Cases with combined facial nerve and trigeminal nerve involvement do
present with complex issues as elucidated by Allevi et al (1) . This
article helped us immensely in managing our case and we are grateful to
the authors and the journal.
A male patient suffering from fifth nerve and seventh nerve palsy
presented to us with similar issues with severely vascularised
hypertrophic insensitive bulging cornea with...
Cases with combined facial nerve and trigeminal nerve involvement do
present with complex issues as elucidated by Allevi et al (1) . This
article helped us immensely in managing our case and we are grateful to
the authors and the journal.
A male patient suffering from fifth nerve and seventh nerve palsy
presented to us with similar issues with severely vascularised
hypertrophic insensitive bulging cornea with zero corneal sensations on
anaesthesiometer .
Leyngold et al (2) (3) suggested endoscopic approach with scalp
incision and Bains et al (4) suggested a microincision approach.We
combined these approaches and did a corneal trasplant as well, as we had
no option since the cornea would otherwise perforate
The facial palsy was treated with gold weight implant and corneal
insensitivity with reinnervation and opacity with keratoplasty. Corneal
reinnervation was done with a different combined approach and we did a
small microincision surgery with endoscopical help , but did not take the
scalp incision and instead anastomoses was done on one side with the
contralateral supraorbital and supratrochlear nerve and the other end of
the sural nerve graft was tunnelled from contralateral side to the
ipsilateral side ,along the line connecting the eyebrows on either side
,and then across the ipsilateral eyelid , between the gold weight implant
and the medial horn of leavator palpebrea superioris and then tunnelled
subconjunctival as well as subtenons and after being dissected into
fascicles , the fascicles were inserted into four scleral tunnels and
sutured intrascleral. We got good short term result at two months and
corneal sensations have returned and we await long term results before
publishing the case . But in the interim we realised that we did see some
findings which could help others in the interim , like we were helped by
this article .
The corneal vascularisation reduced markedly as the corneal nerves
started growing and sensations returned ad the patient started feeling the
eyedrops and actual complained of pain !The palisades of Vogt thickened
and pigmentation was seen migrating into the cornea and corneal
vascularisation was seen reduced significantly in areas where the
pigmentation advanced into the cornea . There was no ptosis which we had
expected since we thought the levator would be damaged during the
procedure.
Corneal innervation is known to be necessary to maintain stemness of
stem cells and in the cornea nerves and neovessels are hypothesised to
inhibit each other (5) but we saw this clinically with areas of corneal
vascularisation disappearing as the corneal nerves grew and sensations
returned.
We thank all authors for the techiniques and would want to point out
that journals like British Journal of Case Report with its open access
policy and speedy publication of recent advances , need to be applauded
for such articles which help us in the developing countries help our poor
patients with the latest advances as soon as they occur.
References :-
1) Allevi F, Fogagnolo P, Rossetti L, Biglioli F. Eyelid reanimation,
neurotisation, and transplantation of the cornea in a patient with facial
palsy. BMJ Case Reports. 2014;2014:bcr2014205372. doi:10.1136/bcr-2014-
205372.
2) Leyngold I, Weller C, Leyngold M, Espana E, Black KD, Hall KL, Tabor
M.Endoscopic Corneal Neurotization: Cadaver Feasibility Study. Ophthal
Plast Reconstr Surg. 2017 May 2. doi: 10.1097/IOP.0000000000000913.
3) Leyngold I, Weller C, Leyngold M, Tabor M. Endoscopic Corneal
Neurotization:Technique and Initial Experience. Ophthal Plast Reconstr
Surg. 2017 Nov 27. doi: 10.1097/IOP.0000000000001023
4) Bains RD, Elbaz U, Zuker RM, Ali A, Borschel GH. Corneal neurotization
from the supratrochlear nerve with sural nerve grafts: a minimally
invasive approach. Plast Reconstr Surg. 2015 Feb;135(2):397e-400e.
doi:10.1097/PRS.0000000000000994.
5) Ferrari G, Hajrasouliha AR, Sadrai Z, Ueno H, Chauhan SK, Dana R.
Nerves and neovessels inhibit each other in the cornea. Invest Ophthalmol
Vis Sci. 2013 Jan 28;54(1):813-20. doi: 10.1167/iovs.11-8379.
Sir,
Its with interest that I read the small and crisp description and medical
images related to Artery of Percheron infarct.
