Factors affecting phantom limb pain in patients undergoing amputation: retrospective study

Abstract

Purpose

The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain.

Methods

Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis.

Results

Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643–0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280–31.50], p = 0.024, respectively).

Conclusion

The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.

http://bit.ly/2EZXiXw

Influence of intraoperative sevoflurane or desflurane on postoperative sore throat: a prospective randomized study

Abstract

Purpose

Tracheal intubation for general anesthesia causes postoperative sore throat. The purpose of this study was to evaluate the effect of sevoflurane and desflurane on prevalence of postoperative sore throat in patients after general anesthesia.

Methods

Ninety-six patients scheduled for orthopedic lower extremity surgery under general anesthesia were assigned to sevoflurane group or desflurane group. In the sevoflurane group (n = 48), sevoflurane was used as a maintenance anesthetic agent. In the desflurane group (n = 48), desflurane was used. Prevalence of sore throat, number of patients with rescue analgesics, and analgesics requirements were evaluated.

Results

The overall prevalence of postoperative sore throat in the sevoflurane group was lower than that in the desflurane group [21 (44%) vs. 32 (67%), p = 0.024]. The prevalence of sore throat at postoperative 4 h in the sevoflurane group was lower than that in the desflurane group [6 (13%) vs. 18 (38%), p = 0.005]. The number of patients requiring rescue analgesics was lower in the sevoflurane group [25 (52%) vs. 36 (75%), p = 0.020]. The requirement of diclofenac was also lower in the sevoflurane group (30 ± 37 mg vs. 47 ± 40 mg, p = 0.031).

Conclusions

We have shown that sevoflurane was associated with less frequent sore throat than desflurane in patients undergoing orthopedic lower extremity surgery.

http://bit.ly/2F1Rn4Y

Shallow nasal RAE tube depth after head and neck surgery: association with preoperative and intraoperative factors

Abstract

Purpose

To evaluate risk factors associated with improper postoperative nasal Ring–Adair–Elwyn (RAE) tube depth.

Methods

We retrospectively enrolled 133 adult patients who were admitted to the intensive care unit (ICU) with the nasal RAE tube after head and neck surgery. Postoperative chest radiography was performed to confirm nasal RAE tube depth immediately after the patient was admitted to the ICU. Proper tube depth was defined as the tube tip between 2 and 7 cm above the carina. The patients were divided into the proper-depth group (78 patients) and the improper-depth group (55 patients). Patients' characteristics were collected. The risk factors for improper postoperative tube depth were assessed using logistic regression analysis.

Main results

All patients who showed improper tube depth had a shallow tube depth (the tube tip > 7 cm above the carina). Multivariable analysis revealed that tall stature [odds ratio (OR) 1.16; 95% confidence interval (CI) 1.08–1.25; P < 0.001], prolonged anesthesia duration (OR 1.16; 95% CI 1.02–1.32; P = 0.026), and right-sided surgical field as compared to the left (OR 0.36; 95% CI 0.14–0.93; P = 0.034) or median field (OR 0.25; 95% CI 0.07–0.85; P = 0.027) were risk factors associated with postoperative shallow tube depth.

Conclusions

Tall stature, prolonged anesthesia duration, and right-sided surgical field were independent risk factors for postoperative shallow nasal RAE tube depth.

http://bit.ly/2EZXcz8

High-Variability Sentence Recognition in Long-Term Cochlear Implant Users: Associations With Rapid Phonological Coding and Executive Functioning

Objectives: The objective of the present study was to determine whether long-term cochlear implant (CI) users would show greater variability in rapid phonological coding skills and greater reliance on slow-effortful compensatory executive functioning (EF) skills than normal-hearing (NH) peers on perceptually challenging high-variability sentence recognition tasks. We tested the following three hypotheses: First, CI users would show lower scores on sentence recognition tests involving high speaker and dialect variability than NH controls, even after adjusting for poorer sentence recognition performance by CI users on a conventional low-variability sentence recognition test. Second, variability in fast-automatic rapid phonological coding skills would be more strongly associated with performance on high-variability sentence recognition tasks for CI users than NH peers. Third, compensatory EF strategies would be more strongly associated with performance on high-variability sentence recognition tasks for CI users than NH peers. Design: Two groups of children, adolescents, and young adults aged 9 to 29 years participated in this cross-sectional study: 49 long-term CI users (≥7 years) and 56 NH controls. All participants were tested on measures of rapid phonological coding (Children's Test of Nonword Repetition), conventional sentence recognition (Harvard Sentence Recognition Test), and two novel high-variability sentence recognition tests that varied the indexical attributes of speech (Perceptually Robust English Sentence Test Open-set test and Perceptually Robust English Sentence Test Open-set test-Foreign Accented English test). Measures of EF included verbal working memory (WM), spatial WM, controlled cognitive fluency, and inhibition concentration. Results: CI users scored lower than NH peers on both tests of high-variability sentence recognition even after conventional sentence recognition skills were statistically controlled. Correlations between rapid phonological coding and high-variability sentence recognition scores were stronger for the CI sample than for the NH sample even after basic sentence perception skills were statistically controlled. Scatterplots revealed different ranges and slopes for the relationship between rapid phonological coding skills and high-variability sentence recognition performance in CI users and NH peers. Although no statistically significant correlations between EF strategies and sentence recognition were found in the CI or NH sample after use of a conservative Bonferroni-type correction, medium to high effect sizes for correlations between verbal WM and sentence recognition in the CI sample suggest that further investigation of this relationship is needed. Conclusions: These findings provide converging support for neurocognitive models that propose two channels for speech-language processing: a fast-automatic channel that predominates whenever possible and a compensatory slow-effortful processing channel that is activated during perceptually-challenging speech processing tasks that are not fully managed by the fast-automatic channel (ease of language understanding, framework for understanding effortful listening, and auditory neurocognitive model). CI users showed significantly poorer performance on measures of high-variability sentence recognition than NH peers, even after simple sentence recognition was controlled. Nonword repetition scores showed almost no overlap between CI and NH samples, and correlations between nonword repetition scores and high-variability sentence recognition were consistent with greater reliance on engagement of fast-automatic phonological coding for high-variability sentence recognition in the CI sample than in the NH sample. Further investigation of the verbal WM–sentence recognition relationship in CI users is recommended. Assessment of fast-automatic phonological processing and slow-effortful EF skills may provide a better understanding of speech perception outcomes in CI users in the clinical setting. ACKNOWLEDGMENTS: The authors thank Shirley Henning and Bethany Colson for administering the speech, language, and neurocognitive tests and Allison Ditmars for coordinating the study. The authors also thank Luis Hernandez for his help and assistance with data analysis connected with the speech production measures. This research was funded by National Institutes of Health-National Institute on Deafness and Other Communication Disorders (NIH-NIDCD) R01DC015257 (to W.G.K. and D.B.P.) and NIH-NIDCD R01DC009581 (to D.B.P.). Portions of this article were presented at the American Cochlear Implant Alliance CI2018 Emerging Issues Symposium on March 8, 2018, in Washington DC, (by W.G.K.) and the Cognitive Neuroscience Society 25th Annual Meeting on March 27, 2018, in Boston, MA, (by G.N.L.S.). G.N.L.S. analyzed the data, wrote the first draft of the paper, and provided critical revisions to subsequent drafts. D.B.P. conceptualized the study, designed the experiments, and provided critical revisions to all drafts of the article. W.G.K. conceptualized the study, designed the experiments, analyzed the data, wrote sections of the article, and provided critical revisions to the article. G.N.L.S., D.B.P., and W.G.K. gave final approval of the paper before submission. W.G.K. is a paid consultant for Shire Pharmaceuticals and the Indiana Hemophilia and Thrombosis Center. Address for correspondence: Gretchen N.L. Smith, Cognitive Neuroscience Laboratory, Shirley Ryan AbilityLab, 355 East Erie Street, Chicago, IL 60611, USA. E-mail: gsmith02@sralab.org Received May 14, 2018; accepted November 6, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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High-Variability Sentence Recognition in Long-Term Cochlear Implant Users: Associations With Rapid Phonological Coding and Executive Functioning

