Endoscopic optic nerve decompression in traumatic optic neuropathy: our experience in a tertiary care centre

<p><strong>Background: </strong>Traumatic optic neuropathy (TON) a vision threatening disorder requires early diagnosis and prompt treatment. High dose steroid injections, optic nerve decompression or combined therapy are the available current treatment options. This study aims to determine the visual outcome with transnasal endoscopic optic nerve decompression in patients with TON having no improvement in vision despite high dose steroids.</p><p><strong>Methods:</strong> A prospective study was conducted at the department of ENT, government medical college Kozhikode; on patients who presented with loss of vision following history of trauma. All patients suspected of compressive optic neuropathy received injection methyl prednisolone (30 mg/kg/day) with assessment of vision and HRCT scan. Patients with deterioration or no improvement in vision despite high steroid therapy were taken up for trans-nasal endoscopic optic nerve decompression.</p><p><strong>Results:</strong> In our study 19 patients with TON underwent trans-nasal endoscopic optic nerve decompression. 11(57.9%) patients had improvement of vision, 7 (36.8%) patients had no improvement of vision and 1 (5.3%) patient had worsening of vision. The visual improvement was seen in 8 (80%) patients when treatment was initiated within 7 days and in only 3(33.3%) patients when treatment was initiated after 7 days. The visual acuity at presentation and time interval between trauma and intervention are factors that determine better visual outcomes.</p><p><strong>Conclusions:</strong> The decreased visual acuity in TON requires prompt treatment. High dose steroid must be started at once when it is suspected or diagnosed. The timely surgical intervention with trans-nasal endoscopic optic nerve decompression is a relatively safe and effective technique enabling better visual prognosis.</p>

Sudden Sensorineural Hearing Loss in a Hyperbaric Oxygen Chamber Employee Following Parotidectomy

Sudden sensorineural hearing loss (SSNHL) is uncommon and oftentimes idiopathic. We describe the unique presentation of SSNHL in an HBO chamber employee following a parotidectomy, whose chief complaint was otalgia and aural fullness during dives. She ultimately recovered completely due to timely diagnosis and a high-dose steroid taper.

The Impact of the "Super Coombs" Test on Patient Management and Outcomes at a Large Tertiary Care Center: A Retrospective Review

Background: The direct antiglobulin test (DAT) identifies the presence of immunoglobulins and complement on the surface of red blood cells and is used to differentiate immune from non-immune hemolysis. Standard DATs done by conventional methods, using anti-IgG or anti-C3 antihuman globulin (AHG) in tube or gel, are performed routinely by laboratories associated with hospital transfusion services. However, if the standard DAT is negative but a strong clinical suspicion for immune-mediated hemolysis remains, serologic testing at an immunohematology reference lab (IRL) can be performed. Subtle differences in reagents and technique in the IRL may identify red cell-bound antibodies missed at the local hospital-based laboratory. In addition, the clinician can request an enhanced DAT, colloquially referred to as a Super Coombs, as a send-out test. This test can detect antibodies that are not detected by standard methods and that have been reported to cause autoimmune hemolysis, namely IgG bound at low levels, low affinity IgG, and IgA. We conducted a retrospective review of enhanced DATs sent by hematologists at the University of Pittsburgh Medical Center and the Allegheny Health Network to an outside IRL to determine the incidence of new autoantibodies detected by the enhanced DAT and assessed the impact of these results on patient management. Methods: We retrospectively identified patients at our center on whom enhanced DATs were sent from January 2019 to January 2021. Demographic, laboratory, and clinical data were collected and analyzed. Results: Twenty one patients were identified as having enhanced DATs sent to one outside IRL during the two year period. The majority of patients had abnormal clinical laboratory markers of hemolysis (81% with an elevated lactate dehydrogenase, 90% with an undetectable haptoglobin) and a history of immune dysregulation (79%). About 2/3 of the patients had a hemoglobin nadir above 6 g/dL. The median number of DATs performed locally prior to requesting the enhanced DAT evaluation was 2 (5 th to 95 th percentile: 1 - 3). Four out of 21 patients (19%) had previously tested positive at the local IRL by conventional serologic methods and 17 (81%) had tested negative. Among the 21 patients, 7 (33%) had at least one positive test on the enhanced DAT battery, including 5 out of the 17 (29%) who had previously tested negative locally. In 5 out of those 7 patients who tested positive by enhanced methods, the positive tests included standard serologic test done by conventional means. The only specialty serologic tests that yielded positive results was testing done at 4 °C, meant to detect low affinity IgG. The mean (±SD) overall turnaround time from sample collection to receipt of the enhanced DAT results was 3.8 (±1.5) days, the bulk of which was transit time from the local hospital to the outside IRL (2.5 (±1.5) days). Empiric high-dose steroid therapy was started in 68% of the patients prior to receipt of the enhanced DAT results. The median time between the first DAT result at the local IRL and the initiation of high dose steroid therapy was 1.5 (5 th to 95 th percentile: 0 - 12.5) days, while the median time from steroid initiation to the time the enhanced DAT was ordered was 5 (5 th to 95 th percentile: 1-256) days. Four patients were diagnosed with DAT-negative autoimmune hemolytic anemia based on response to steroids, whether complete (Hb ≥ 12 g/dL and normalization of LDH and haptoglobin) or partial (Hb improvement by 2 g/dL and no transfusion requirement), despite negative local and enhanced DAT results (table 1). Patients who had self-limited (2 patients) or subacute, non-severe anemia (5 patients) did not undergo a steroid trial and were diagnosed by non-serologic testing, specifically peripheral blood flow cytometry or bone marrow biopsy. Conclusions: The tests that most often yielded positive results on the enhanced DAT were standard serologic tests, suggesting that differences in timing of sample collection or technique may have explained result disparity between the local and outside IRL. Specialty testing done at 4 °C detects low affinity IgG antibodies bound to red cells, but the clinical significance of these antibodies is unclear. The majority of patients in our cohort underwent an empiric trial of high dose steroids prior to receipt of the enhanced DAT results. For these patients, the response to steroids was the deciding factor in AIHA diagnosis rather than the enhanced DAT results. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Meta-analysis of the Effectiveness of Steroid Pulse Therapy in Treating Patients with Spinal Cord Injury

