Familial Celiac Disease Remission as a Result of a Full Donor Immunologic Recovery After Sibling Cord Blood Transplantation for Chronic Granulomatous Disease: A Case Report

We present a case report of a boy diagnosed with both chronic granulomatous disease (CGD) and familial celiac disease (CD) who underwent cord blood transplantation from a partially matched sibling donor. The presentation of CD resembled Crohn-like enteropathy, which is a canonical manifestation of CGD. Nearly 1 year post-hematopoietic stem cell transplantation (HSCT), a gluten-containing diet was reintroduced, and no reappearance of clinical, serologic, or histologic markers of CD was observed. The relatively high incidence of rare genetic diseases in pediatric patients suggests the need for additional caution in the interpretation of symptoms mimicking already known hallmarks of more common conditions. In addition, the presented data confirm the previous rare observations that allogeneic HSCT leads to durable induction of gluten tolerance in patients with CD, which can warrant its use in patients with refractory subtypes of CD.     

Multiple measures of anesthesia workload during teaching and nonteaching cases

In this study, we sought to examine several measures of anesthesia provider workload during different phases of anesthesia care and during teaching and nonteaching cases. Clinical work was assessed in real-time during 24 general anesthetics performed by consenting anesthesia providers. Workload was measured using physiological (provider heart rate), psychological (self-assessment and observer rating), and procedural (response latency to an alarm light and workload density) techniques. Clinicians' heart rates, observer and self-reported workload scores, and nonteaching workload density were consistently increased during anesthetic induction and emergence compared with maintenance. In nonteaching cases, workload density correlated with heart rate and with psychological workload. Workload density during teaching cases did not decrease during the induction and was significantly greater than during nonteaching cases. Alarm-light response latency (a measure of clinical vigilance) was significantly prolonged during the teaching compared with nonteaching cases. These results suggest that intraoperative teaching increases the workload of the clinician instructor and may reduce vigilance during anesthesia care. Additionally, multiple workload measures may provide a more comprehensive profile of the work demands of clinical cases. IMPLICATIONS: Psychological, physiological, and procedural workload measures during routine general anesthesia cases documented the increased work demands of induction and emergence. Intraoperative teaching increased workload and decreased vigilance, suggesting the need for caution when educating during patient care.     

Propofol-induced bronchoconstriction: two case reports

IMPLICATIONS: Bronchoconstriction was induced by anesthetic induction with propofol in two patients with allergic diseases. One had severe bronchospasm improved by epinephrine. Propofol should be used with caution in patients with allergic disease.     

Right coronary artery injury during tricuspid valve annuloplasty

An unusual complication after tricuspid valve annuloplasty is described where a ring suture ligated right coronary artery and precipitated myocardial infarct and patient death. The need for caution to prevent this complication with such surgery is emphasized.     

Comparison of propofol and thiopentone anaesthesia (with special reference to recovery characteristics)

Thiopentone and propofol were used for the induction and maintenance of anaesthesia in unpremedicated patients undergoing minor gynaecological procedures. There were no significant differences in the induction and maintenance characteristics except for a high incidence of pain on injection and a greater fall in the mean systolic blood pressure associated with propofol in comparison with thiopentone. Propofol was associated with a quicker early recovery as well as a faster psychomotor recovery, as tested by a peg-board. However, complete psychomotor recovery was not achieved for up to three hours in some patients receiving propofol and so caution is advised regarding the early street fitness of patients receiving repeated doses of the drug for day case surgery.     

Collapsing focal segmental glomerulosclerosis in a liver transplant recipient on alendronate

We describe a case of collapsing focal segmental glomerulosclerosis and severe kidney dysfunction in a liver transplant recipient after the initiation of alendronate for osteopenia. In view of the increasing incidence of chronic kidney disease in long-term liver transplant patients, bisphosphonates need to be used with caution in these patients. The usefulness of bisphosphonates for the prevention of early bone loss after liver transplantation is increasingly reported. However, there is little information on the safety and efficacy of these drugs when used in the later stages of liver transplant, particularly in the presence of chronic kidney disease. Bisphosphonates are excreted unchanged via the kidneys after reaching the systemic circulation. Some cases of severe kidney injury, in particular collapsing focal segmental glomerulosclerosis, have been described that are associated with the use of pamidronate. Alendronate, a widely used bisphosphonate in transplant patients, has not been related to kidney toxicity. We describe a case of collapsing focal segmental glomerulosclerosis and severe kidney dysfunction in a liver transplant recipient soon after the initiation of alendronate for osteopenia. Possible pathogenetic mechanisms are discussed. In view of the increasing incidence of chronic kidney disease in long-term liver transplant patients, bisphosphonate need to be used with caution in patients with a low glomerular filtration rate.     

