Surgical decompression of an accessory bicipital aponeurosis associated with median neuropathy in the antecubital fossa: A case report

Background: Accessory muscles in the arm are well-known anatomical variants which have been hypothesized as sources of neurovascular compression syndromes. We report a rare presentation of neuropathy secondary to an accessory biceps aponeurosis causing compression of the median nerve in the antecubital fossa. Case Description: A 65-year-old man presented with a 5-year history of numbness and pain associated with arm flexion. Electromyography was normal and exam revealed mild weakness in the median nerve distribution; however, magnetic resonance imaging demonstrated an accessory biceps tendon overlaying the median nerve in the antecubital fossa. The patient underwent surgical decompression of the median nerve with detachment of the accessory tendon resulting in clinical improvement. Conclusion: Anomalous biceps musculature should be considered in the workup and treatment of proximal median neuropathy.

Republished: Manual reduction of a radial artery loop under direct fluoroscopic visualization

Transradial access has become increasingly used in neurointerventions because it reduces access site complications. However, radial artery anomalies can be difficult to navigate, often necessitating conversion to femoral access. We describe the case of a female patient in her early 70 s who underwent preoperative embolization of a carotid body tumor via right transradial access. Her radial angiogram demonstrated the presence of a radial artery loop which was successfully navigated with a triaxial system but would not spontaneously reduce even after the guide catheter was advanced into the subclavian artery. However, manual manipulation of the catheters in the antecubital fossa under direct fluoroscopic visualization reduced the loop allowing the procedure to continue transradially. Although a majority of radial loops can be traversed and reduced using standard techniques, this case demonstrates that manual reduction can be successful when other measures fail. We recommend attempting this method before converting the access site.

Manual reduction of a radial artery loop under direct fluoroscopic visualization

Transradial access (TRA) has become increasingly utilized in neurointerventions because it reduces access site complications. However, radial artery anomalies can be difficult to navigate, often necessitating conversion to femoral access. We describe the case of a female patient in her early 70s who underwent preoperative embolization of a carotid body tumor via right TRA. Her radial angiogram demonstrated the presence of a radial artery loop which was successfully navigated with a triaxial system but would not spontaneously reduce, even after the guide catheter was advanced into the subclavian artery. However, manual manipulation of the catheters in the antecubital fossa under direct fluoroscopic visualization reduced the loop, allowing the procedure to continue transradially. Although most radial loops can be traversed and reduced using standard techniques, this case demonstrates that manual reduction can be successful when other measures fail. We recommend attempting this method prior to converting the access site.

Assessment of Peripheral Intravenous Catheter Site in Oncologic Patients Receiving Chemotherapy: Delphi Technique

Background: A peripheral intravenous catheterization is performed for injecting therapeutic agents into the blood stream. However, it is not easily done in most cancer patients due to the abnormalities of blood vessels because of the repetition of intravenous insertion as well as toxicity of the chemotherapeutic agents. Objective: To study the proper venipuncture sites for chemotherapy in cancer patients. Materials and Methods: Using the Delphi technique, nine of the ten experts, with more than seven years of experience, volunteered to respond to the Likert rating questionnaires. Results: All participants accomplished the study without procedure-related problems. Items concerning peripheral intravenous assessment on the dorsum of hand, forearm, antecubital fossa, and upper arm on the first, second, and third round were 58.3%, 58.3%, 58.3% and 48.3%; 71.6%, 71.6%, 73.3%, and 60.0%; 78.3%, 75.0%, 76.6%, and 65.0%, respectively. Discussion: Veins located on the dorsum of hand were preferred in the first rank due to the facility to identify as well as to care, clean and control infection. This was followed by antecubital veins for its larger size, small risks of thrombophlebitis, and less irritation during chemotherapy, and veins at the forearm for its facilitating self-care management, as well as preventing dislodgement and occlusion. Conclusion: The dorsum of hand followed by the antecubital fossa, forearm and upper arm of the non-dominant hand were the favorable sites of venipuncture for all cancer patients. Keywords: Delphi Technique; Venipuncture sites; Chemotherapy

Case Report: An Atypical Erysipeloid Presentation of Cutaneous Leishmaniasis from the Hilly Region of Nepal

Cutaneous leishmaniasis, which is the most common form of leishmaniasis, classically presents as small erythematous papules and nodules that develop into ulcers with indurated, raised outer borders. However, lesions of cutaneous leishmaniasis can have pleomorphic and atypical presentations. The erysipeloid form is one of the rare, atypical presentations of cutaneous leishmaniasis. Reported is a case of a 58-year-old man from the hilly region of Nepal who presented with an atypical erythematous and edematous plaque over the left antecubital fossa. Cutaneous leishmaniasis was not considered as an initial diagnosis because of the atypical appearance of the lesion as well as his residence in the hilly region of Nepal. The diagnosis was made after detection of amastigotes on histopathological examination of a cutaneous biopsy specimen. There was complete regression of the lesion after treatment with oral miltefosine followed by oral fluconazole. Clinicians should be aware of atypical presentations of cutaneous leishmaniasis and it should be considered in the differential diagnosis, regardless of the presentation or geographic location.

Why we missed it? Computational analysis reveals distribution patterns of of Malassezia furfur, the etiological agent of Pityriasis versicolor, in skin metagenomes

Malassezia furfur is the main causative species in pityriasis versicolor infections and is now widely believed to be a part of the skin microbiota, yet it was systematically missed in the early skin metagenomic studies. Here, we curated a specific set of M. furfur sequences and used them to reanalyze publicly available skin metagenomes to computationally investigate the distribution of M. furfur and its relative abundance at different skin sites. To this end, we used BLASTN to match and align these marker genes to the selected metagenomic datasets and estimated M. furfur relative abundance as the number of BLASTN hits per million metagenomic reads. We found a relative enrichment of M. furfur in the retro auricular crease, the antecubital fossa, and the forehead. Among skin categories, sebaceous areas were the most significantly enriched in M. furfur, while in terms of exposure/occlusion, exposed areas had the highest abundance. This work will facilitate and allow the estimation and correction of past estimates of this important fungal species in shot gun metagenomic data sets.

Comparison of Serum Iron, Zinc, and Selenium Levels in Premenopausal and Postmenopausal Women in Ekpoma, Nigeria: A Descriptive Study

Background: Estrogen deficiency following menopause creates an imbalance in plasma micronutrient resulting in several degenerative pathological conditions, including hypertension, cardiovascular disease, osteoporosis, etc. Objectives: The present study was designed to compare zinc (Zn), iron (Fe), and selenium (Se) concentrations between premenopausal and postmenopausal women. Methods: In this descriptive study a total of 200 participants were classified into two groups of postmenopausal (age range: 46-75 years, served as experimental) and premenopausal (age range: 30-45 years, served as control). Each group consisted of 100 subjects. After obtaining informed consent from all participants, blood samples were collected from the antecubital fossa vein of each participant by venipuncture. The concentrations of Fe, Zn, and Se in each blood sample were determined using Atomic Absorption Spectrophotometer. Results: No significant difference (P>0.05) was observed in serum Fe (114.24 ± 26.79 µg/dL), Zn (83.11 ± 20.45 µg/dL), and Se (41.99 ± 9.78 µg/dL) levels between the control and experimental groups. However, serum Fe and Zn showed progressive significant (P=0.04, 0.03, respectively) increase with increasing postmenopausal age. Conversely, serum Se concentration decreased significantly (P=0.03) with increasing menopausal age. Conclusion: Although no significant difference was observed in serum levels of Fe, Zn, and Se between pre- and post-menopausal women, the progressive significant increase in the serum Fe and Zn levels as well as significant decrease in serum Se level with advancing post-menopausal age portend a great risk.