Notes

Presence of your HLADR13 allele among Spanish Mestizos recommends a protective issue versus relapsing-remitting ms (RRMS).
A 29-year-old previously healthy patient presented with a hyperparathyroid-induced hypercalcaemic crisis refractory to conventional therapy. The patient developed ventricular fibrillation and subsequently required emergency parathyroidectomy and extracorporeal membrane oxygenation support. Extensive intracardiac and pulmonary trunk thrombi were identified soon after the commencement of extracorporeal membrane oxygenation, despite full anticoagulation. In this report we highlight the non-specific presentations of hypercalcaemia which may lead to delayed diagnosis, and discuss the incidence, risk factors and treatment of a hyperparathyroid-induced hypercalcaemic crisis. We emphasise the role of emergency parathyroidectomy as a salvage therapy in medically refractory We consider the likely factors leading to intracardiac thrombi formation in this case, including how hypercalcaemia may have been a contributing factor. © 2019 Association of Anaesthetists.A 71-year-old woman with a known accessory cervical rib and distinct scoliosis was scheduled for elective, percutaneous stereotactic radiofrequency ablation of a non-resectable intrahepatic cholangiocellular carcinoma. Patient positioning and fixation using a Bluebag fixation system (Medical Intelligence, Schwabmünchen, Germany) and a dedicated adjustable armrest were customised in the patient while awake. In order to provide safe conditions for mask ventilation and tracheal intubation, the patient was returned to standard supine positioning without changing the position of the armrest. Following the induction of general anaesthesia, the patient's arm was returned to the previously defined position. Upon completion of the procedure and emergence from anaesthesia, the patient immediately reported symptoms of severe brachial plexus damage. Therefore, we suggest that awake positioning according to current recommendations does not completely preclude the possibility of neurologic injury. © 2019 Association of Anaesthetists.We report the use of a sacral plexus catheter for continuous local anaesthetic infusion in a patient with a unilateral sacral ala fracture following a fall from a horse. Although sacral plexus blockade has been well described for lower limb surgery, an ultrasound-guided continuous catheter technique for conservatively managed fractures has not been described. Despite appropriate oral analgesia, the patient reported severe pain, particularly in the right gluteal region, which meant she was unable to sit upright or take deep breaths. A sacral plexus catheter was inserted with ultrasound guidance and an initial bolus of 30 ml levobupivicaine 0.25% was delivered followed by infusion of 8 ml.h-1 levobupivicaine 0.125%. Daily follow-up and assessment were provided by the acute pain team. We judged the procedure to be a success as measured by an improvement in mobilisation, deep breathing, cough and patient satisfaction. © 2019 Association of Anaesthetists.McArdle disease (glycogen storage disease type V) is a rare, autosomal recessive disorder with an incidence of roughly 1100,000. Despite concern that labour could predispose these patients to muscle damage, there are no evidence-based guidelines for the management of labour and delivery in this population. We describe the case of a nulliparous parturient with both McArdle disease and adenosine monophosphate deaminase 1 deficiency who developed rhabdomyolysis after vaginal delivery. In the absence of common triggers, we believe that prolonged pushing efforts contributed to the increase in postpartum creatinine kinase. There are no previous cases of postpartum rhabdomyolysis after caesarean or assisted vaginal delivery within 45 min. We recommend that practitioners be alert to the possibility of rhabdomyolysis occurring with greater than 2 h of pushing efforts in parturients with McArdle disease. © 2019 Association of Anaesthetists.Patients undergoing subglottic airway surgery present a challenge to both anaesthetist and surgeon, and often a balance between surgical access and method of ventilation has to be struck. We report a case in which a 38-year-old female with a large mediastinal mass causing distal tracheal obstruction underwent tracheal laser resection. In order to maintain oxygenation throughout she required simultaneous transnasal humidified rapid-insufflation ventilatory exchange, supraglottic high-frequency jet ventilation and suprastomal manual jet ventilation through her tracheostomy stoma. Where the use of one technique alone failed, the simultaneous use of all three maintained oxygenation and facilitated surgical access for the duration of the procedure. © 2019 Association of Anaesthetists.The ultrasound-guided midpoint transverse process to pleura block has been described as an alternative end-point for thoracic paravertebral blockade. Although originally described as a single-level block, midpoint transverse process to pleura blockade may cover more than one level when larger volumes of injectate are used. Moreover, a continuous catheter midpoint transverse process to pleura blockade technique was previously thought to be unfeasible. We report three cases where a midpoint transverse process to pleura continuous catheter technique was successfully used for postoperative analgesia following video-assisted thoracoscopic surgery. © 2019 Association of Anaesthetists.We describe the case of a 37-year-old normally fit and well man who presented to hospital with fever, lethargy and myalgia. He was found to have a creatine kinase level of over 1 million IU.l-1. He initially underwent fluid resuscitation, but despite this his renal function declined and he required continuous veno-venous haemodiafiltration. Subsequent testing revealed a positive viral swab for influenza A and that he was a carrier of sickle cell trait. see more We review the literature for previous reports describing this association and demonstrate the rarity of such a presentation. © 2019 Association of Anaesthetists.Premature ventricular contractions are common in the general population and are often seen during general anaesthesia. A high frequency of premature ventricular contractions may be associated with underlying left ventricular dysfunction. Premature ventricular contraction-induced cardiomyopathy is a rare disease and requires cardiologist input into peri-operative management. Medical and interventional management strategies may completely reverse the disease process. A 19-year-old man was scheduled for removal of tibial metalwork, due to chronic pain, and ventricular bigeminy was noted in the anaesthetic room before induction of anaesthesia. Surgery was postponed and he was later diagnosed with premature ventricular contraction-induced cardiomyopathy. Ventricular bigeminy noted before induction of anaesthesia may not always be benign. © 2019 Association of Anaesthetists.
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