Objectives: The objective of the present study was to determine whether long-term cochlear implant (CI) users would show greater variability in rapid phonological coding skills and greater reliance on slow-effortful compensatory executive functioning (EF) skills than normal-hearing (NH) peers on perceptually challenging high-variability sentence recognition tasks. We tested the following three hypotheses: First, CI users would show lower scores on sentence recognition tests involving high speaker and dialect variability than NH controls, even after adjusting for poorer sentence recognition performance by CI users on a conventional low-variability sentence recognition test. Second, variability in fast-automatic rapid phonological coding skills would be more strongly associated with performance on high-variability sentence recognition tasks for CI users than NH peers. Third, compensatory EF strategies would be more strongly associated with performance on high-variability sentence recognition tasks for CI users than NH peers. Design: Two groups of children, adolescents, and young adults aged 9 to 29 years participated in this cross-sectional study: 49 long-term CI users (≥7 years) and 56 NH controls. All participants were tested on measures of rapid phonological coding (Children’s Test of Nonword Repetition), conventional sentence recognition (Harvard Sentence Recognition Test), and two novel high-variability sentence recognition tests that varied the indexical attributes of speech (Perceptually Robust English Sentence Test Open-set test and Perceptually Robust English Sentence Test Open-set test-Foreign Accented English test). Measures of EF included verbal working memory (WM), spatial WM, controlled cognitive fluency, and inhibition concentration. Results: CI users scored lower than NH peers on both tests of high-variability sentence recognition even after conventional sentence recognition skills were statistically controlled. Correlations between rapid phonological coding and high-variability sentence recognition scores were stronger for the CI sample than for the NH sample even after basic sentence perception skills were statistically controlled. Scatterplots revealed different ranges and slopes for the relationship between rapid phonological coding skills and high-variability sentence recognition performance in CI users and NH peers. Although no statistically significant correlations between EF strategies and sentence recognition were found in the CI or NH sample after use of a conservative Bonferroni-type correction, medium to high effect sizes for correlations between verbal WM and sentence recognition in the CI sample suggest that further investigation of this relationship is needed. Conclusions: These findings provide converging support for neurocognitive models that propose two channels for speech-language processing: a fast-automatic channel that predominates whenever possible and a compensatory slow-effortful processing channel that is activated during perceptually-challenging speech processing tasks that are not fully managed by the fast-automatic channel (ease of language understanding, framework for understanding effortful listening, and auditory neurocognitive model). CI users showed significantly poorer performance on measures of high-variability sentence recognition than NH peers, even after simple sentence recognition was controlled. Nonword repetition scores showed almost no overlap between CI and NH samples, and correlations between nonword repetition scores and high-variability sentence recognition were consistent with greater reliance on engagement of fast-automatic phonological coding for high-variability sentence recognition in the CI sample than in the NH sample. Further investigation of the verbal WM–sentence recognition relationship in CI users is recommended. Assessment of fast-automatic phonological processing and slow-effortful EF skills may provide a better understanding of speech perception outcomes in CI users in the clinical setting. ACKNOWLEDGMENTS: The authors thank Shirley Henning and Bethany Colson for administering the speech, language, and neurocognitive tests and Allison Ditmars for coordinating the study. The authors also thank Luis Hernandez for his help and assistance with data analysis connected with the speech production measures. This research was funded by National Institutes of Health-National Institute on Deafness and Other Communication Disorders (NIH-NIDCD) R01DC015257 (to W.G.K. and D.B.P.) and NIH-NIDCD R01DC009581 (to D.B.P.). Portions of this article were presented at the American Cochlear Implant Alliance CI2018 Emerging Issues Symposium on March 8, 2018, in Washington DC, (by W.G.K.) and the Cognitive Neuroscience Society 25th Annual Meeting on March 27, 2018, in Boston, MA, (by G.N.L.S.). G.N.L.S. analyzed the data, wrote the first draft of the paper, and provided critical revisions to subsequent drafts. D.B.P. conceptualized the study, designed the experiments, and provided critical revisions to all drafts of the article. W.G.K. conceptualized the study, designed the experiments, analyzed the data, wrote sections of the article, and provided critical revisions to the article. G.N.L.S., D.B.P., and W.G.K. gave final approval of the paper before submission. W.G.K. is a paid consultant for Shire Pharmaceuticals and the Indiana Hemophilia and Thrombosis Center. Address for correspondence: Gretchen N.L. Smith, Cognitive Neuroscience Laboratory, Shirley Ryan AbilityLab, 355 East Erie Street, Chicago, IL 60611, USA. E-mail: gsmith02@sralab.org Received May 14, 2018; accepted November 6, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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High-Variability Sentence Recognition in Long-Term Cochlear Implant Users: Associations With Rapid Phonological Coding and Executive Functioning