The diagnosis of this condition indeed is sometimes difficult and
requires clinical suspicion accompanied by proper radiological imaging.
What i would also like to highlight is the fact that its not only the
imaging modality i.e MRI which is required,or the sequence DWI/ADC which
is also important, the imaging machinery should also be optimal i.e a
magnetic strength of at least 1.5 tesla or higher.
I emphasize this point because many MRI machines in the Indian
context are suboptimally designed to pick up these important but often
small lesions and prescribing physicians often donot have the proper
knowledge and thus fail to arrive at a proper diagnosis.
Thanks and regards,
Dr Deep Das
Consultant Interventional Neurology
Kolkata, West Bengal,
India
I would like to congratulate and thank you for taking the courage in
publishing this case report for the benefit of the neonatal trainees and
all neonatologist in general. I am not surprised that there aren't more
case reports published as such cases tend not be published because of
general feeling of guilt for negligence and not exposing the hospital for
fear of bad name as the outcome is very poor as you rightly poi...
I would like to congratulate and thank you for taking the courage in
publishing this case report for the benefit of the neonatal trainees and
all neonatologist in general. I am not surprised that there aren't more
case reports published as such cases tend not be published because of
general feeling of guilt for negligence and not exposing the hospital for
fear of bad name as the outcome is very poor as you rightly pointed out. I
am personally aware of few such incidents from different hospitals though
not directly involved in the care .Also because of the poor outcome and
distress which these incidents cause to the family there is reluctance
to get consent .
Health industry is a risky business and specially in the neonatal units
due to our heroic efforts to save the tiny babies unavoidable
complications can occur.There is also an incessant desire to succeed in
performing procedures on the part of the junior doctors, so more than
acceptable attempts are seen in general to be made with different
procedures like intubations , long line insertions,umbilical
catheterizations etc, which increase the chances of undesirable
outcomes. This can be witnessed in all the units from time to time which
increase the chances of undesirable outcomes and if the doctors share
such experiences then the wider doctor's community can benefit from other
people's experiences in reducing the incidences of undesirable outcomes
and thus help the babies /patients ultimately with a more positive
experience .
We read with interest the case report concerning a transient global
amnesia (TGA) in an individual who was previously submitted to a session
of whole body cryotherapy (WBC).1
The scientific literature is already sufficiently wide to realize
that the WBC is a safe procedure, while it could seem apparently dangerous
due to very low temperature of the air used in the chambers during
treatment...
We read with interest the case report concerning a transient global
amnesia (TGA) in an individual who was previously submitted to a session
of whole body cryotherapy (WBC).1
The scientific literature is already sufficiently wide to realize
that the WBC is a safe procedure, while it could seem apparently dangerous
due to very low temperature of the air used in the chambers during
treatment.2 Only burns owing to sweat or water traces are reported as
adverse events, considering some pathological, universally accepted,
conditions as exclusion criteria for the treatment.3-9
It is possible that some rare adverse events are neither known nor
described in literature, thus possible pathological modifications of
metabolism or behaviour can be important. However, in the case report,1 in
order to build on a robust hypothesis about WBC-induced TGA, we believe
that additional findings are needed. The patient previously underwent to
WBC, thus the direct cause-effect relationship is in doubt; we outline
that a standard treatment is based on two or three weeks (10-15 sessions).
Moreover, the type of treatment should be more deeply detailed: was that a
classical cryochamber doing a whole-body treatment or, instead, a
cryosauna which is used to treat the body but the head; in the latter case
the nitrogen could partially escape possibly causing nervous symptoms.
The anamnestic evaluation lacks of drugs eventually taken by the
individual and of mental reactivity and cognition evaluation, in order to
exclude early sign of cognitive impairment due to Alzheimer or similar
diseases. Furthermore, since the speculative association between WBC and
TGA, it should be also taken into account the possible side effects (i.e.,
amnesia) of the proton pump inhibitors (PPI, e.g., omeprazole), taken by
the patient, which were previously reported by Fireman et al.10 More
recently, Feng et al. also reported about the psychotic symptoms of
dissociative disorder, including amnesia, in a patient treated with
clarithromycin and the PPI rabeprazole.11 Hence, if cold could be a risk
factor for TGA, as reported by the authors,1 also the PPI use cannot be
excluded as a potential trigger.
