Compromised breast flap treated with leech therapy, hyperbaric oxygen, pentoxifylline and topical nitroglycerin: A case report.

INTRODUCTION: Hyperbaric oxygen (HBO2) is often indicated in compromised surgical flaps. Although limited to animal models and human case reports, the utilization of leech therapy (Hirudo medicinalis) with HBO2 provides better outcomes than each modality alone. Topical nitroglycerin and pentoxifylline are also frequently used adjunctively for compromised flaps. We present a case of successful breast flap salvage utilizing a combination of leech therapy, HBO2, topical nitroglycerin and pentoxifylline. CASE REPORT: A 34-year-old female, one day post-status cosmetic breast reduction mammoplasty developed a dusky discoloration of the left nipple areolar complex, indicating imminent flap failure. The patient was immediately treated with topical nitroglycerin, oral pentoxifylline, and referred for HBO2. After her first HBO2 treatment, there was clinical improvement to the superior portion of the areolar flap, with little improvement inferiorly where the discoloration had remained essentially unchanged. To address this, we added leech therapy and discontinued the topical nitroglycerin. Ceftriaxone for Aeromonas prophylaxis was started, and leeches were attached two at a time and removed from the area once feeding had ceased. These were applied three times per day for three days while receiving HBO2 twice per day for six days. The patient's flap improved and completely healed by Week 8 without need for further surgery. CONCLUSION: This is the first case to our knowledge of successful breast flap salvage using a combination of leech therapy, HBO2, topical nitroglycerin and pentoxifylline.

Research report: Charcoal type used for hookah smoking influences CO production.

A hookah smoker who was treated for severe carbon monoxide poisoning with hyperbaric oxygen reported using a different type of charcoal prior to hospital admission, i.e., quick-light charcoal. This finding led to a study aimed at determining whether CO production differs between charcoals commonly used for hookah smoking, natural and quick-light. Our hypothesis was that quick-light charcoal produces significantly more CO than natural charcoal. A medium-sized hookah, activated charcoal filter, calibrated syringe, CO gas analyzer and infrared thermometer were assembled in series. A single 9-10 g briquette of either natural or quick-light charcoal was placed atop the hookah bowl and ignited. CO output (ppm) and temperature (degrees C) were measured in three-minute intervals over 90 minutes. The mean CO levels produced by quick-light charcoal over 90 minutes was significantly higher (3728 ± 2028) compared to natural charcoal (1730 ± 501 ppm, p = 0.016). However, the temperature was significantly greater when burning natural charcoal (292 ± 87) compared to quick-light charcoal (247 ± 92 degrees C, p = 0.013). The high levels of CO produced when using quick-light charcoals may be contributing to the increase in reported hospital admissions for severe CO poisoning.

Synchrotron radiation computed laminography for polymer composite failure studies.

Synchrotron radiation computed laminography is applied to the three-dimensional micro-imaging of damage in large polymer composite plates with high spatial resolution. The influence of different experimental conditions is studied with respect to measurement time optimization, dose minimization and reduction of artefacts in the reconstructed images. Failures like delaminations, transverse ply cracks and splits are observed under in situ loads. The propagation of up to 2 mm-long cracks is non-destructively followed in situ and investigated in detail. By phase retrieval using a single detector distance, the failures can be easily visualized in three dimensions.

An intact microbiota is required for the gastrointestinal toxicity of the immunosuppressant mycophenolate mofetil.

BACKGROUND: Mycophenolate mofetil (MMF) is commonly prescribed after transplantation and has major advantages over other immunosuppressive drugs, but frequent gastrointestinal (GI) side-effects limit its use. The mechanism(s) underlying MMF-related GI toxicity have yet to be elucidated. METHODS: To investigate MMF-related GI toxicity, experimental mice were fed chow containing MMF (0.563%) and multiple indices of toxicity, including weight loss and colonic inflammation, were measured. Changes in intestinal microbial composition were detected using 16S rRNA Illumina sequencing, and downstream PICRUSt analysis was used to predict metagenomic pathways involved. Germ-free (GF) mice and mice treated with orally administered broad-spectrum antibiotics (ABX) were utilized to interrogate the importance of the microbiota in MMF-induced GI toxicity. RESULTS: Mice treated with MMF exhibited significant weight loss, related to loss of body fat and muscle, and marked colonic inflammation. MMF exposure was associated with changes in gut microbial composition, as demonstrated by a loss of overall diversity, expansion of Proteobacteria (specifically Escherichia/Shigella), and enrichment of genes involved in lipopolysaccharide (LPS) biosynthesis, which paralleled increased levels of LPS in the feces and serum. MMF-related GI toxicity was dependent on the intestinal microbiota, as MMF did not induce weight loss or colonic inflammation in GF mice. Furthermore, ABX prevented and reversed MMF-induced weight loss and colonic inflammation. CONCLUSIONS: An intact intestinal microbiota is required to initiate and sustain the GI toxicity of MMF. MMF treatment causes dynamic changes in the composition of the intestinal microbiota that may be a targetable driver of the GI side-effects of MMF.