Objectives: The objective of the present study was to determine whether long-term cochlear implant (CI) users would show greater variability in rapid phonological coding skills and greater reliance on slow-effortful compensatory executive functioning (EF) skills than normal-hearing (NH) peers on perceptually challenging high-variability sentence recognition tasks. We tested the following three hypotheses: First, CI users would show lower scores on sentence recognition tests involving high speaker and dialect variability than NH controls, even after adjusting for poorer sentence recognition performance by CI users on a conventional low-variability sentence recognition test. Second, variability in fast-automatic rapid phonological coding skills would be more strongly associated with performance on high-variability sentence recognition tasks for CI users than NH peers. Third, compensatory EF strategies would be more strongly associated with performance on high-variability sentence recognition tasks for CI users than NH peers. Design: Two groups of children, adolescents, and young adults aged 9 to 29 years participated in this cross-sectional study: 49 long-term CI users (≥7 years) and 56 NH controls. All participants were tested on measures of rapid phonological coding (Children’s Test of Nonword Repetition), conventional sentence recognition (Harvard Sentence Recognition Test), and two novel high-variability sentence recognition tests that varied the indexical attributes of speech (Perceptually Robust English Sentence Test Open-set test and Perceptually Robust English Sentence Test Open-set test-Foreign Accented English test). Measures of EF included verbal working memory (WM), spatial WM, controlled cognitive fluency, and inhibition concentration. Results: CI users scored lower than NH peers on both tests of high-variability sentence recognition even after conventional sentence recognition skills were statistically controlled. Correlations between rapid phonological coding and high-variability sentence recognition scores were stronger for the CI sample than for the NH sample even after basic sentence perception skills were statistically controlled. Scatterplots revealed different ranges and slopes for the relationship between rapid phonological coding skills and high-variability sentence recognition performance in CI users and NH peers. Although no statistically significant correlations between EF strategies and sentence recognition were found in the CI or NH sample after use of a conservative Bonferroni-type correction, medium to high effect sizes for correlations between verbal WM and sentence recognition in the CI sample suggest that further investigation of this relationship is needed. Conclusions: These findings provide converging support for neurocognitive models that propose two channels for speech-language processing: a fast-automatic channel that predominates whenever possible and a compensatory slow-effortful processing channel that is activated during perceptually-challenging speech processing tasks that are not fully managed by the fast-automatic channel (ease of language understanding, framework for understanding effortful listening, and auditory neurocognitive model). CI users showed significantly poorer performance on measures of high-variability sentence recognition than NH peers, even after simple sentence recognition was controlled. Nonword repetition scores showed almost no overlap between CI and NH samples, and correlations between nonword repetition scores and high-variability sentence recognition were consistent with greater reliance on engagement of fast-automatic phonological coding for high-variability sentence recognition in the CI sample than in the NH sample. Further investigation of the verbal WM–sentence recognition relationship in CI users is recommended. Assessment of fast-automatic phonological processing and slow-effortful EF skills may provide a better understanding of speech perception outcomes in CI users in the clinical setting. ACKNOWLEDGMENTS: The authors thank Shirley Henning and Bethany Colson for administering the speech, language, and neurocognitive tests and Allison Ditmars for coordinating the study. The authors also thank Luis Hernandez for his help and assistance with data analysis connected with the speech production measures. This research was funded by National Institutes of Health-National Institute on Deafness and Other Communication Disorders (NIH-NIDCD) R01DC015257 (to W.G.K. and D.B.P.) and NIH-NIDCD R01DC009581 (to D.B.P.). Portions of this article were presented at the American Cochlear Implant Alliance CI2018 Emerging Issues Symposium on March 8, 2018, in Washington DC, (by W.G.K.) and the Cognitive Neuroscience Society 25th Annual Meeting on March 27, 2018, in Boston, MA, (by G.N.L.S.). G.N.L.S. analyzed the data, wrote the first draft of the paper, and provided critical revisions to subsequent drafts. D.B.P. conceptualized the study, designed the experiments, and provided critical revisions to all drafts of the article. W.G.K. conceptualized the study, designed the experiments, analyzed the data, wrote sections of the article, and provided critical revisions to the article. G.N.L.S., D.B.P., and W.G.K. gave final approval of the paper before submission. W.G.K. is a paid consultant for Shire Pharmaceuticals and the Indiana Hemophilia and Thrombosis Center. Address for correspondence: Gretchen N.L. Smith, Cognitive Neuroscience Laboratory, Shirley Ryan AbilityLab, 355 East Erie Street, Chicago, IL 60611, USA. E-mail: gsmith02@sralab.org Received May 14, 2018; accepted November 6, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Malfunctioning of Chaperone-Mediated Autophagy in Parkinson’s Disease: Feats, Constraints, and Flaws of Modulators