The description of the case is important to outline the impact of WBC
on nervous system, since this procedure is now indicated for the
symptomatic treatment of nervous and psychiatric disorders, after the
successful symptomatic treatment of chronic inflammatory ones.12,13
However, care should be taken in associating this universally considered
safe procedure with possibly spurious, and not surely associated, adverse
events.
References
1. Carrad J, Lambert AC, Genn? D. Transient global amnesia following
a whole-body cryotherapy session. BMJ Case Rep. Epub Aehad of Print. doi:
10.1136/bcr-2017-221431
2. Lombardi G, Ziemann E, Banfi G. Whole-Body Cryotherapy in
Athletes: From Therapy to Stimulation. An Updated Review of the
Literature. Front Physiol 2017;8:258. doi:10.3389/fphys.2017.00258
3. Cholewka A, Stanek A, Sieron A, Drzazga Z. Thermography study of
skin response due to whole-body cryotherapy. Skin Res Technol
2012;18(2):180-7. doi:10.1111/j.1600-0846.2011.00550.x
4. Hausswirth C, Schaal K, Le Meur Y, et al. Parasympathetic activity
and blood catecholamine responses following a single partial-body
cryostimulation and a whole-body cryostimulation. PloS One
2013;8(8):e72658. doi:10.1371/journal.pone.0072658
5. Demoulin C, Vanderthommen M. Cryotherapy in rheumatic diseases.
Joint Bone Spine 2012;79(2):117-8. doi:10.1016/j.jbspin.2011.09.016
6. Louis J, Schaal K, Bieuzen F, et al. Head Exposure to Cold during
Whole-Body Cryostimulation: Influence on Thermal Response and Autonomic
Modulation. PloS One 2015;10(4):e0124776. doi:10.1371/journal.pone.0124776
7. Pournot H, Bieuzen F, Louis J, et al. Time-course of changes in
inflammatory response after whole-body cryotherapy multi exposures
following severe exercise. PloS One 2011;6(7):e22748.
doi:10.1371/journal.pone.0022748
8. Kruger M, de Marees M, Dittmar KH, et al. Whole-body cryotherapy's
enhancement of acute recovery of running performance in well-trained
athletes. Int J Sport Physiol Perform 2015;10(5):605-12.
doi:10.1123/ijspp.2014-0392
9. Schaal K, Le Meur Y, Louis J, et al. Whole-Body Cryostimulation
Limits Overreaching in Elite Synchronized Swimmers. Med Sci Sports Exerc
2015;47(7):1416-25. doi:10.1249/MSS.0000000000000546
10. Fireman Z, Kopelman Y, Sternberg A. Central nervous system side
effects after proton pump inhibitor treatment. J Clin Gastroenterol
1997;25(4):718.
11. Feng Z, Huang J, Xu Y, et al. Dissociative disorder induced by
clarithromycin combined with rabeprazole in a patient with gastritis. J
Int Med Res 2013;41(1):239-43. doi: 10.1177/0300060513475384.
12. Bettoni L, Bonomi FG, Zani V, et al. Effects of 15 consecutive
cryotherapy sessions on the clinical output of fibromyalgic patients. Clin
Rheumatol 2013;32(9):1337-45. doi: 10.1007/s10067-013-2280-9.
13. Bouzigon R, Grappe F, Ravier G, Dugue B. Whole- and partial-body
cryostimulation/cryotherapy: Current technologies and practical
applications. J Therm Biol. 2016;61:67-81. doi:
10.1016/j.jtherbio.2016.08.009.
I read with interest the case report about a fatal case of
neurocysticercosis. I want to emphasize that deaths are rare in
neurocysticercosis and in neurocysticercosis there is no malignant course.
Lesion load seems to be quite low. In fact the patient not fully worked up
for more likely diagnosis. For example miliary tuberculosis and miliary
secondary malignancy. The CSF should have examined for malignant cells and
Mycoba...
I read with interest the case report about a fatal case of
neurocysticercosis. I want to emphasize that deaths are rare in
neurocysticercosis and in neurocysticercosis there is no malignant course.
Lesion load seems to be quite low. In fact the patient not fully worked up
for more likely diagnosis. For example miliary tuberculosis and miliary
secondary malignancy. The CSF should have examined for malignant cells and
Mycobacterium tuberculosis. X-ray chest would have revealed miliary
lesions in lungs as well. Multiple tiny parenchymal rim-enhancing lesions
are characteristically not seen in neurocysticercosis.
