Spontaneous perirenal hemorrhage is mainly due to renal malignancy.But its presence in a patient who are on anticoagulant make it challenging for the diagnosis.We report a case of 50-year-old man who presented with brain stroke and started on an anticoagulant.Post anticoagulant treatment he presented with flank fullness.On evaluation, he found to have right perirenal hematoma suspicious of renal malignancy and severely stenosed aortic valve.We did right nephrectomy and aortic valve replacement simultaneous and on histopathologically found to have papillary renal cell carcinoma.
Background & objectives The choice of anesthetic for better perioperative conservation of immune responses has always been contentious. This study investigated the differential impact of the intravenous anesthetic, propofol, and the volatile anesthetic, isoflurane on the T cell immune responses, if any, among individuals going through perioperative breast cancer. Methods Perioperative blood samples (preoperative, intraoperative and postoperative) collected from participants with breast cancer in two arms namely isoflurane arm (n=50) and the propofol arm (n=50) were analyzed for T cell immune response using flow cytometry and ELISA. The interactions of anesthetics with CD4/CD8 were probed with molecular docking and molecular dynamic (MD) simulations. Results Linear mixed model analysis showed that isoflurane in comparison to propofol inhibited CD4+ helper (Th) [β-coefficient: -8.75; 95% CI: -13.00 to -4.51] and CD19+ B cell (β: -7.51; 95% CI: -15.46 to 0.44) frequencies during the intraoperative period in perioperative breast cancer patients. Further, interleukin (IL)-10 and IL-12 were significantly increased during the intra- and postoperative periods in the isoflurane group as compared to the propofol group. Molecular docking (MD) validated propofol's better binding energy with CD4/CD8 than isoflurane. MD simulations propagated that in contrast to isoflurane, propofol formed a more compact and stabilized structure with CD4/CD8, making the amino acid residues on the surface of CD4/CD8 inaccessible for any interaction. Interpretation & conclusions The clinical observations and the in silico findings exhibited that propofol in comparison to isoflurane better regulated T cell immuno-inflammatory response in perioperative breast cancer patients.
Background and Aims: Moderate to severe postburn contractures (PBCs) of the neck lead to multiple areas of difficulty in airway management. Awake flexible fiberscope guided intubation with cuffed endotracheal tube (ETT) is considered the “gold standard” for securing the airway in these cases. Supraglottic airway devices (SADs), if at all used, are used either as rescue devices or as conduits for ETT. This case series looks at the possibility of using SADs as a planned airway securing device in these cases. Material and Methods: We managed 24 cases of moderate to severe PBC neck using six types of pre shaped SADs as the first choice airway device. These SADs were placed after either airway topicalization (19 cases) or general anesthesia (GA) (5 cases). Once SAD placement was confirmed, all the patients received GA and muscle relaxant. Tests for proper placement and function and fiberscopy (conducted in four cases) were performed at various times during the procedure. The SADs were removed once the patients were fully awake. Results: SADs could be placed in one attempt in all the cases. The time taken to hand over the patients to surgeons was 12–20 min. SADs maintained their proper placement and function in spite of changing airway dimensions during contracture release. The patients tolerated the SADs well right until the time they were fully awake. The SADs could be successfully removed on the operation table in all the cases. Conclusion: Pre shaped SADs secure the airway quickly and are free from the risk of intraoperative displacements and allow uneventful emergence in moderate and severe PBC neck cases and need to be considered as the first choice in these cases.
Abstract Atherosclerotic cardiovascular disease (ASCVD) is a chronic inflammatory disease of the vessel wall with a secondary autoimmune component based on a loss of tolerance to self-antigens. Soluble biomarkers for ASCVD include hsCRP and IL-6, but these are not specific for ASCVD. Cell-based immune biomarkers for ASCVD are not established. Here, we identified surface markers in human peripheral blood mononuclear cells (PBMCs) using spectral flow cytometry. The PBMCs came from the Cardiovascular Assessment Virginia (CAVA) cohort with angiographically verified coronary artery disease (CAD) or not. Cell types were identified by established lineage markers. In myeloid cells, 24 surface markers were labeled and analyzed. In nonclassical monocytes (CD14-CD16+), we found that CD38 was significantly higher in cases than controls (p<2.2E-16). This was also true in all 25 male subjects tested, which was driven by a large signal in 15 younger males (age below median 70). To test the impact of statin use, we stratified male subjects by statin use and diabetes. In both subgroups, CAD cases showed significantly higher CD38 expression in NMOs than controls. In 5 female subjects tested, NMO CD38 expression was also significantly higher in cases than controls. This group was too small to test further subsets. We conclude that CD38 in NMOs is significantly higher in most subjects with CAD and represents a good candidate immune cell surface biomarker that needs to be validated in other cohorts.