Abstract

Homeostatic regulation of class II programmed cell death/autophagy for the degradation and elimination of substandard organelles and defective proteins is decisive for the survival of dopaminergic neurons. Chaperone-mediated autophagy (CMA), one of the most highly dedicated self-sacrificing events, is accountable for the partial elimination of redundant soluble cytoplasmic proteins in Parkinson's disease (PD). CMA is characterized by the selective delivery of superfluous protein containing lysine-phenylalanine-glutamate-arginine-glutamine (KFERQ)/KFERQ-like motif to the lysosome through molecular chaperones, such as heat shock cognate-70 (Hsc-70). KFERQ/KFERQ-like motif present in the poor quality cytoplasmic substrate protein and Hsc-70 complex is recognized by a janitor protein, which is referred to as the lysosome-associated membrane protein-2A (LAMP-2A). This protein is known to facilitate an entry of substrate-chaperone complex in the lumen for hydrolytic cleavage of substrate and elimination of end-products. Impaired CMA is repeatedly blamed for an accumulation of surplus soluble proteins. However, it is still an enigma if CMA is a bonus or curse for PD. Case-control studies and cellular and animal models have deciphered the contribution of impaired CMA in PD. Current article updates the role of CMA in toxicant models and recapitulates the evidences that have highlighted a link between impaired CMA and PD. Although PD is an irreversible happening and CMA is a dual edging phenomenon, it is anticipated that fine-tuning of the latter encounters the former to a certain extent. Besides, the truth, embellishment, and propaganda regarding the issue are also emphasized in the final segment of the article.

http://bit.ly/2CKjcwi

A C. elegans Model for the Study of RAGE-Related Neurodegeneration

Abstract

The receptor for advanced glycation products (RAGE) is a cell surface, multi-ligand receptor belonging to the immunoglobulin superfamily; this receptor is implicated in a variety of maladies, via inflammatory pathways and induction of oxidative stress. Currently, RAGE is being studied using a limited number of mammalian in vivo, and some complementary in vitro, models. Here, we present a Caenorhabditis elegans model for the study of RAGE-related pathology: a transgenic strain, expressing RAGE in all neurons, was generated and subsequently tested behaviorally, developmentally, and morphologically. In addition to RAGE expression being associated with a significantly shorter lifespan, the following behavioral observations were made when RAGE-expressing worms were compared to the wild type: RAGE-expressing worms showed an impaired dopaminergic system, evaluated by measuring the fluorescent signal of GFP tagging; these worms exhibited decreased locomotion—both general and following ethanol exposure—as measured by counting body bends in adult worms; RAGE expression was also associated with impaired recovery of quiescence and pharyngeal pumping secondary to heat shock, as a significantly smaller fraction of RAGE-expressing worms engaged in these behaviors in the 2 h immediately following the heat shock. Finally, significant developmental differences were also found between the two strains: RAGE expression leads to a significantly smaller fraction of hatched eggs 24 h after laying and also to a significantly slower developmental speed overall. As evidence for the role of RAGE in a variety of neuropathologies accumulates, the use of this novel and expedient model should facilitate the elucidation of relevant underlying mechanisms and also the development of efficient therapeutic strategies.

http://bit.ly/2TsNtFF

Development of Soybean Yellow Mottle Mosaic Virus-Based Expression Vector for Heterologous Protein Expression in French Bean

Abstract

Plant virus-based vectors provide attractive and valuable tools for rapid production of recombinant protein in large quantities as they produce systemic infections in differentiated plant tissues. In the present study, we engineered the Soybean yellow mottle mosaic virus (SYMMV) as a gene expression vector which is a promising candidate for systemic expression of foreign proteins in French bean plants. Full virus vector strategy was exploited for insertion of foreign gene by inserting MCS through PCR in the circular pJET-SYMMV clone. To examine the ability of the SYMMV vector system, GFP gene was cloned after the start codon of coat protein (CP) so that its expression was driven by the SYMMV-CP subgenomic promoter. When in vitro run off SYMMV-GFP transcript was mechanically inoculated to French bean leaves, good level of GFP expression was observed through confocal microscopy up to 40 dpi. Expression of heterologous protein was also confirmed through ISEM, DAC-ELISA and RT-PCR with specific primers at 20 dpi. The recombinant SYMMV construct was stable in in vitro runoff transcript inoculated plants but the inserted GFP was lost in progeny virion inoculated plants. The system developed here will be useful for further studies of SYMMV gene functions and exploitation of SYMMV as a gene expression vector.

http://bit.ly/2QgtiZs

B Cells Increase Myocardial Inflammation by Suppressing M2 Macrophage Polarization in Coxsackie Virus B3-Induced Acute Myocarditis

Abstract

The role of B cells in viral myocarditis (VMC) remains controversial. In order to establish a role and mechanism of action for B cells in acute VMC, we established an acute VMC mouse model by intraperitoneal injection of Coxsackie virus group B type 3 (CVB3). At day 7, mice were analyzed using myocardial histopathology, and the presence of M2 macrophages in spleen and heart. Mice were divided into four groups, all having a C57BL/6 background: control group; wild-type (WT) VMC; mMt/mMt (−/−) VMC (BKO), and BKO + B cell VMC. A role for B cells was demonstrated by a significant reduction in myocardial pathological score and an increase in the frequency of M2 macrophages in the BKO group, when compared to the WT group. Once BKO mice underwent B cell reconstitution with isolated WT B cells, the myocardial pathological score was increased significantly, while the frequency of M2 macrophages decrease. Our findings demonstrate that B cells increase myocardial inflammation by suppressing M2 polarization in acute VMC in vivo.

http://bit.ly/2s40JVj

Pasteurella multocida meningitis following mastoidectomy Το P. multocida προκαλεί μια σειρά ασθενειών σε άγρια ​​και εξημερωμένα ζώα, καθώς και σε ανθρώπους. Το βακτήριο μπορεί να βρεθεί σε πουλιά, γάτες , σκύλους, κουνέλια, βοοειδή και χοίρους. Στα πτηνά, το P. multocida προκαλεί ασθένεια της χολέρας των πτηνών ή των πτηνών. μια σημαντική ασθένεια που υπάρχει σε εμπορικά και οικόσιτα σμήνη πουλερικών παγκοσμίως, ιδιαίτερα σμήνη στρώματος και σμήνη πατρικών εκτροφέων. Τα στελέχη P. multocida που προκαλούν τη χολέρα των πτηνών στα πουλερικά συνήθως ανήκουν στους σεροβάρους 1, 3 και

