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PurposeObtaining an objective, reproducible, and accurate assessment of volume status is one of the more difficult tasks in the perioperative arena. Since its advent in 2020, the Venous Excess Ultrasound (VExUS) score has gained popularity in the minimally invasive assessment of venous congestion. The VExUS exam has been well described as an additional series of images (hepatic vein, portal vein, and intrarenal vein) obtained with a phased-array probe during a transthoracic echocardiogram. Nevertheless, there are no descriptions of comprehensive VExUS exams performed using transesophageal echocardiography (TEE)—a modality that is routinely employed in patients undergoing cardiac surgery. Clinical featuresWe describe techniques to acquire and interpret a comprehensive TEE-supported VexUS exam, which may be used to optimize the perioperative care of cardiac surgical patients.ConclusionGiven the risks of fluid overload in critically ill cardiac surgery patients, TEE-supported VExUS examination may be a way to reduce morbidity in this population.

PurposeBrain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines.Clinical featuresWe report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33–34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression.ConclusionsTherapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.

Despite initial treatment, breast cancer recurrence affects approximately 30% of patients. Currently, there exists no standardized approach to detect recurrence before clinical or radiologic signs manifest. Circulating tumor DNA (ctDNA) is a minimally invasive blood test that offers potential to monitor molecular disease and individualize care. This study explores the utility of ctDNA in recurrence monitoring and clinical decision-making for high-risk breast cancer cases within a community setting. Seventy-two patients with high-risk breast cancer features-defined as stage III disease, triple-negative or HR-/HER2+ following neoadjuvant treatment, metastatic breast cancer without evidence of disease, bilateral breast cancer history, high-risk genetics (BRCA1/BRCA2 mutations), <40 years old at diagnosis, or history of breast cancer recurrence-were offered tumor-informed ctDNA assays at 3- to 6-month intervals. Analysis was conducted on 67 cases with a mean diagnostic age of 52.69 at diagnosis. The cohort was ethnically diverse, including White (  = 21, 31.82%), Japanese (  = 15, 22.73%), Native Hawaiian (  = 11, 16.67%), and Filipino (  = 7, 10.61%) patients. Seven (10.45%) tests were positive: six predicted recurrence despite four with initially negative radiological findings, and one prompted treatment resumption following prior non-adherence. However, one negative result was false and later showed a contralateral breast recurrence, and another negative test coincided with a new primary cholangiocarcinoma. In two cases, ctDNA negativity was utilized to monitor treatment response in metastatic disease and inform therapeutic adjustments. In real-world settings, ctDNA served as a valuable tool for earlier recurrence prediction, expediting radiological confirmation, and influencing treatment. Nevertheless, false results carry the risk of hindering effective care and inducing considerable patient anxiety. Future large-scale studies are warranted in high-risk breast cancer populations to evaluate ctDNA's impact on patient survival outcomes, treatment monitoring, and patients' emotional experiences.

Lipoprotein(a) (Lp(a)) is an atherogenic low-density lipoprotein (LDL)-like particle that is currently regarded as a non-modifiable risk factor for atherosclerotic cardiovascular disease. The number of patients detected with elevated Lp(a) concentrations has been increasing in recent years, although the implication of this finding is unclear for patients and physicians. We screened our lipid clinic database for patients aged >65 years with very high Lp(a) concentrations, which were defined as >230 nmol/L, and cardiovascular outcomes were assessed. The patients’ (n = 16) mean (±standard deviation) age was 72.2 ± 7.1 years and the mean Lp(a) concentration was 313 ± 68 nmol/L. After a cumulative 129.0 patient-year follow-up (mean: 8.1 ± 4.2 years), the mean age was 80.3 ± 7.0 years. We observed a low baseline prevalence of cardiovascular events, with only two patients having a history of cardiovascular events. Furthermore, zero incident adverse cardiovascular events were recorded over the follow-up. Therefore, very high Lp(a) concentrations and disease-free old age are not mutually exclusive. Our aggregated clinical experience is that there is only a modest association between elevated Lp(a) concentrations and adverse outcomes. Nonetheless, we still advise treating modifiable risk factors in these patients.