Another point I want to mention is that neurocysticercosis can not
occur via direct consumption of infected pork because a human is a
definitive host and pork consumption will produce adult worms in human
intestine. It will not lead to larval spread to brain.
I wonder whether that plastic toy could be spotted in the CT images
by a reader who has been informed about it. Did the radiology department
comment about this?
I am pretty shure the cone cannot be detected on a plain x-ray. The
ABS polymer used by toy manufacturers like Playmobile or Lego seems to
have x-ray attenuation properties very near to human tissue (Saps et al.,
World J Clin Pediatr 201...
I wonder whether that plastic toy could be spotted in the CT images
by a reader who has been informed about it. Did the radiology department
comment about this?
I am pretty shure the cone cannot be detected on a plain x-ray. The
ABS polymer used by toy manufacturers like Playmobile or Lego seems to
have x-ray attenuation properties very near to human tissue (Saps et al.,
World J Clin Pediatr 2014, PMC4173203).
Dear Sir,
We read with great interest the case report by Dattani and Jackson
detailing a case of potential cardioembolic stroke in a young man with
sickle cell anemia (SCA), without significant cerebral vasculopathy but
with PFO. We have conducted a controlled clinical study to determine
the prevalence of potential left-to-right shunting (intracardiac or
intrapulmonary) in children with SCA and overt clinical stroke...
Dear Sir,
We read with great interest the case report by Dattani and Jackson
detailing a case of potential cardioembolic stroke in a young man with
sickle cell anemia (SCA), without significant cerebral vasculopathy but
with PFO. We have conducted a controlled clinical study to determine
the prevalence of potential left-to-right shunting (intracardiac or
intrapulmonary) in children with SCA and overt clinical stroke using
contrasted echocardiography in 147 children with SCA +overt stroke and a
control group of 123 children without SCA or stroke. Right-to-left
shunting was defined as any potential shunting detected by any method
(conventional 2D, Doppler, or contrasted echocardiogram, with 2 contrast
injections without Valsalva and 2 injections with Valsalva). We found
that the prevalence of potential right-to-left shunting was significantly
higher in the SCA+stroke group than in controls (45.6% vs 23.6%, p<
0.001). In post hoc analyses, the SCA+stroke group had a higher
prevalence of intrapulmonary (23.8% vs 5.7% p<0.001) but not
intracardiac shunting (21.8% vs 18.7%, p=0.533) (Dowling, et al., 2016).
We agree with the Dattani and Jackson, that adults and children with
SCA, while at high risk for stroke from SCA-specific risk factors such as
sickle vasculopathy, are also at risk for stroke from the "traditional"
risk factors for stroke in adults, including potentially treatable risk
factors such as paradoxical embolization across a PFO (Dowling and Ikemba,
2011).
Common SCA related conditions such as acute chest syndrome or
pulmonary hypertension, as well as anemia itself, can increase right heart
pressures, favoring right-to-left shunting and thus favoring paradoxical
embolization. In patients without SCA, hypercoagulable states predispose
to paradoxical embolization in adults with potential shunting and SCA is
itself a hypercoagulable state. Studies of fat embolization syndrome in
SCA also support the role of paradoxical embolization syndrome in SCA.
Thus, we concur that both children and adults with SCA and stroke warrant
more extensive clinical evaluation for "traditional" risk factors for
stroke, particularly as they may be amenable to treatment.
We suspect that similar mechanisms may be involved in the etiology of
at least some of the "silent cerebral infarctions" that can be detected by
MRI in up to 40% of children with SCA. We concur that further research
is needed in this area but applaud the authors for highlighting the need
for exploration of alternative etiologies for stroke in patients with SCA,
and raising the clinical awareness of other potentially treatable stroke
etiologies in this high risk population.
Michael Morgan Dowling, MD, PhD, MSCS
Departments of Pediatrics and Neurology & Neurotherapeutics
University of Texas Southwestern Medical Center, Dallas, Texas
Fenella J Kirkham, MD, FRCP, FRCPCH
Developmental Neurosciences
UCL Institute of Child Health
London, UK
References
Dattani A, Jackson A, The cause of the stroke: a diagnostic
uncertainty. BMJ Case Rep. 2017 doi:10.1136/bcr-2016-218358.
Dowling, M.M. & Ikemba, C.M. (2011) Intracardiac shunting and
stroke in children: a systematic review. Journal of Child Neurology, 26,
72-82.
Dowling MM, Quinn CT, Ramaciotti C, Kanter J, Osunkwo I, Inusa B,
Iyer R, Kwiatkowski JL, Johnson C, Rhodes M, Owen W, Strouse JJ, Panepinto
JA, Neumayr L, Sarnaik S, Plumb PA, Dlamini N, Kirkham F, Hynan LS; PFAST
Investigators. Increased prevalence of potential right-to-left shunting in
children with sickle cell anaemia and stroke. Br J Haematol 2017
Jan;176(2):300-308
Disclosures
The authors were supported by the Doris Duke Charitable Foundation. They
have no other disclosures and no conflicts of interest to report.
It is important to consider the very high dose of elemental magnesium
(Mg) in this case of severe livery injury due to Epsom salt intake (1).
Using information from the Epsom Salt Council that Epsom Salts is 10%
elemental Mg by weight, and that one pound of Epsom Salts = 32 Tbsp, I
calculate that 3 Tbsp. Epsom Salts would deliver 4,250 mg elemental Mg.
This amount of supplemental Mg is definitely exces...
It is important to consider the very high dose of elemental magnesium
(Mg) in this case of severe livery injury due to Epsom salt intake (1).
Using information from the Epsom Salt Council that Epsom Salts is 10%
elemental Mg by weight, and that one pound of Epsom Salts = 32 Tbsp, I
calculate that 3 Tbsp. Epsom Salts would deliver 4,250 mg elemental Mg.
This amount of supplemental Mg is definitely excessive for only one
day let alone as a daily dose for 15 days.
The adult male RDA for Mg is 420 mg/day, one tenth of the daily dose
given in this case study (2). It is amazing that drug withdrawal and
adequate hydration were enough for an uneventful recovery with
normalization of liver function test after 38 days, showing how safe oral
Mg supplementation can be. However, even though quite safe, such
excessive doses (> 1,000 mg Mg/day) of this essential nutrient should
be avoided.
References
1. Philips CA, Paramaguru R, Mahadevan P, et al. Severe liver injury due
to Epsom salt naturopathy. BMJ Case Rep 2017;2017 doi: 10.1136/bcr-2017-
221718 [published Online First: 2017/10/04]
2. Institute of Medicine. Dietary reference intakes for calcium,
phosphorus, magnesium, vitamin D, and fluoride. Washington, D.C.: National
Academy Press 1997.
I felt that the article was highly informative. We as nurses and
doctors see many patients each day and on some occasions we do not have
answers for peculiar symptoms or pains a patient may complain of. In my
opinion, the pains and symptoms, are there because there is a cause but
the cause is not known to the examiner or the patient.
It is my view that we do our best but we seldom go far enough before we
label a pain or...
I felt that the article was highly informative. We as nurses and
doctors see many patients each day and on some occasions we do not have
answers for peculiar symptoms or pains a patient may complain of. In my
opinion, the pains and symptoms, are there because there is a cause but
the cause is not known to the examiner or the patient.
It is my view that we do our best but we seldom go far enough before we
label a pain or a symptom as being "idiopathic" or "no known reason". It
is my view that if we were more diligent, it may be possible to find the
causes of those idiopathic pains etc. Sometimes, being a health care
professional is like an investigator searching for a needle in a haystack.
I enjoyed the important and educational case report submitted by Dr.
Little, and congratulate him on a successful outcome using aggressive
resuscitation techniques. One additional option to transfer heat
efficiently to the patient's core is via a device recently introduced that
allows warming through the esophagus using a closed-system silicone tube
connected to standard water blanket heat exchanger.[1] This approach ha...
I enjoyed the important and educational case report submitted by Dr.
Little, and congratulate him on a successful outcome using aggressive
resuscitation techniques. One additional option to transfer heat
efficiently to the patient's core is via a device recently introduced that
allows warming through the esophagus using a closed-system silicone tube
connected to standard water blanket heat exchanger.[1] This approach has
been shown to provide sufficient heat to patients to avoid hypothermia in
the operating room during challenging burn cases that are prone to
substantial heat loss.[2] As such, esophageal warming may allow avoidance
of a more invasive thoracotomy in some patients, although in the extreme
case described, it is likely that adding esophageal rewarming using this
modality would instead be supplementary to the thoracotomy.
1. Kulstad E, Metzger AK, Courtney DM, Rees J, Shanley P, Matsuura T,
McKnite S, Lurie K: Induction, maintenance, and reversal of therapeutic
hypothermia with an esophageal heat transfer device. Resuscitation 2013,
84(11):1619-1624.
2. Williams D, Leslie G, Kyriazis D, O'Donovan B, Bowes J, Dingley J. Use
of an esophageal heat exchanger to maintain core temperature during burn
excisions and to attenuate pyrexia on the burns intensive care unit. Case
Rep Anesthesiol. 2016;2016:6.
Conflict of Interest:
Co-inventor of a device, and equity holder in Attune Medical developing device mentioned in response.
Cases with combined facial nerve and trigeminal nerve involvement do present with complex issues as elucidated by Allevi et al (1) . This article helped us immensely in managing our case and we are grateful to the authors and the journal.
A male patient suffering from fifth nerve and seventh nerve palsy presented to us with similar issues with severely vascularised hypertrophic insensitive bulging cornea with...
Sir, Its with interest that I read the small and crisp description and medical images related to Artery of Percheron infarct.
The diagnosis of this condition indeed is sometimes difficult and requires clinical suspicion accompanied by proper radiological imaging.
What i would also like to highlight is the fact that its not only the imaging modality i.e MRI which is required,or the sequence DWI/ADC which...
I would like to congratulate and thank you for taking the courage in publishing this case report for the benefit of the neonatal trainees and all neonatologist in general. I am not surprised that there aren't more case reports published as such cases tend not be published because of general feeling of guilt for negligence and not exposing the hospital for fear of bad name as the outcome is very poor as you rightly poi...
Dear Editor,
We read with interest the case report concerning a transient global amnesia (TGA) in an individual who was previously submitted to a session of whole body cryotherapy (WBC).1
The scientific literature is already sufficiently wide to realize that the WBC is a safe procedure, while it could seem apparently dangerous due to very low temperature of the air used in the chambers during treatment...
I read with interest the case report about a fatal case of neurocysticercosis. I want to emphasize that deaths are rare in neurocysticercosis and in neurocysticercosis there is no malignant course. Lesion load seems to be quite low. In fact the patient not fully worked up for more likely diagnosis. For example miliary tuberculosis and miliary secondary malignancy. The CSF should have examined for malignant cells and Mycoba...
Sirs,
I wonder whether that plastic toy could be spotted in the CT images by a reader who has been informed about it. Did the radiology department comment about this?
I am pretty shure the cone cannot be detected on a plain x-ray. The ABS polymer used by toy manufacturers like Playmobile or Lego seems to have x-ray attenuation properties very near to human tissue (Saps et al., World J Clin Pediatr 201...
Dear Sir, We read with great interest the case report by Dattani and Jackson detailing a case of potential cardioembolic stroke in a young man with sickle cell anemia (SCA), without significant cerebral vasculopathy but with PFO. We have conducted a controlled clinical study to determine the prevalence of potential left-to-right shunting (intracardiac or intrapulmonary) in children with SCA and overt clinical stroke...
It is important to consider the very high dose of elemental magnesium (Mg) in this case of severe livery injury due to Epsom salt intake (1).
Using information from the Epsom Salt Council that Epsom Salts is 10% elemental Mg by weight, and that one pound of Epsom Salts = 32 Tbsp, I calculate that 3 Tbsp. Epsom Salts would deliver 4,250 mg elemental Mg.
This amount of supplemental Mg is definitely exces...
I felt that the article was highly informative. We as nurses and doctors see many patients each day and on some occasions we do not have answers for peculiar symptoms or pains a patient may complain of. In my opinion, the pains and symptoms, are there because there is a cause but the cause is not known to the examiner or the patient. It is my view that we do our best but we seldom go far enough before we label a pain or...
I enjoyed the important and educational case report submitted by Dr. Little, and congratulate him on a successful outcome using aggressive resuscitation techniques. One additional option to transfer heat efficiently to the patient's core is via a device recently introduced that allows warming through the esophagus using a closed-system silicone tube connected to standard water blanket heat exchanger.[1] This approach ha...
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