DISPATCH

Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 78-80

Pasteurella multocida meningitis following mastoidectomy: A case report and literature review

Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
Department of Medicine, Federal University of Santa Maria, Santa Maria, RS, Brazil

Correspondence Address:

Jamir Pitton Rissardo
Department of Medicine, Federal University of Santa Maria, Santa Maria, RS 

DOI: 10.4103/IJAMR.IJAMR_35_18

Abstract

Pasteurella multocida (PM) is part of the normal nasopharyngeal flora of many animals. The most common PM infections occur in soft tissue, secondary to animal contact. Meningitis is rarely associated. An adult female developed chronic right-sided otorrhea and tympanic membrane perforation. Elective mastoidectomy was performed. On the postoperative day 2, the patient experienced a decreased level of consciousness, headache, nausea, and seizures. Cerebrospinal fluid (CSF) analysis revealed low glucose, high protein, and high cellularity. Blood tests were within normal limits, except for high leukocyte count. Two days after the neurological manifestations, bacteria, identified as PM, grew in the aerobic cultures of CSF and preoperative ear swab. The isolate was sensitive to penicillins. She was started on intravenous penicillin G. The patient had a full recovery. On further questioning, she admitted having a dog, which licks on her face frequently.

Keywords: Mastoidectomy, meningitis, Pasteurella multocida

Introduction

Pasteurella multocida (PM) is a Gram-negative coccobacillus and facultative anaerobe. It is present in the nasopharyngeal flora of domestic pets.^[1] Frequently, PM infections in humans are located in the soft tissue and are associated with animal bites. In rare cases, severe infection, like meningitis, can occur. In this context, it is known that surgical procedures such as mastoidectomy may contribute to meningitis, particularly in a predisposed individual.^[1],[2] To the authors' knowledge, only two cases of mastoidectomy followed by PM meningitis have been reported.^[3],[4] Herein, we report a case of an adult woman who had PM meningitis after mastoidectomy.

Case Report

A 51-year-old female patient presented with chronic right-sided otorrhea and ipsilateral tympanic membrane perforation within 2 months of onset. She was admitted for elective mastoidectomy with tympanoplasty. Her medical history included recurrent ear infections with otorrhea through a tympanic perforation. On neurological examination, conductive hearing loss was observed. The left otoscopy was normal, and right otoscopy showed perforated tympanic membrane with tympanosclerosis. There was no evidence of otorrhea, soft-tissue mass, crusting, or desquamated debris. Her comorbid conditions were dyslipidemia, hypertension, and major depressive disorder. She was in use of sertraline, hydrochlorothiazide, enalapril, and simvastatin.

On the postoperative day 2, the patient experienced a decreased level of consciousness, headache, nausea, and seizures presenting with bilateral tonic-clonic movements and impaired awareness. There was no fever or focal neurological signs. Cranial computed tomography scan showed the mastoidectomy and the absence of mass or hematoma [Figure 1]. Cerebrospinal fluid (CSF) analysis revealed low glucose (5 mg/dL), high protein (114 mg/dL), and high cellularity (158/mm³) with 85% of neutrophils. Blood tests, including glucose level (90 mg/dL), were within normal limits, except for the presence of leukocytosis (20,010/mm³). Initial gram stain of the CSF showed abundant neutrophils and the absence of microorganisms. She was treated empirically for bacterial meningitis with intravenous (IV) ceftriaxone and vancomycin.

Figure 1: Images of computed tomography scan showing the right mastoidectomy, the communication between the right ear and right middle cranial fossa (indicated by the arrow). Coronal (a) and axial (b) views of head computed tomography scan. Axial with brain window (c) and coronal with bone window (d) views of computed tomography scan of the temporal bone Click here to view

Two days after the neurological manifestations, PM grew in the aerobic cultures of CSF and preoperative ear swab. The isolate was sensitive to penicillin. She was started on IV penicillin G 2 million units, every 4 h, for 14 days. After 10 days, the patient had a full recovery.

On further questioning, she admitted having a dog which lives inside her house and licks on her face frequently. In the follow-up, investigation for immunosuppression was negative.

Discussion

PM meningitis was first documented in 1925 by Claudius.^[5] Since 1950, about 39 cases have been reported in the English literature. In these cases, the infection was generally associated with cranial surgery or trauma, chronic otitis media, and soft-tissue infection with secondary spread.^[1],[2],[6] History of recent animal contact was reported in 89% of cases.^[2]

There are only a few case reports of PM meningitis following mastoidectomy. We identified two cases after a review of the English literature, and we compared them with the present case [Table 1].^[3],[4] Literature search was performed in Embase, Google Scholar, Lilacs, Medline, Scielo, and ScienceDirect, using a set of terms that included mastoidectomy, meningitis, and PM.

Table 1: Reported cases of Pasteurella multocida meningitis following mastoidectomy Click here to view

In the case reported by Dammeijer and McCombe, PM meningitis occurred after a modified radical mastoidectomy due to recurrent cholesteatoma.^[4] On the other hand, in the study from Pond et al., PM meningitis was associated with a typanomastoidectomy and removal of the incus and malleus with tympanoplasty performed for chronic otorrhea related to tympanic membrane perforation.^[3]

The pathogenesis in PM meningitis following mastoidectomy is probably related with the contiguous spread of the bacteria from a colonized external acoustic meatus, which has contaminated the CSF during the surgery. This hypothesis is based on the preoperative growth of PM in the ear swab, the absence of clinical meningitis signs, and the development of the infection 24 h after the mastoidectomy.^[3],[4]

We agree with the statement of Pond et al.^[3] and Dammeijer and McCombe,^[4] that any patient requiring mastoidectomy should be asked about contact with animals, and in the case of a positive answer, a preoperative ear swab is mandatory since it allows early intervention and prevents possible complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984;63:133-54.
2.	Green BT, Ramsey KM, Nolan PE. Pasteurella multocida meningitis: Case report and review of the last 11 y. Scand J Infect Dis 2002;34:213-7.
3.	Pond ED, El-Bailey S, Webster D. An unusual case of meningitis. Can J Infect Dis Med Microbiol 2015;26:e62-4.
4.	Dammeijer PF, McCombe AW. Meningitis from canine Pasteurella multocida following mastoidectomy. J Laryngol Otol 1991;105:571-2.
5.	Claudius M. The bacteria plague-like. Ugesk Laeger 1925;87:194-5.
6.	Kumar A, Devlin HR, Vellend H. Pasteurella multocida meningitis in an adult: Case report and review. Rev Infect Dis 1990;12:440-8.