Subacute thyroiditis is a condition with varied and often misleading symptoms, which can lead to diagnostic delays and inappropriate treatment. This case series focuses on 32 patients who presented with unilateral pharyngalgia as the primary symptom and were ultimately diagnosed with subacute thyroiditis. The patients, aged 28–52 years with a female predominance (23 females and nine males), reported pharyngeal pain that lasted from 7 days to 3 months, with 19 having left-sided and 13 having right-sided initial pain. Of these patients, 43.7% (14/32) were initially misdiagnosed, primarily as pharyngitis or tonsillitis. Key diagnostic findings included thyroid tenderness, abnormal thyroid function, elevated erythrocyte sedimentation rate, characteristic manifestations on thyroid ultrasound, and decreased radioactive iodine uptake. Treatment varied by pain severity. In conclusion, unilateral pharyngalgia is frequently mistaken as other common throat conditions. Thyroid palpation should be routine in patients with unilateral pharyngalgia; positive findings warrant further tests (C-reactive protein, ultrasound, radioactive iodine uptake) to confirm subacute thyroiditis.

Background Acute transverse myelitis (ATM) has been reported as a potential association between COVID‐19 vaccination. In this study, we aimed to investigate the association between the COVID‐19 vaccination and ATM. Methods A self‐controlled case series study was performed using a large database that combine the COVID‐19 vaccine registry and the national claims database. The COVID‐19 vaccination data included information on individuals aged 18 and above who received COVID‐19 vaccination from February 26, 2021, to August 31, 2022. The claims database covered the entire Korean population for the period between January 1, 2002 to August 31, 2022. Patients who develop ATM within 1–42 days following COVID‐19 vaccination were included. The observation period was 270 days after the first dose of the COVID‐19 vaccine. The incidence rate ratio (IRR) and 95% confidence interval (CI) were estimated using a conditional Poisson regression model. Results A total of 159 ATM patients were included. Among them, 82 (51.6%) were male, and mean age was 55.4 (±17.4) years. The IRR was 2.41 (95% CI: 1.76–3.30) for the ATM risk within 1–42 days after COVID‐19 vaccination. The IRR by vaccine product was 3.31 (95% CI: 1.81–6.05) for ChAdOx1‐S; 1.99 (95% CI: 1.30–3.03) for BNT162b2; 2.57 (95% CI: 1.14–5.97) for mRNA‐1273; and 3.33 (95% CI: 0.30–36.44) for Ad26.COV2.S. Conclusion These findings indicated an increased risk of ATM following COVID‐19 vaccination within 42 days. An association with the risk of ATM was found both for viral vector and mRNA vaccines.

A group of four healthy Canadian travellers visited a cenote in the Yucatán peninsula in April 2024 and subsequently developed symptomatic histoplasmosis. Diagnosis was made in the acute period with a positive urine antigen test in three of the cases. Two developed severe presentations and were treated with itraconazole, including a three-year-old child with disseminated disease. The sensitivity of different modalities for diagnostics depends on the timing and severity of illness, with urine antigen being most sensitive in early infection, serology converting 4-8 weeks following exposure and cultures generally of low sensitivity. Treatment depends on the disease manifestations and host immunologic status. Many patients have relatively mild, self-limited, influenza-like illness and the diagnosis may be overlooked. Given the number of Canadian tourists travelling to the Yucatán peninsula and the popularity of visiting cenotes, awareness of the risk of histoplasmosis associated with this exposure should be promoted.

