease.

The authors of this study used the method of increased stimulus rate on brainstem auditory evoked potentials (BAEPs) in 30 patients with ischemic heart disease (IHD) and in an equal number of healthy age-matched control subjects. The BAEPs were recorded using 100- to 3000-Hz alternating polarity clicks at a rate of 22.6 per second. Measurements included the absolute latencies of waves I through V, the interpeak latencies I-III, III-V, and I-V, and the peak amplitudes of peaks I, III, and V. The measured absolute latencies and interpeak latencies were found to be significantly increased, and the peak amplitudes were found to be diminished. The audiometric tests revealed no significant hearing loss in IHD patients. This study is the first to demonstrate prolongation of BAEPs in IHD patients. BAEP recording may become an additional noninvasive tool for detecting IHD patients with impaired microcirculation.

Electrocardiographic changes in elderly patients during endoscopic retrograde cholangiopancreatography.

BACKGROUND: Cardiorespiratory complications may occur during gastrointestinal endoscopy, and elderly people seem to be more vulnerable to these complications during endoscopic procedures involving the manipulation of abdominal viscera. OBJECTIVES: To determine the incidence of cardiac arrhythmias, changes in oxygen saturation, heart rate and blood pressure during endoscopic retrograde cholangiopancreatography (ERCP) via Holter monitoring in elderly patients older than 70 years of age. METHODS: Holter monitoring and 12-lead electrocardiograms were performed in 30 elderly patients undergoing ERCP and in 30 control subjects undergoing routine chest, abdomen, bone and upper gastrointestinal small bowel follow-through studies. A computerized nontriggered template system was used to analyze the electrocardiograms qualitatively and quantitatively. Arrhythmias, cardiac axis, conduction defects, pauses, ST segment changes, ectopic beats, oxygen desaturation and changes in blood pressure and rate-pressure product were evaluated. RESULTS: Increased heart rate, ST segment changes resulting from myocardial ischemia, oxygen desaturation and transient atrial and ventricular ectopic beats were frequent during ERCP compared with the control group. In one patient, transient left bundle branch block developed and this was attributed to pre-existing hypertension with cardiomegaly. One patient developed ventricular tachycardia and one other sinus bradycardia, but this was attributed to sick sinus syndrome. CONCLUSIONS: Transient myocardial ischemia and various cardiac arrhythmias are frequent in elderly patients undergoing ERCP. Appropriate noninvasive monitoring seems to be justified during this procedure.

A modified per os double contrast examination of the colon in the elderly.

A modified per os double contrast examination of the colon was used in 62 elderly patients in whom conventional barium enema had been unsuccessful. We created endogenous gas generation instead of air insufflation by per os administration of a special mixture containing barium sulfate, lactulose and gastrografin. Good quality double contrast images of the colon were obtained after 12 hours in 59 of the 62 patients. The sensitivity of the method was 100% in 6 patients suffering from carcinoma and in 15 patients suffering from diverticular disease. However, the method failed to demonstrate small solitary polyps in 5 patients and it was also negative in another 27 patients. 7 of these had negative endoscopy and in the remaining a definite diagnosis was not established by any other method. It seems that this method may become an alternative for investigation of suspected colonic pathology in the elderly patients with difficulty in retaining the barium enema.

Dose-dependent appearance and disappearance of amiodarone-induced skin pigmentation.

A 66-year-old man suffering from atrial flutter developed cutaneous blue-gray pigmentation while receiving 600 mg of amiodarone daily for 15 months. With reduction of the dose to 100 mg, skin discoloration disappeared within 16 months, to reappear within 7 months after increasing the dose to 400 mg. Finally, the discoloration disappeared within 13 months with a dose reduction to 200 mg daily. It seems that a tissue threshold level for amiodarone exists in this patient, above which skin discoloration appears and below which it fades. Dose, duration, metabolism, macrophage transfer, and spillover saturation-excretion may be relevant in amiodarone-induced skin pigmentation.

Pregnancy-induced increase of supraventricular arrhythmias in Wolff-Parkinson-White syndrome.

Six women suffering from Wolff-Parkinson-White syndrome and who were previously asymptomatic or nearly asymptomatic, were followed prospectively during and after their subsequent pregnancies. Three women experienced several attacks of supraventricular tachycardia (SVT) for the first time and the rest experienced an increase in their attacks. It seems that there is an increased tendency for SVT in pregnancy. Increased adrenergic sensitivity by estrogens, increased plasma volume, stress, and anxiety during pregnancy may be some of the causative factors.