Should intraoperative nerve monitoring be used routinely in primary thyroid surgeries?

Objective: This study presents the effects of intraoperative nerve monitoring on RLN injuries in patients who underwent primary surgery for benign thyroid pathology. Methods: We retrospectively evaluated the data of 273 patients who had primary thyroidectomy due to benign thyroid pathology between January 2012 and July 2017. The patients were classified into two groups. Group-1 consists of patients whose nerves were monitored. We separated the patients whose nerves were not monitored into Group-2. Results: There were 140 and 133 patients in Groups 1 and 2, respectively. Regarding the age, gender and surgical indication between the groups, statistically significant difference was not found (P > 0.05). In Group-1, transient paralysis developed in four patients (2.9%). The permanent paralysis developed in one patient (0.7%). In Group-2, transient paralysis developed in nine patients (6.8%). The permanent paralysis developed in four patients (3%). When the groups were evaluated, there was statistically significant difference in terms of transient and permanent paralysis (P=0.01, P =0.001, respectively). Conclusions: In view of the negative effects of RLN injury on the patient, we think that intraoperative nerve monitoring should be used routinely in benign thyroid surgeries. doi: https://doi.org/10.12669/pjms.36.2.1054 How to cite this:Akici M, Cilekar M, Yilmaz S, Arikan Y. Should intraoperative nerve monitoring be used routinely in primary thyroid surgeries? Pak J Med Sci. 2020;36(2):---------. doi: https://doi.org/10.12669/pjms.36.2.1054 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

43 Tinnitus as an Aura for Sleep Paralysis

ObjectiveTo understand that tinnitus may be an aura for sleep paralysis.BackgroundSleep paralysis is a transient-paralysis which occurs during awakening or falling asleep (Wilson, 1928). Those affected experience symptoms including visual, auditory, and haptic hallucinations, voluntary motor paralysis with intact ocular and respiratory motor movements, and diffuse or localized paresthesias. Sleep paralysis associated with tinnitus as an aura, has not heretofore been described.MethodsA 34 year-old, right-handed female presented with a 13 year history of sleep paralysis. One month prior, she began to notice tinnitus prior to the onset of sleep paralysis. The tinnitus was bilateral, high-pitched, with a volume intensity of 5/10, lasting seven seconds prior to sleep initiation. She denied hearing loss, vertigo, dizziness, cataplexy, deja vu and jamais vu. After termination of tinnitus, she experienced paresthesia, “like at a dentist’s office” radiating from her posterior neck, to her tongue and down to her toes. She described seeing a white-shadowy male figure moving around her room, lasting seven seconds. Accompanied by a masculine “ahh” sound, lasting for three seconds. The sleep paralysis occurred after these events, lasting up to eight hours, or until her husband wakes her.ResultsAbnormalities in Physical Examination: General Examination: right arm hemangioma 4 by 5cm. Reflexes: absent bilateral brachioradialis, 1+ bilateral quadriceps femoris and bilateral Achilles tendon. Neuropsychiatric Examination: Calibrated Finger Rub Auditory Screening Test: faint 70 AU (normal).DiscussionTinnitus has been described as an aura for migraines (Schankin, 2014), temporal lobe epilepsy (TLE) (Florindo, 2006), and narcolepsy-cataplexy (Marco, 1978). These epochs may represent amigranous migraines, which initially present with tinnitus that occurs both during the day and night, forcing the patient to be partially awoken at night with induction of the sleep paralysis sequence. It would be worthwhile to query those with narcolepsy or sleep paralysis if tinnitus precedes the event.

Host acceptance by three native braconid parasitoid species attacking larvae of the Mexican fruit fly, Anastrepha ludens (Diptera, Tephritidae)

We studied the oviposition and host acceptance behavior of three braconid parasitoid species native to Mexico, Doryctobraconcrawfordi (Viereck), Opiushirtus (Fischer), and Utetesanastrephae (Viereck), with potential to be considered as biocontrol agents against tephritid fruit fly pests in the Neotropics. Third instar larvae of Anastrephaludens (Loew), with and without previous parasitization by conspecifics, were simultaneously offered to females of each species, and the individual behavior was video recorded to construct oviposition flow diagrams. The patterns of foraging and host acceptance were similar in the studied species; all rejected mostly parasitized hosts suggesting that this strategy is common in the guild of larval parasitoids attacking Anastrepha spp. The complete searching and host acceptance process took 2.2 ± 0.1 min (mean ± SE) in D.crawfordi, 1.7 ± 0.1 s in U.anastrephae and 1.5 ± 0.1 s in O.hirtus. Notably, because of toxins injected by parasitoid females during oviposition, the parasitized hosts experienced a transient paralysis of variable duration. Hosts attacked by U.anastrephae remained immobile for the shortest time (12.5 ± 1 min) (mean±SE), followed by D.crawfordi (20.5 ± 3.4 min) and O.hirtus (24.1 ± 2 min). Our data revealed a notable discrimination ability in all three species, and that behavioral differences lay mainly in the time of parasitization and in the duration of paralysis experienced by attacked hosts. This suggest that the three species could be valuable as biocontrol agents, but additional studies are necessary to better understand the advantages and limitations of each one as natural enemies of fruit fly pests.

Stabbing Yourself in the Heart: A Case of Autoimmunity Gone Awry

Within internal medicine, cardiac and neurologic pathology comprises a vast majority of patient complaints. Physicians and advanced-care practitioners must be highly educated and comfortable in the evaluation, diagnosis, and management of these entities. Chest pain accounts for millions of annual visits to the emergency room with pericarditis diagnosed in approximately four percent of patients with nonischemic chest pain. Guillain-Barre Syndrome is autoimmune polyneuropathy that often results in transient paralysis. Simultaneous diagnosis of both entities is a rare but described phenomenon. Here, we present a clinical case of GBS associated pericarditis. A fifty-five-year-old man with history of renal transplant presented with lower extremity weakness and urinary incontinence. Physical exam and diagnostic studies confirmed Guillain-Barre Syndrome. Patient subsequently developed stabbing chest pain with clinical presentation and electrocardiogram consistent with pericarditis. The patient was successfully treated for both diseases. This case highlights that although infrequent, internal medicine care providers must be cognizant of this correlation to ensure timely diagnosis and treatment.