Are intravenous corticosteroids required in status asthmaticus?

Seventy-seven patients with status asthmaticus were prospectively studied to compare oral with intravenous methylprednisolone. Patients were given methylprednisolone, either 160 or 320 mg orally or 500 or 1000 mg intravenously, daily in equally divided doses. They were randomly assigned to either group on a daily sequential basis. Spirometry was performed within one hour of the initial dose of steroids. The mean presenting forced expiratory volume in 1 s was 26% of the predicted value. Spirometry was then repeated every six hours for the first 24 hours and then every eight to 12 hours until discharge or 72 hours, whichever occurred first. There were no significant differences in the incidence of respiratory failure, forced expiratory volume in 1 s, days of hospitalization, rate of improvement in pulmonary function, or side effects. No patient who went into respiratory failure did so more than three hours after receiving the initial dose of steroids. We conclude that oral methylprednisolone is safe and effective in the treatment of status asthmaticus.     

Ossifying fibroma of nose in a two year old child

We report a cast of ossifying fibroma of the nose, arising from the bony septum and extending into the nasophaynx in a 2 yrs. old child presenting with features of obstructed nose.     

Lipomas where you least expect them.

Although lipomas are relatively common and found in most anatomical sites, we are not aware of any previous reports of lipomas arising between the two layers of the deep temporal fascia above the zygomatic arch. This is surprising because a fat pad is seen and used during surgery in this area to protect the frontal branch of the facial nerve. This case highlights the importance of understanding the anatomy of this region, because lipomas can potentially arise in any of three fat pads laying near the facial nerve in this area.     

A hernia in the inguinal region is not always an inguinal hernia

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger’s disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 × 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 × 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.     

Airway obstruction after extubation following use of transesophageal echocardiography for posterior fossa surgery in the sitting position.

We report respiratory obstruction following surgery in the sitting position with tracheal intubation and placement of a transesophageal echocardiography probe. Obstruction was due to pharyngeal oedema, which resolved with 24 hours. The mechanisms of this complication are discussed.     

Preemptive Plasmapheresis and Recurrence of FSGS in High-Risk Renal Transplant Recipients

Recurrent focal segmental glomerulosclerosis (FSGS) following transplantation is ascribed to the presence of a circulating FSGS permeability factor (FSPF). Plasmapheresis (PP) can induce remission of proteinuria in recurrent FSGS. This study addressed the efficacy of pre-transplant PP in decreasing the incidence of recurrence in high-risk patients. Ten patients at high-risk for FSGS recurrence because of rapid progression to renal failure (n = 4) or prior transplant recurrence of FSGS (n = 6) underwent a course of 8 PP treatments in the peri-operative period. Recurrences were identified by proteinuria >3 g/day and confirmed by biopsy. Seven patients, including all 4 with first grafts and 3 of 6 with prior recurrence, were free of recurrence at follow-up (238-1258 days). Final serum creatinine in 8 patients with functioning kidneys averaged 1.53 mg/dL. FSGS recurred within 3 months in 3 patients, each of whom had lost prior transplants to recurrent FSGS. Two of these progressed to end-stage renal disease (ESRD) and the third has significant renal dysfunction. Based on inclusion criteria, recurrence rates of 60% were expected if no treatment was given. Therefore, PP may decrease the incidence of recurrent FSGS in high-risk patients. Definitive conclusions regarding optimal management can only be drawn from larger, randomized, controlled studies.     

Modafinil augmentation of selective serotonin reuptake inhibitor therapy in MDD partial responders with persistent fatigue and sleepiness.

BACKGROUND: Partial response, no response, or residual symptoms following antidepressant therapy is common in clinical psychiatry. This study evaluated modafinil in patients with major depressive disorder (MDD) who were partial responders to adequate selective serotonin reuptake inhibitor (SSRI) therapy and excessive sleepiness and fatigue. METHODS: This retrospective analysis pooled the data of patients (18-65 yrs) who participated in two randomized, double-blind, placebo-controlled studies of modafinil (6-week, flexible-dose study of 100-400 mg/day or 8-week, fixed-dose study of 200 mg/day) plus SSRI therapy. Patients (n=348) met criteria for several residual symptoms (Epworth Sleepiness Scale [ESS] score>or=10; 17-item Hamilton Depression Scale [HAM-D] score between 4 and 25; and Fatigue Severity Scale [FSS] score>or=4). RESULTS: Compared to placebo, modafinil augmentation rapidly (within 1 week) and significantly improved overall clinical condition (Clinical Global Impression-Improvement), wakefulness (ESS), depressive symptoms (17-item HAM-D), and fatigue (FSS) (p<.01 for all). At final visit, patients receiving modafinil augmentation experienced statistically significant improvements in overall clinical condition, wakefulness, and depressive symptoms. Modafinil was well tolerated in combination with SSRI. CONCLUSIONS: Results of this pooled analysis provide further evidence suggesting that modafinil is an effective and well-tolerated augmentation therapy for partial responders to SSRI therapy, particularly when patients continue to experience fatigue and excessive sleepiness.