Background: High-dose steroid injection therapy is effective in reducing anti-inflammation and edema and is often used to treat patients with acute spinal cord injury. To evaluate the effectiveness of steroid pulse therapy and identify the factors that affect its effectiveness in patients with acute traumatic spinal cord injury. Methods: A comprehensive literature search of the databases Pubmed, Medline, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL was performed on July 31, 2019, with no language and time limits. For analysis, studies conducted within the last 10 years were included to reflect on the recent trend. Results: A total of 3 randomized controlled trials and 5 observational studies with 2418 patients were included in this meta-analysis. High-dose steroid injection therapy was found to have a high effect on patients with acute spinal cord injury. The following factors had a strong influence on the effectiveness of high-dose steroid treatment in patients with acute spinal cord injuries: injury, onset ASIA, onset neurological assessment scales, time to start treatment after injury, age, BMI, and gender. Conclusion: It is necessary to accurately assess the scope of spinal injury in the early stages and actively provide nursing interventions to identify and mediate factors affecting the treatment effect.

The role of high-dose steroid therapy in Covid-19 pneumonia

Introduction: Today, whereas hypoxemia and respiratory failure is the major challenging problem in the course of severe COVID-19 pneumonia, to control the disease at a mild-moderate stage or to stop the inflammation by recognizing the cytokine storm early should be the most prominent goal. We aimed to reveal the clinical efficacy and safety of short-term high-dose corticosteroids in severe COVID-19. Material and Methods: This retrospective observational study consisted of 54 patients who were given high-dose steroid (HDS (>250 mg/day methylprednisolone, 3 days.). Low-dose steroid (LDS) therapy (dexamethasone 8 mg ) was applied to all patients. HDS group was reviewed in terms of decreasing hospital mortality and preventing fibrosis development in follow-up. Results: During the observation period, out of 317 severe COVID-19 pneumonia hospitalized, HDS and LDS were administered to 54 and 216 patients, respectively. Higher body mass index, younger age, more oxygen need of patients at admission, and more need for advanced oxygen therapy during hospitalization were found in the HDS group (p<0.001). Furthermore, 18.5% of patients in the HDS group had need transfer to the intensive care unit whereas it was 3.8% in LDS (p<0.001). Additionally, the mortality rate was determined higher in the HDS group (25. 9% vs 9.9%, p<0.001). The HDS group had lower saturated O2 [IQR, 85% (76-89), p <0.001], and higher ferritin at admission. It was found that HDS was given simultaneously with the increased ferritin with deepening lymphopenia on the third and fifth days. There was no difference in fibrosis development between HDS patients receive and not (15.4% vs 26.2%, p=0.11) Conclusion: The use of HDS in hospitalized COVID-19 patients remains unclear. Along with this, our study demonstrated the use of high-dose corticosteroids might not be associated with a lower mortality rate among hospitalized severe COVID-19 patients.

Immediate and Short-term Outcome of Acute Disseminated Encephalomyelitis (ADEM) after corticosteroid therapy

Background : Acute disseminated encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system (CNS) occurring predominantly but not exclusively in children. The presence of severe disturbance of consciousness together with multifocal neurological symptoms and signs especially in a child under 10 years of age; favours a diagnosis of ADEM. Neuroimaging is essential investigation for establishing the diagnosis of ADEM. High-dose steroid treatment frequently results in a dramatic clinical improvement. Objective: This study aimed to describe our experience with Acute Disseminated Encephalomyelitis (ADEM) focusing on the clinical features, neuroimaging, and outcome after treatment with high-dose steroid. Method: This retrospective observational study was conducted in children who were admitted as inpatients in Paediatric Neurosciences Department of Dhaka Shishu Hospital (DSH) with the diagnosis of ADEM during the period of 2017- 2019. All patients got high dose IV methylprednisolone for 5 days followed by 2 weeks tapering dose of steroid. Outcome was observed on the 7th day of treatment and 6 months after discharge from hospital. Result: A total of 16 patients who were diagnosed as ADEM were included in this study. Twelve children (75%) had a recent upper respiratory tract illness. Patients presented most often with motor deficits (88%) and secondly with altered consciousness (63% ) followed by seizure ( 50% ). MRI brain was the preferable neuroimaging which mostly (41.7%) showed multifocal symmetrical demyelination patch. On the 7th day of steroid treatment, significant improvement in motor function and level of consciousness occurred (p values were 0.001% and 0.014% respectively). After 6 months of discharge from hospital; no motor deficit, age-appropriate cognitive level and no seizure in 71%, 57% and 71% respectively. Conclusion: High dose corticosteroid treatment in ADEM is significantly effective in improvement of motor impairment and consciousness level on immediate follow up. Northern International Medical College Journal Vol.11 (2) Jan 2020: 468-470

Necrotizing myopathy presenting as congestive heart failure and life-threatening ventricular arrhythmias: a case report

Background Necrotizing autoimmune myopathy is a rare subtype of idiopathic inflammatory myopathy; however, it can be associated with fatal cardiac manifestations. Case summary A 58-year-old female patient was referred for congestive heart failure with dysrhythmia. Electrocardiograms showed ventricular arrhythmias of various QRS complex morphologies and coupling intervals with beat-to-beat differences. Despite optimal medical therapy for heart failure, the patient was admitted for the progression of dyspnoea and generalized motor weakness. The burden of non-sustained ventricular tachycardia gradually increased, and ventricular fibrillation eventually occurred. In view of a differential diagnosis of an inflammatory myocardial diseases such as sarcoidosis, a cardiac biopsy was performed. However, pathologic examinations revealed only necrotic muscle fibres without granuloma. Further examinations revealed proximal dominant motor weakness, an elevated serum creatinine-phosphokinase level, myogenic potentials on needle electromyography, and biceps muscle biopsy findings that were compatible with necrotizing autoimmune myopathy. High-dose steroid therapy improved the patient’s motor weakness, including her respiratory impairment, and successfully suppressed ventricular arrhythmias. Discussion This case suggests that intensive immunosuppressive therapy with high-dose steroid could be useful in the necrotizing autoimmune myopathy manifested as congestive heart failure and life-threatening ventricular arrhythmias.

Lupus Pneumonitis Therapy Masks Coronavirus (COVID-19)

Introduction. Coronavirus pneumonitis can mimic, or present as, lupus pneumonitis. Lupus may cause inflammation of the myocardium. Lupus pneumonitis high-dose steroid therapy may mask coronavirus (COVID-19). Case Study. The patient is a 65 y/o Hispanic female with lupus pneumonitis complicated by COVID-19. Her diagnosis was confirmed by a renal biopsy. She had nephritic and nephrotic syndrome. She was hospitalized a month earlier with shortness of breath with pulmonary infiltrates and was treated with steroids. The symptoms resolved quickly with shrinking consolidations and infiltrates. The patient returned to the office for shortness of breath with a presumptive diagnosis of recurrent lupus pneumonitis from steroid taper. The patient had a CT scan of the chest that revealed upper lobe interstitial and peripheral infiltrates. The radiologist felt that this was suspicious for coronavirus pneumonitis, and the patient was placed in isolation and continued therapy for lupus pneumonitis. She deteriorated, became hypoxic, and ventilated. Conclusion. All lupus pneumonitis patients, in fact all lupus patients in general (personal experience), on high-dose steroid therapy should be tested for COVID-19 to ensure proper diagnosis and therapy planning.