Figures

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Tables

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http://www.ijamhrjournal.org/article.asp?issn=2349-4220;year=2018;volume=5;issue=2;spage=78;epage=80;aulast=Rissardo

Advanced Medical and Health Research

Cutting to cure to cutting down the incision: From kindest cut to virtually no cut Vikram Kate, Raja Kalayarasan International Journal of Advanced Medical and Health Research 2018 5(2):41-42

Suicide prevention strategies: An overview of current evidence and best practice elements Vikas Menon, Karthick Subramanian, Nivedhitha Selvakumar, Shivanand Kattimani International Journal of Advanced Medical and Health Research 2018 5(2):43-51 Suicide is a complex human behavior with multiple interacting determinants. Clinicians and practitioners often face difficulties in assimilating the evidence base for suicide prevention interventions, evaluating their effectiveness and decoding the best practice elements of each approach. In this article, we do not aim to provide an exhaustive coverage of every approach. Instead, we provide an overview of the following eight major suicide prevention interventions: awareness programs, screening, gatekeeper training, access to means restriction, follow-up care, hotlines, media strategies, pharmacotherapeutic and psychotherapeutic approaches. The evidence base and components of each approach are described to facilitate replication. The best practice elements are synthesized from each approach and presented to aid program development and practice. Although a number of approaches hold promise, there are difficulties in ascertaining the effective elements under each of them. Innovative research designs are needed to address this knowledge gap as it will facilitate optimal allocation of resources for suicide prevention.

Healthcare-seeking behavior for infectious diseases in a community in Bangladesh Md Shafiqul Islam Khan, Jannatul Ferdous Ani, Bithika Rani, Shafaet Jamil Apon, Fahmida Rashid, Tanjil Islam Yead, Musammet Rasheda Begum, Sukanta Chowdhury International Journal of Advanced Medical and Health Research 2018 5(2):52-56 Background: Healthcare-seeking behavior is associated with the severity of infectious diseases, particularly in low-income countries. We need better understanding about the current healthcare-seeking behavior of rural people in low-resource settings. This study aimed to describe the healthcare-seeking behavior of rural people for infectious diseases and identify the associated factors. Methods: We conducted a cross-sectional survey in a rural community in Bangladesh. We interviewed a total of 450 persons to collect data on demographics, household income, household expenditure, and healthcare-seeking behavior. We performed a descriptive analysis to summarize the demographic characteristics and multivariate logistic regression analysis to identify the association between healthcare-seeking behavior and variables of interest. Results: Among the study participants, 42% went to the health facilities, 30% went to the pharmacy, 14% went to the nonregistered doctors, 1% went to the traditional healers, 1% went to the spiritual healer, and 2% took self-treatment. Proximity of the health-care facilities (prevalence ratio [PR] 1.97, 95% confidence interval [CI]: 1.55–2.49) and number of clinical symptoms (PR 1.23, 95% CI: 1–1.52) were significantly associated with the care-seeking behavior. Conclusions: Healthcare-seeking behavior for infectious diseases among rural people in Bangladesh was poor. Information obtained from this study could be useful to develop, design, and improve health-care systems in low-resource settings.

Assessment of the level of knowledge and universal cross-infection control practices against lassa fever among health workers in Sokoto, Nigeria: A hospital survey during lassa fever outbreak in Nigeria Catherine Fidelis, Johnson Olajolumo International Journal of Advanced Medical and Health Research 2018 5(2):57-65 Introduction: Lassa fever (LF) is an endemic West African viral hemorrhagic fever which presents acutely and is often fatal. This study assessed the level of knowledge about LF among the health workers in Sokoto State and also examined their cross-infection control practices against LF during ongoing outbreaks in health facilities in Nigeria. Methods: Data obtained from a total of 298 health workers in five hospitals in Sokoto metropolis, Nigeria, were used for this study. The study tool was a 25-item questionnaire. Data obtained were analyzed using the SPSS version 20 Software. Results: Three-tenth of the participants were within the age bracket of 26–30 years. About 54% were men, 54.4% were nursing officers, and 75.2% of the participants had practice ≤10 years. All of the surveyed medical doctors and dentists were aware of the ongoing LF outbreak in Nigeria. All of the dentists and medical laboratory scientists surveyed accurately identified the virus as the cause of LF. Only the dentists accurately identified Mastomys natalensis rodents as the vector for LF, and its transmission from person-person. Less than 20% of the participants in each occupational category did not know the universal precaution measures against infections, and about 12% of the respondents wore their personal protective equipment outside the surroundings of their duty posts. It was observed that more than 50% of the participants were below 60% on a scale of 1%–100% regarding their cross-infection and control practices. Conclusion: The findings obtained from this study revealed a very low level of knowledge about LF and very poor universal cross-infection control practices against LF among the health workers in Sokoto City, Nigeria.

