Acromegaly is a rare syndrome in which there is unregulated hypersecretion of growth hormone. The anesthetic management of patients with this disorder is particularly challenging due to pre-existing ...cardiovascular and respiratory dysfunction, as well as recognized difficulties with airway management. Because of the insidious progression of the disease and the presence of nonspecific signs and symptoms, diagnosis is often made late when characteristic acromegalic features become apparent.
We report the management of a 35-year-old African American man with previously undiagnosed acromegaly, who underwent a general anesthetic for same day surgery. Subtle physical features and difficult endotracheal intubation raised our suspicion for the diagnosis of acromegaly. Following an uncomplicated postoperative course he underwent workup for the disease, which was confirmed. In addition, brain magnetic resonance imaging showed a pituitary adenoma. A subsequent transsphenoidal hypophysectomy was performed successfully.
This case underscores the notable absence of recognizing the clinical presentation of acromegaly in this patient by his primary care physician, and the value of thorough history taking, vigilance, and observation in making a new diagnosis that has the potential to alter a patient's health care and mitigate impending morbidity and/or mortality.
•Agglomeration of oil powders is proposed to improve their functional characteristics.•Agglomerates demonstrate free-flowing and good reconstitutability in water.•Encapsulation efficiency of oil ...decreases after the agglomeration.•Application of trehalose in agglomeration increases the oxidative stability of microencapsulated oil.•Application of trehalose determines high hygroscopicity of material and its susceptibility to caking.
Sunflower oil has been microencapsulated by spray drying method in the matrix with trehalose and whey protein isolate (WPI) or sodium caseinate (NaCas). The obtained preparations have been subjected to wet fluidized-bed agglomeration with the use of trehalose and polyvinylpyrrolidone (PVP). Agglomeration of fine powders, irrespective of the wetting liquid, enabled obtaining a free-flowing product easily reconstitutable in water. Encapsulation efficiency of oil reached up to 96% and 99% in powder with WPI and NaCas respectively, whereas it decreased to 90–96% after the agglomeration, on account of insufficient agglomerate strength. The lower level of oil oxidation was observed for the agglomerate preparations, especially the agglomerate obtained with the use of the trehalose solution as a wetting liquid. The impact of agglomeration was reflected in a significant decrease of the level of adsorbed water, being sufficient to initiate the transition of amorphous trehalose to the crystalline state.
We undertook a prospective laboratory study to examine the effect of head position on the relative positions of the carotid artery and the internal jugular vein (IJV).Volunteers (n = 12) from ...departmental staff, 18-60 yr of age, who had never undergone cannulation of the IJV underwent imaging of their IJV and carotid artery. With the subject in a 15 degrees Trendelenburg position, two-dimensional ultrasound images of the IJV and the carotid artery were obtained on the left and right sides of the neck at 2 and 4 cm from the clavicle along the lateral border of the sternal head of the sternocleidomastoid muscle at 0 degrees, 40 degrees, and 80 degrees of head rotation from the midline. The percent overlap of the carotid artery and IJV increased significantly at 40 degrees and 80 degrees head rotation to both the right and left (P < 0.05). Data from 2 and 4 cm above the clavicle did not differ and were pooled. The percent overlap was larger on the left than the right only with 80 degrees of head rotation (P < 0.05). The increased overlap of carotid artery and IJV with head rotation >40 degrees increases the risk of inadvertent puncture of the carotid artery associated with the common occurrence of transfixion of the IJV before it is identified during needle withdrawal. The IJV frequently collapses with needle insertion. This may result in puncture of the posterior wall of the vessel, and thus of the carotid artery when the two vessels overlap. To decrease this risk, the head should be kept in as neutral a position as possible, that is <40 degrees rotation, during IJV cannulation.(Anesth Analg 1996;82:125-8)
Despite clinical and genetic similarities, myotonic dystrophy type 1 (DM1) and type 2 (DM2) are distinct disorders requiring different diagnostic and management strategies. Although the standard ...quantitative EMG is useful in diagnosis of myotonic syndromes, it does not differentiate between DM1 and DM2. Other electrophysiological methods such as the short exercise test (SET) and the short exercise test with cooling (SETC), which seem to be more sensitive, have recently been recommended in DM1/DM2 differentiating diagnosis. The aim of our study was to analyze the results of SET/SETC in myotonic dystrophies and to estimate their usefulness in differentiating between DM1 and DM2. Material and method: 60 patients with genetically proven myotonic dystrophy: 32 patients with DM1, (mean age 35.8 ± 12.7yrs) and 28 patients with DM2 (mean age 44.5 ± 12.5 yrs). For every patient a short exercise test (SET) and short exercise test with cooling (SETC) were performed. Results: In DM1 with SET as well as with SETC a significant decline of compound motor action potential (CMAP) amplitude immediately after effort was observed (mean value CMAP amplitude decline was about 20%). In DM2 there was no marked change of CMAP amplitude with either SET or SETC. Conclusions: Electrophysiological tests such as the short exercise test and short exercise test with cooling, may serve as useful tools for differentiating between DM1 and DM2 and in clinical practice as a guide for molecular testing. In contrast to DM2, in DM1 a marked decline of CMAP amplitude was observed in SET as well as in SETC. The mechanism of these opposites remains unclear. Hypothetically the different pattern of response to SET/SETC in DM1 and DM2 could be explained by multifactorial disabilities of muscle ion channels of different intensity in these two diseases.
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