PurposeProlonged postoperative neuromuscular respiratory paralysis after administration of a nondepolarizing neuromuscular blocking agent is a serious concern during anesthetic management of patients with Charcot-Marie-Tooth disease (CMTD). Some recent reports have described rocuronium use without respiratory paralysis in CMTD patients when sugammadex was used for its reversal. We report a case in which an induction dose of rocuronium caused a prolonged respiratory paralysis in a patient with undiagnosed type 1A CMTD (CMT1A).Clinical featuresA 63-yr-old-male with an American Society of Anesthesiologists Physical Status score of III underwent a left hip arthroplasty under general anesthesia for osteoarthritis. Preoperative pulmonary function testing indicated a restrictive impairment. Anesthesia was induced with fentanyl, remifentanil, propofol, and 0.73 mg·kg-1 of rocuronium. The train-of-four (TOF) count was 0 for the 273-min duration of surgery. After repeated doses of sugammadex failed to recover the TOF count and spontaneous respirations, a total of 1,200 mg (17.3 mg·kg-1) of sugammadex, which was assumed to be a sufficient amount for capturing the residual rocuronium, was administered. Although the patient expressed that he was awake via eye blinking, he could not breathe. Thus, he was placed on mechanical ventilation for 18 hr after surgery. A postoperative neurology consultation revealed a delayed nerve conduction velocity of 20 m·sec-1 and a mutated duplication of the PMP22 gene; a diagnosis of CMT1A was made.ConclusionsOur case shows that rocuronium can cause a prolonged neuromuscular respiratory paralysis refractory to sugammadex in patients with CMT1A and impaired respiratory function. Our case may also indicate that restrictive pulmonary impairment and low nerve conduction velocity of 20 m·sec-1 are predictive factors that cause prolonged neuromuscular respiratory paralysis refractory to sugammadex in CMT1A.

ABSTRACT The current study aims to present our clinical observations and experience gathered during the diagnosis, clinical presentation, medical/surgical treatment, and functional prosthetic rehabilitation of cases of rhino-orbital/cerebral Mucormycosis patients. Mucormycosis is an aggressive, life-threatening invasive fungal infection that occurs in people who are immune-compromised. The rise of ROCM during the second wave of the COVID-19 pandemic in India suggests a more effective association between Mucormycosis and the SARS-CoV-2 delta variant. The treatment strategy for Mucormycosis is an early diagnosis which is critical for a successful outcome. The initial step is to reduce or remove underlying risk factors followed by surgical excision and debridement of the afflicted tissues supplemented with antifungal medication. The first-line antifungal treatment is Liposomal Amphotericin B. Postsurgical resection defects are rehabilitated by either removable partial prosthesis (obturators) or by fixed zygomatic implant/patient-specific implant supported prosthesis. Management of ROCM requires a multidisciplinary approach. This case series highlights detailed medical, surgical, and functional prosthetic management modalities adopted by our team in managing such a dreaded disease which may be used as a tool for the formulation of standardized prevention and management/treatment/rehabilitation protocols in the future so that disease morbidity and mortality be reduced and an endemic outbreak could be averted.

Ectopic adrenocorticotropic hormone syndrome (EAS) is a rare condition caused by pancreatic neuroendocrine tumors (p-NETs). The severe hypercortisolemia that characterizes EAS is associated with a poor prognosis and survival. Mitotane is the only adrenolytic drug approved by the Food and Drug Administration and is often used to treat adrenocortical carcinoma. Combination therapy with mitotane and other adrenal steroidogenesis inhibitors is common for patients with Cushing’s syndrome (CS). Here, we describe three patients who developed EAS secondary to the liver metastasis of p-NETs. All three rapidly developed hypercortisolemia but no typical features of CS. They underwent anti-tumor and mitotane therapy, which rapidly reduced their blood cortisol concentrations and ameliorated their symptoms. Their hypercortisolemia was controlled long term using a low dose of mitotane. The principal adverse effects were a slight loss of appetite and occasional dizziness, and there were no severe adverse effects. Importantly, even when the tumor progressed, the patients’ circulating cortisol concentrations remained within the normal range. In summary, the present case series suggests that mitotane could be used to treat hypercortisolemia in patients with EAS caused by advanced p-NETs, in the absence of significant adverse effects.