Recipient hemovigilance at a tertiary care hospital in Southern India: A cross-sectional study Vikram Kumar Gente, Abhishekh Basavarajegowda, Rajendra Kulkarni, Debdatta Basu International Journal of Advanced Medical and Health Research 2018 5(2):66-70 Introduction: Information on incidence of various transfusion reactions could help in early recognition as well as management and could also help to institute adequate measures to make blood transfusion as safe as possible. The primary objective of the present study was to determine the frequency and types of adverse transfusion reactions in patients who required blood component transfusion. Methodology: This was a cross-sectional, observational study conducted over a period of 22 months from September 2014 to June 2016 in the Department of Transfusion Medicine, JIPMER. All patients admitted to the wards of various specialty departments who were transfused with blood components and reported to have transfusion reaction during or after transfusion of blood components were included in the study. Results: A total of 90,758 components were issued during the study period, and 137 transfusion reactions were reported which accounted for 0.15% of total transfusions. Febrile nonhemolytic transfusion reaction (46.7%) was the most common reaction followed by allergic reaction (31.3%). Among different blood components, packed red blood cells (82%) were most commonly associated with transfusion reactions. Conclusion: Transfusion reactions unless serious are grossly underreported either due to lack of attributing the adverse event to transfusion or because the milder reactions are usually managed and unreported as the staff are too often used to having them, especially in chronically transfused patients.

Human immunodeficiency virus-associated neurocognitive disorder masquerading as psychiatric illness Jitender Aneja, Navratan Suthar, Gopal K Bohra, Pawan Garg International Journal of Advanced Medical and Health Research 2018 5(2):71-74 Human immunodeficiency virus-1 (HIV-1)/acquired immunodeficiency syndrome (AIDS) has been shown to be associated with a constellation of neuropsychiatric disorders. The presence of depressive symptoms may obscure the evaluation of cognitive manifestation of a neurodegenerative disorder like dementia associated with AIDS. Further, it is uncommon to see catatonia in association with HIV/AIDS. In this report, we present a case who had an array of psychiatric syndromes as the initial manifestation of AIDS. The subsequent management issues are also dealt with.

A case report of dyskeratosis congenita associated with both psychosis and mood disorder Vigneshvar Chandrasekaran, Gopinath Sathyanarayanan, Vikas Menon, Balaji Bharadwaj International Journal of Advanced Medical and Health Research 2018 5(2):75-77 Dyskeratosis congenita (DC) is a rare heritable skin disorder with progressive bone marrow failure. Psychiatric manifestations could also be a presentation of this rare skin condition. Although it has been associated with psychiatric manifestations, there is a dearth of information regarding mood symptoms in this condition. We report a 41-year-old male who had presented with predominant psychotic followed by affective symptoms and was diagnosed with DC and comorbid organic delusional and mood disorder. He was also worked up for other physical manifestations of DC.