Management of multiple tension pneumatoceles refractory to tube thoracostomy decompression

A 10-month-old boy had multiple tension pneumatoceles develop 4 weeks after pneumonia with parapneumonic empyema caused by methicillin-resistant Staphylococcus aureus. The pneumatoceles failed to completely respond to tube thoracostomy drainage, and sudden onset of cardiopulmonary collapse occurred after induction of anesthesia. He was rescued by multiple percutaneous venous catheter decompressions, followed by lobectomy. Our experience showed that surgery remains the definitive treatment for pediatric patients with multiple tension pneumatoceles. However, extra caution should be taken in the preoperative management of these patients, even in the presence of tube thoracostomy.     

UPTAKE OF NITROUS OXIDE DURING THE INDUCTION OF ANAESTHESIA PART II: EXPERIMENTAL PROCEDURE AND RESULTS

An experiment designed to measure the breath-by-breath uptakeof nitrous oxide during the induction of anaesthesia is described.The uptake of nitrous oxide was obtained from the differencebetween the quantities inhaled and exhaled. The methods usedwere described in Part I (Smith, 1963). The uptake measuredwas greater than had been anticipated. The results are presentedwith caution. They are compared with those of Severinghaus (1954)and their implications are discussed.     

Delayed deformation of self-expanding stents after carotid artery stenting for postendarterectomy restenoses

Carotid artery stenting has become an acceptable alternative for treating patients with severe atherosclerotic lesions, particularly those with significant surgical risks, such as recurrent stenosis after endarterectomy. Stent deformation, a phenomenon primarily associated with balloon-expandable stents, is largely avoided by exclusively using self-expanding stents in treating carotid artery stenosis. Nonetheless, we herein report two patients who presented with delayed Wallstent deformation after carotid artery stenting for postendarterectomy restenosis. Our cases highlight the need for caution because delayed deformation of self-expanding stents can occur, particularly during treatment of patients with postendarterectomy stenosis. Furthermore, poststent surveillance is imperative in identifying patients with severe restenosis after carotid artery stenting who need reintervention.     

An unusual complication of laparoscopic cholecystectomy.

An unusual series of complications of laparoscopic cholecystectomy is presented. The complications occurred after use of laparoscopic technique in the treatment of acute cholecystitis. The authors feel that this is a problem that points up the need for experience and caution in the use of laparoscopic cholecystectomy in the setting of acute cholecystitis.     

Prolonged perioperative myocardial ischemia in a young male: due to topical intranasal cocaine?

We present a case of prolonged myocardial ischemia in a young healthy male presenting for nasal polypectomy and tonsillectomy. Induction of anesthesia proceeded uneventfully. Immediately after surgical incision, the patient developed a sinus tachycardia with ST-segment depression in leads II and III, and ST elevation in leads aVR, aVL, aVF, and V. Depth of anesthesia was increased, esmolol was administered, which slowed the heart rate, and the procedure was terminated. However, myocardial ischemia only gradually resolved, leaving residual T-wave flattening in lead III by day 3 postoperatively. After extensive investigation to rule out other causes of ischemia, we considered cardiotoxicity due to intranasally administered cocaine with epinephrine to be the most likely precipitant. Nasal packing with gauze soaked in a solution containing cocaine 3 mg/kg and epinephrine 1 mg occurred just 40 minutes prior to induction of anesthesia. Topical intranasal cocaine is rapidly and reliably absorbed systemically, with peak plasma concentrations occurring within 30 to 60 minutes, corresponding to the time course of cocaine administration and surgical stimulation in this patient. Systemic absorption of topical intranasal cocaine has previously been reported to cause adverse cardiac sequelae, including myocardial infarction. This report reinforces the need for caution regarding the use of topical intranasal cocaine, particularly if used in combination with epinephrine.     

Anaphylactoid reaction to intravenous sodium ferric gluconate complex during pregnancy

We report the first case of a severe anaphylactic or anaphylactoid reaction to sodium ferric gluconate complex in a pregnant patient. Sodium ferric gluconate complex is felt to be one of the safest forms of iron therapy during pregnancy. This case highlights the need for extreme caution and vigilance in pregnant patients receiving any type of parenteral iron therapy.     

Luteinizing hormone-releasing hormone agonists and meningioma: a treatment dilemma

The relative contraindication of hormonal therapy for patients with prostate cancer and a history of meningioma has not been widely emphasized. Using immunohistochemistry to determine the presence of hormone receptors in meningioma specimens proved potentially valuable in 2 patients with biochemical recurrence after prostatectomy who were being considered for androgen deprivation therapy. These cases also highlight the need for caution against assuming that skull-based intracranial growths in patients receiving hormonal therapy for prostate cancer are metastatic lesions rather than hormonally induced primary tumors.     

Reliability of rodent animal models in biomedical research

Despite the discrepancies observed between the data generated from humans and animals, it is a usual practice that the results obtained from animal models are extrapolated on humans. This review stresses that while animal models are essential for the research and development, a critical caution needs to be practiced in interpreting the results. Uncritical reliance on the results of animal experimentation can be dangerously misleading and has resulted in damages to human health in several cases. This review also discusses the role of certain confounding factors in using animal models due to which appropriate precautions need to be taken while deciding to conduct a study using animal models and caution is warranted in extrapolating the data obtained from pre-clinical studies on humans.     

Elevated serum glucose levels following ketamine intravenous anaesthesia: a report of 2 cases

Ketamine is widely used as a sole anaesthetic agent in Nigeria, although data on its use and the associated side effects are generally lacking. This paper presents two cases of elevated blood glucose levels during caesarean deliveries under intravenous ketamine anaesthesia. Literature on complications of ketamine use is reviewed and the need for caution in the use of this drug as a single anaesthetic agent is emphasised.     

Immunohistochemical localization of myoglobin in nonmuscular cells

Myoglobin has been detected by the immunoperoxidase technique in the cytoplasm of nonmuscular cells present in malignant tumors infiltrating skeletal muscle. The positive cells were reactive histiocytes in one case, and malignant cells (breast carcinoma, malignant melanoma, and malignant lymphoma) in the others. These findings indicate the need to exercise caution in the interpretation of myoglobin stain for the diagnosis of rhabdomyosarcoma under these circumstances.     

Severe respiratory depression in the obstetric patient after intrathecal meperidine or sufentanil

Two cases of severe respiratory depression in the obstetric population are presented. The first occurred after intrathecal injection of a modest dose (50 mg) of meperidine. The second followed intrathecal administration of 10 microg of sufentanil after intravenous fentanyl. These cases illustrate the potential gravity of this complication and highlight the need for caution when giving intrathecal opioid following parenteral opioid administration.     

Rapid resorption of calcium sulfate and hardware failure following corrective radius osteotomy: 2 case reports

Bone substitutes are being increasingly used and may avert the need for autogenous bone graft in orthopedic surgery. Thus it is important to note complications that occur with them to better understand the limitations. We report on early mechanical failure of injectable calcium sulfate leading to implant failure in 2 elderly patients who had corrective osteotomies for malunited distal radius fractures. We hypothesize that these occurred because there was inadequate new bone formation to replace the resorbing bone substitute. We advise caution when using bone substitutes in patients with expected delayed fracture healing.     

Der kindliche Knick-Senk-Fuß

Flexible flatfoot in childhood is a common cause for repetitive consultations and the diagnosis is verified by the clinical examination. In most cases the findings are age-dependent variants of the norm and if asymptomatic there is no need for treatment. In the first decade of life symptomatic flexible flatfoot should initially be treated with shoe inserts. Further diagnostic steps are required once conservative treatment is unsuccessful or a rigid structural deformity is found in the clinical examination. The underlying reasons may be neuropathic or structural anatomical in origin. Lateral column lengthening as described by Evans or minimally invasive arthroereisis are well established surgical options but for arthroereisis the number of long-term studies is low. In general the indications for surgical and conservative therapy have to be judged with caution although parents often see an urgent need for treatment.     

Continuous urinary incontinence presenting as the initial symptoms demonstrating acontractile detrusor and intrinsic sphincter deficiency in multiple system atrophy

Severe stress incontinence due to intrinsic sphincter deficiency may be common in aged women. However stress urinary incontinence could be the initial symptom of severe neurogenic bladder even if no neurological signs have previously been recognized. Urodynamic study is necessary in such a case. Tension-free vaginal tape surgery and intermittent self-catheterization may be one option, but self catheterization might become difficult when the neurological disorders develop. In this case report, we highlight the need for caution in identifying the presence of an occult neurogenic bladder when intending to carry out surgery for patients with severe stress incontinence.