Non–surgical management of abdominal ectopic pregnancy with uterine artery embolization

Abdominal pregnancy is a rare but life-threatening variation of ectopic pregnancy that is often treated with laparoscopic management; however, we present a case successfully treated using only minimally invasive techniques. A 36-year-old female G1P0 with a history of infertility is diagnosed with 11-weeks abdominal pregnancy by transvaginal ultrasound. She presented with vaginal bleeding and abdominal pain, and her beta-human chorionic gonadotropin was 53,680 mIU/mL. The location of the fetal sac was not amenable to surgery or percutaneous injection. We performed bilateral uterine artery embolization and subsequent intramuscular methotrexate injection. The procedure was successful with no complications. The patient was followed at postoperative week 11, and beta-human chorionic gonadotropin was 2 mIU/mL, and at 3 months, a transvaginal ultrasound revealed resolution of the abdominal pregnancy.     

Hematopoietic stem cell transplantation with reduced toxicity conditioning regimen in mitochondrial neurogastrointestinal encephalopathy syndrome

Background

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare autosomal recessive disorder due to mutations in the TYMP gene. Clinical findings are characterized by neurologic manifestations and severe gastrointestinal dysfunction. The syndrome is usually fatal, the most effective treatment appears to be hematopoietic stem cell transplantation (HSCT).

Procedure

In this retrospective study, we evaluated HSCT that was performed using a reduced toxicity myeloablative conditioning regimen in patients with MNGIE at our center.

Results

A total of six allogeneic transplant procedures were performed in four patients. Three patients had fully matched donors, and one patient had a haploidentical donor. Treosulfan-based myeloablative conditioning regimen was applied in five of six transplants. Bone marrow was used as a stem cell source. One patient is being followed up in the 4th year of posttransplant with full chimeric and without graft versus host disease (GVHD). One patient died of acute stage IV gastrointestinal system GVHD. Two patients underwent second transplantation due to engraftment failure, one of which was the patient who had a haploidentical transplant.

Conclusions

Treosulfan-based regimen is well tolerated, although engraftment failure with this conditioning regimen can be a significant problem. We share our haploidentical transplant experience, which will be the first reported case in the literature.     

Efficacy of open-label counterconditioning for reducing nocebo effects on pressure pain

Background

Nocebo effects can adversely affect the experience of physical symptoms, such as pain and itch. Nocebo effects on itch and pain have shown to be induced by conditioning with thermal heat stimuli and reduced by counterconditioning. However, open-label counterconditioning, in which participants are informed about the placebo content of the treatment, has not been investigated, while this can be highly relevant for clinical practice. Furthermore, (open-label) conditioning and counterconditioning has not been investigated for pain modalities relevant to musculoskeletal disorders, such as pressure pain.

Methods

In a randomized controlled trial, we investigated in 110 healthy female participants whether nocebo effects on pressure pain combined with open-label verbal suggestions can be (1) induced via conditioning and (2) reduced via counterconditioning. Participants were allocated to either a nocebo- or sham-conditioning group. Next, the nocebo group was allocated to either counterconditioning, extinction or continued nocebo conditioning; sham conditioning was followed by placebo conditioning.

Results

Nocebo effects were significantly larger after nocebo conditioning than sham conditioning (d = 1.27). Subsequently, a larger reduction of the nocebo effect was found after counterconditioning than after extinction (d = 1.02) and continued nocebo conditioning (d = 1.66), with effects similar to placebo conditioning (following sham conditioning).

Conclusions

These results show that (counter)conditioning combined with open-label suggestions can modulate nocebo effects on pressure pain, which provides promise in designing learning-based treatments to reduce nocebo effects in patients with chronic pain disorders, particularly for musculoskeletal disorders.

Significance

Few studies have investigated the efficacy counterconditioning to reduce nocebo effects. Whereas typically deceptive procedures are used, these are not ethically appropriate for use in clinical practice. The current study demonstrates that open-label counterconditioning in a pain modality relevant for many chronic pain conditions may be a promising new strategy for reducing nocebo effects in a non-deceptive and ethical manner, which provides promise in designing learning-based treatments to reduce nocebo effects in patients with chronic pain disorders.     

Post-cardioversion atrial stunning – Not to be forgotten

We present a case of a 60-year-old male who was found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 h and he was referred for TEE-guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however, the appendage was large and had a tongue-like accessory lobe along with spontaneous contrast in the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a marked increase in left atrial and left atrial appendage spontaneous contrast along with the development of tear drop shaped thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with an unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.