Madam, Oropharyngeal throat packs (TPs) are commonly inserted during maxillofacial surgeries to protect the airway from blood, secretions, and surgical debris.[123] Retention of TP is a relatively common occurrence and can be fatal.[456] A 42-year-old, 47 kg, American Society of Anesthesiologists physical status I, male with carcinoma of buccal mucosa was posted for debridement and repair of deltopectoral flap. He had a Mallampatti class 4 and grossly restricted neck extension [Figure 1a]. The airway was secured by awake fiberscope guided intubation with a cuffed nasotracheal tube. As it was an extraoral surgery, no oropharyngeal pack was inserted. The 7-hour surgery was uneventful, and the trachea was extubated after ensuring adequate recovery from anaesthesia. Immediately after extubation patient started having restlessness, difficulty in breathing and desaturation. We suspected airway obstruction due to incomplete recovery from neuromuscular blockade or laryngospasm as the possible cause. Since bag and mask was not effective and we inserted Laryngeal mask airway (LMA) Supreme size 3 after administering propofol. This resulted in immediate improvement of respiration and oxygen saturation (100%). When patient became conscious, LMA-Supreme was removed after thorough suctioning, but patient again started destaurating and had paradoxical respiration. This was again relieved by reinsertion of LMA-Supreme. Since, the cause of recurrent airway obstruction was not clear, we decided to intubate the patient's trachea using C-Mac videolaryngoscope. During videolaryngoscopy, to our great surprise, a blood soaked gauze pack was found in the laryngopharynx which was removed [Figure 1b]. Subsequently, we came to know that the surgical assistant had inserted it without informing anyone.Figure 1: (a) The patient with carcinoma buccal mucosa posted for flap revision retained throat; (b) pack being removed during videolaryngoscopyIn our case, the initial episode of respiratory distress was probably due to the TP positioned around and right over the laryngeal inlet. The placement of LMA-Supreme relieved the airway obstruction by pushing the pack into the hypopharynx. However, as the LMA-Supreme was removed, probably a part of the TP stuck under its tip was pulled back over the laryngeal inlet and caused airway obstruction again. The decision to use the C-MAC video laryngoscope proved fortuitous and helped us identify the cause and remove the forgotten TP. The present case highlights the potentially serious consequences of lack of communication between the surgical and anesthesia teams. TPs have been placed in oral and maxillofacial surgery under general anesthesia to prevent aspiration of blood, prevent leakage of gases around the endotracheal tube (ETT), stabilize the ETT, and passage of blood into stomach.[47] Complications like airway obstruction due to retained TP after extubation have been reported and a number of reports have highlighted the patient safety risks associated with TPs. During insertion or removal, the TP may be swallowed by the patient, damage oral structures (the tongue, fraenulum, uvula or teeth), cause airway obstruction, necessitate additional interventions for its removal, and may also lead to death of the patient due to hypoxia.[56] The TP may be forgotten by the entire team because of the change of the anesthesiologist, additional packs placed during the procedure, rapid recovery of the patient, or wrong claim by the staff. In our case also TP was inserted during the course of surgery by the surgeon without communicating to the anaesthesia team. The WHO Surgical Safety Checklist mentions about ensuring things have not been left inside under "THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT" at the SIGN OUT time and highlights that the whole Team is responsible for this action. In our case, noncompliance with the WHO Checklist along with lack of communication at the time of TP insertion (between surgeon, anesthesiologist, and the two nurses) became an important reason its retention.[4] A number of methods have been suggested to reduce the retention of TPs like attaching a suture to the TP, leaving some part of TP outside, suturing it to ETT, putting a label indicating pack insertion (patients forehead, ETT, wrist band, or machine), including the TP in the swab count, documenting the placement/removal of the pack and ensuring the removal by verbal check.[4] This case once again highlights the need to follow the WHO surgical safety list meticulously and including TP as a separate part of sponge count. It also highlights the importance of good communication and proper handing over of the cases among healthcare professionals. Finally, it may be prudent to suggest that a video laryngoscopic airway examination should be conducted in cases of unexplained respiratory distress in the perioperative period. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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