Changes in Composition of the Gut Bacterial Microbiome after Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in a Pediatric Heart Transplant Patient.

The microbiome is increasingly recognized as an important influence on human health and many of the comorbidities that affect patients after solid organ transplantation (SOT) have been shown to involve changes in gut bacterial populations. Thus, microbiome changes in an individual patient may have important health implications after SOT but this area remains understudied. We describe changes in the composition of the fecal microbiome from a pediatric heart transplant recipient before and >2.5 years after he underwent repeated fecal microbiota transplantation (FMT) for recurrent Clostridium difficile infection (CDI). With both documented episodes of CDI, there was marked loss of bacterial diversity with overgrowth of Proteobacteria (>98.9% of phyla identified) associated with symptomatic colitis that was corrected after FMT. We hypothesize that a second CDI occurring after FMT was related to incomplete restoration of normal bowel flora post-FMT with relative deficiencies of the phyla Firmicutes and Bacteroidetes and the families Lachnospiraceae and Ruminococcaceae. Following the second FMT, there was a gradual shift in gut bacterial composition coincident with the recipient developing lymphonodular hyperplasia of the colon and painless hematochezia that resolved with discontinuation of mycophenolate mofetil (MMF). This case documents dynamic changes in the bacterial microbiome after FMT and suggests that MMF may influence the gut microbiome with consequences for the patient.

Herpetic cranial polyneuritis mimicking brain stem infarction-an atypical presentation of Ramsay Hunt syndrome.

An elderly man presented with severe right ear pain and discharge, hoarseness and dysphagia causing significant involuntary weight loss. Extensive investigations by varied specialties only highlighted right vocal cord palsy and right parotid lymphadenitis. Reassessment on transfer to a rehabilitation ward noted clinically subtle right Ramsay Hunt syndrome with multiple lower cranial nerve involvement. We illustrate a case of varicella zoster virus cranial polyneuritis with bulbar symptoms mimicking bulbar stroke, requiring percutaneous endoscopic gastrostomy feeds, with significant clinical and radiological recovery over 1 year.

Functional movement disorder: a long journey to diagnosis.

A 61-year-old man presented to a country clinic with involuntary orofacial movements and progressive cognitive decline, causing significant disability and psychosocial distress. Review of records uncovered a 7-year history of presentations to several specialties, including memory clinics, neurology, internal medicine and emergency departments, with varied symptoms, extensive complex work up and inconclusive diagnosis. Comprehensive review at our hospital highlighted inconsistent neurological signs, fluctuating cognition and psychosocial stressors, which preceded symptom onset, leading to the diagnosis of a functional movement disorder (FMD), which subsequently improved with relaxation therapy, cognitive-behavioural therapy and physiotherapy. We illustrate a variety of somatic symptoms, diagnostic clues and management outcomes for FMDs, and the importance of diagnostic criteria to minimise costly, time-consuming and ultimately unnecessary tests of exclusion.

Health impacts of wildfires.

Introduction Wildfires are common globally. Although there has been considerable work done on the health effects of wildfires in countries such as the USA where they occur frequently there has been relatively little work to investigate health effects in the United Kingdom. Climate change may increase the risk of increasing wildfire frequency, therefore there is an urgent need to further understand the health effects and public awareness of wildfires. This study was designed to review current evidence about the health effects of wildfires from the UK standpoint. Methods A comprehensive literature review of international evidence regarding wildfire related health effects was conducted in January 2012. Further information was gathered from authors' focus groups. Results A review of the published evidence shows that human health can be severely affected by wildfires. Certain populations are particularly vulnerable. Wood smoke has high levels of particulate matter and toxins. Respiratory morbidity predominates, but cardiovascular, ophthalmic and psychiatric problems can also result. In addition severe burns resulting from direct contact with the fire require care in special units and carry a risk of multi - organ complications. The wider health implications from spreading air, water and land pollution are of concern. Access to affected areas and communication with populations living within them is crucial in mitigating risk. Conclusion This study has identified factors that may reduce public health risk from wildfires. However more research is needed to evaluate longer term health effects from wildfires. An understanding of such factors is vital to ensure preparedness within health care services for such events.

Transient presyncope secondary to posterior descending artery occlusion.

We describe the case of a 64-year-old male initially presenting with presyncope and bradycardia, without any anginal symptoms or objective evidence of myocardial ischemia. A stress test induced no physical symptoms but revealed a left bundle branch block with multiple preventricular contractions on electrocardiogram. Subsequent catheterization revealed severe obstructive disease throughout the coronary arteries. He was treated percutaneously on two separate heart catheterizations. The presyncope and bradycardia resolved after reperfusion of the posterior descending artery.