Pasteurella multocida meningitis following mastoidectomy: A case report and literature review Jamir Pitton Rissardo, Ana Letícia Fornari Caprara International Journal of Advanced Medical and Health Research 2018 5(2):78-80 Pasteurella multocida (PM) is part of the normal nasopharyngeal flora of many animals. The most common PM infections occur in soft tissue, secondary to animal contact. Meningitis is rarely associated. An adult female developed chronic right-sided otorrhea and tympanic membrane perforation. Elective mastoidectomy was performed. On the postoperative day 2, the patient experienced a decreased level of consciousness, headache, nausea, and seizures. Cerebrospinal fluid (CSF) analysis revealed low glucose, high protein, and high cellularity. Blood tests were within normal limits, except for high leukocyte count. Two days after the neurological manifestations, bacteria, identified as PM, grew in the aerobic cultures of CSF and preoperative ear swab. The isolate was sensitive to penicillins. She was started on intravenous penicillin G. The patient had a full recovery. On further questioning, she admitted having a dog, which licks on her face frequently. EDITORIAL   Cutting to cure to cutting down the incision: From kindest cut to virtually no cut  p. 41 Vikram Kate, Raja Kalayarasan DOI:10.4103/IJAMR.IJAMR_81_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta REVIEW ARTICLE Suicide prevention strategies: An overview of current evidence and best practice elements p. 43 Vikas Menon, Karthick Subramanian, Nivedhitha Selvakumar, Shivanand Kattimani DOI:10.4103/IJAMR.IJAMR_71_18   Suicide is a complex human behavior with multiple interacting determinants. Clinicians and practitioners often face difficulties in assimilating the evidence base for suicide prevention interventions, evaluating their effectiveness and decoding the best practice elements of each approach. In this article, we do not aim to provide an exhaustive coverage of every approach. Instead, we provide an overview of the following eight major suicide prevention interventions: awareness programs, screening, gatekeeper training, access to means restriction, follow-up care, hotlines, media strategies, pharmacotherapeutic and psychotherapeutic approaches. The evidence base and components of each approach are described to facilitate replication. The best practice elements are synthesized from each approach and presented to aid program development and practice. Although a number of approaches hold promise, there are difficulties in ascertaining the effective elements under each of them. Innovative research designs are needed to address this knowledge gap as it will facilitate optimal allocation of resources for suicide prevention. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta ORIGINAL ARTICLES Healthcare-seeking behavior for infectious diseases in a community in Bangladesh  p. 52 Md Shafiqul Islam Khan, Jannatul Ferdous Ani, Bithika Rani, Shafaet Jamil Apon, Fahmida Rashid, Tanjil Islam Yead, Musammet Rasheda Begum, Sukanta Chowdhury DOI:10.4103/IJAMR.IJAMR_38_18   Background: Healthcare-seeking behavior is associated with the severity of infectious diseases, particularly in low-income countries. We need better understanding about the current healthcare-seeking behavior of rural people in low-resource settings. This study aimed to describe the healthcare-seeking behavior of rural people for infectious diseases and identify the associated factors. Methods: We conducted a cross-sectional survey in a rural community in Bangladesh. We interviewed a total of 450 persons to collect data on demographics, household income, household expenditure, and healthcare-seeking behavior. We performed a descriptive analysis to summarize the demographic characteristics and multivariate logistic regression analysis to identify the association between healthcare-seeking behavior and variables of interest. Results: Among the study participants, 42% went to the health facilities, 30% went to the pharmacy, 14% went to the nonregistered doctors, 1% went to the traditional healers, 1% went to the spiritual healer, and 2% took self-treatment. Proximity of the health-care facilities (prevalence ratio [PR] 1.97, 95% confidence interval [CI]: 1.55–2.49) and number of clinical symptoms (PR 1.23, 95% CI: 1–1.52) were significantly associated with the care-seeking behavior. Conclusions:Healthcare-seeking behavior for infectious diseases among rural people in Bangladesh was poor. Information obtained from this study could be useful to develop, design, and improve health-care systems in low-resource settings. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Assessment of the level of knowledge and universal cross-infection control practices against lassa fever among health workers in Sokoto, Nigeria: A hospital survey during lassa fever outbreak in Nigeria p. 57 Catherine Fidelis, Johnson Olajolumo DOI:10.4103/IJAMR.IJAMR_11_18   Introduction: Lassa fever (LF) is an endemic West African viral hemorrhagic fever which presents acutely and is often fatal. This study assessed the level of knowledge about LF among the health workers in Sokoto State and also examined their cross-infection control practices against LF during ongoing outbreaks in health facilities in Nigeria. Methods: Data obtained from a total of 298 health workers in five hospitals in Sokoto metropolis, Nigeria, were used for this study. The study tool was a 25-item questionnaire. Data obtained were analyzed using the SPSS version 20 Software. Results: Three-tenth of the participants were within the age bracket of 26–30 years. About 54% were men, 54.4% were nursing officers, and 75.2% of the participants had practice ≤10 years. All of the surveyed medical doctors and dentists were aware of the ongoing LF outbreak in Nigeria. All of the dentists and medical laboratory scientists surveyed accurately identified the virus as the cause of LF. Only the dentists accurately identified Mastomys natalensis rodents as the vector for LF, and its transmission from person-person. Less than 20% of the participants in each occupational category did not know the universal precaution measures against infections, and about 12% of the respondents wore their personal protective equipment outside the surroundings of their duty posts. It was observed that more than 50% of the participants were below 60% on a scale of 1%–100% regarding their cross-infection and control practices. Conclusion: The findings obtained from this study revealed a very low level of knowledge about LF and very poor universal cross-infection control practices against LF among the health workers in Sokoto City, Nigeria. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Recipient hemovigilance at a tertiary care hospital in Southern India: A cross-sectional study p. 66 Vikram Kumar Gente, Abhishekh Basavarajegowda, Rajendra Kulkarni, Debdatta Basu DOI:10.4103/IJAMR.IJAMR_33_18   Introduction: Information on incidence of various transfusion reactions could help in early recognition as well as management and could also help to institute adequate measures to make blood transfusion as safe as possible. The primary objective of the present study was to determine the frequency and types of adverse transfusion reactions in patients who required blood component transfusion. Methodology: This was a cross-sectional, observational study conducted over a period of 22 months from September 2014 to June 2016 in the Department of Transfusion Medicine, JIPMER. All patients admitted to the wards of various specialty departments who were transfused with blood components and reported to have transfusion reaction during or after transfusion of blood components were included in the study. Results:A total of 90,758 components were issued during the study period, and 137 transfusion reactions were reported which accounted for 0.15% of total transfusions. Febrile nonhemolytic transfusion reaction (46.7%) was the most common reaction followed by allergic reaction (31.3%). Among different blood components, packed red blood cells (82%) were most commonly associated with transfusion reactions. Conclusion: Transfusion reactions unless serious are grossly underreported either due to lack of attributing the adverse event to transfusion or because the milder reactions are usually managed and unreported as the staff are too often used to having them, especially in chronically transfused patients. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta DISPATCHES Human immunodeficiency virus-associated neurocognitive disorder masquerading as psychiatric illness p. 71 Jitender Aneja, Navratan Suthar, Gopal K Bohra, Pawan Garg DOI:10.4103/IJAMR.IJAMR_31_18   Human immunodeficiency virus-1 (HIV-1)/acquired immunodeficiency syndrome (AIDS) has been shown to be associated with a constellation of neuropsychiatric disorders. The presence of depressive symptoms may obscure the evaluation of cognitive manifestation of a neurodegenerative disorder like dementia associated with AIDS. Further, it is uncommon to see catatonia in association with HIV/AIDS. In this report, we present a case who had an array of psychiatric syndromes as the initial manifestation of AIDS. The subsequent management issues are also dealt with. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta A case report of dyskeratosis congenita associated with both psychosis and mood disorder p. 75 Vigneshvar Chandrasekaran, Gopinath Sathyanarayanan, Vikas Menon, Balaji Bharadwaj DOI:10.4103/IJAMR.IJAMR_5_18   Dyskeratosis congenita (DC) is a rare heritable skin disorder with progressive bone marrow failure. Psychiatric manifestations could also be a presentation of this rare skin condition. Although it has been associated with psychiatric manifestations, there is a dearth of information regarding mood symptoms in this condition. We report a 41-year-old male who had presented with predominant psychotic followed by affective symptoms and was diagnosed with DC and comorbid organic delusional and mood disorder. He was also worked up for other physical manifestations of DC. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Pasteurella multocida meningitis following mastoidectomy: A case report and literature review p. 78 Jamir Pitton Rissardo, Ana Letícia Fornari Caprara DOI:10.4103/IJAMR.IJAMR_35_18   Pasteurella multocida (PM) is part of the normal nasopharyngeal flora of many animals. The most common PM infections occur in soft tissue, secondary to animal contact. Meningitis is rarely associated. An adult female developed chronic right-sided otorrhea and tympanic membrane perforation. Elective mastoidectomy was performed. On the postoperative day 2, the patient experienced a decreased level of consciousness, headache, nausea, and seizures. Cerebrospinal fluid (CSF) analysis revealed low glucose, high protein, and high cellularity. Blood tests were within normal limits, except for high leukocyte count. Two days after the neurological manifestations, bacteria, identified as PM, grew in the aerobic cultures of CSF and preoperative ear swab. The isolate was sensitive to penicillins. She was started on intravenous penicillin G. The patient had a full recovery. On further questioning, she admitted having a dog, which licks on her face frequently. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta