False Low ETCO2 Measurements From Carbon Dioxide Sampling Nasal Cannula and How to Correct the Situation.

No abstract available

http://ift.tt/2sRWTBb

Respiratory System Mechanics During Low Versus High Positive End-Expiratory Pressure in Open Abdominal Surgery: A Substudy of PROVHILO Randomized Controlled Trial.

BACKGROUND: In the 2014 PROtective Ventilation using HIgh versus LOw positive end-expiratory pressure (PROVHILO) trial, intraoperative low tidal volume ventilation with high positive end-expiratory pressure (PEEP = 12 cm H2O) and lung recruitment maneuvers did not decrease postoperative pulmonary complications when compared to low PEEP (0-2 cm H2O) approach without recruitment breaths. However, effects of intraoperative PEEP on lung compliance remain poorly understood. We hypothesized that higher PEEP leads to a dominance of intratidal overdistension, whereas lower PEEP results in intratidal recruitment/derecruitment (R/D). To test our hypothesis, we used the volumedependent elastance index %E2, a respiratory parameter that allows for noninvasive and radiation-free assessment of dominant overdistension and intratidal R/D. We compared the incidence of intratidal R/D, linear expansion, and overdistension by means of %E2 in a subset of the PROVHILO cohort. METHODS: In 36 patients from 2 participating centers of the PROVHILO trial, we calculated respiratory system elastance (E), resistance (R), and %E2, a surrogate parameter for intratidal overdistension (%E2 > 30%) and R/D (%E2

http://ift.tt/2trPm9c

In Response.

No abstract available

http://ift.tt/2sSxjvI

A Descriptive Survey of Anesthesiology Residency Simulation Programs: How Are Programs Preparing Residents for the New American Board of Anesthesiology APPLIED Certification Examination?.

BACKGROUND: Anesthesiology residency programs may need new simulation-based programs to prepare residents for the new Objective Structured Clinical Examination (OSCE) component of the American Board of Anesthesiology (ABA) Primary Certification process. The design of such programs may require significant resources, including faculty time, expertise, and funding, as are currently needed for structured oral examination (SOE) preparation. This survey analyzed the current state of US-based anesthesiology residency programs regarding simulation-based educational programming for SOE and OSCE preparation. METHODS: An online survey was distributed to every anesthesiology residency program director in the US. The survey included 15 to 46 questions, depending on each respondent's answers. The survey queried current practices and future plans regarding resident preparation specifically for the ABA APPLIED examination, with emphasis on the OSCE. Descriptive statistics were summarized. [chi]2 and Fisher exact tests were used to test the differences in proportions across groups. Spearman rank correlation was used to examine the association between ordinal variables. RESULTS: The responding 66 programs (49%) were a representative sample of all anesthesiology residencies (N = 136) in terms of geographical location ([chi]2 P = .58). There was a low response rate from small programs that have 12 or fewer clinical anesthesia residents. Ninety-one percent (95% confidence interval [95% CI], 84% -95%) of responders agreed that it is the responsibility of the program to specifically prepare residents for primary certification, and most agreed that it is important to practice SOEs (94%; 95% CI, 88%-97%) and OSCEs (89%; 95% CI, 83%-94%). While 100% of respondents reported providing mock SOEs, only 31% (95% CI, 24%-40%) of respondents provided mock OSCE experiences. Of those without an OSCE program, 75% (95% CI, 64%-83%) reported plans to start one. The most common reasons for not having an OSCE program already in place, and the perceived challenges for implementing an OSCE program, were the same: lack of time (faculty and residents), expertise in OSCE development and assessment, and funding. CONCLUSIONS: The results provide data from residency programs for benchmarking their simulation curriculum and ABA APPLIED Examination preparation offerings. Despite agreement that residency programs should prepare residents for the ABA APPLIED Examination, many programs have yet to implement an OSCE preparation program, in part due to lack of financial resources, faculty expertise, and time. Additionally, in contrast to the SOE, the OSCE is a new format for ABA primary certification. As a result, the lack of consensus concerning preparation needs could be related to the amount information that is available regarding the examination content and assessment process. (C) 2017 International Anesthesia Research Society

http://ift.tt/2ts08w3

Postpartum Tubal Sterilization: Making the Case for Urgency.

The parturient who requests postpartum sterilization has given consideration to and has made decisions regarding this aspect of her medical care long before her delivery. She arrives at parturition expecting the postpartum procedure to be performed as intended. The American Congress of Obstetricians and Gynecologists has reaffirmed its opinion that postpartum sterilization is an urgent procedure, owing to the safety and superior effectiveness of tubal sterilization via minilaparotomy in the immediate postpartum period, and the adverse consequences for mothers, babies, and society when the procedure is not actualized as desired and intended. In contrast, recent practice guidelines for obstetric anesthesia address anesthetic procedural aspects and short-term safety but overlook the long-term complications and considerations associated with failure to perform postpartum sterilization as planned. In practice, procedure completion rates are strikingly low, reportedly ranging from 31% to 52%. Reasons for failure to complete abound and include inadequate resources or inavailability of necessary personnel; obstetrician reluctance due to concerns for patient regret in younger women or medical comorbidities; barriers related to provision of obstetric care in a religiously affiliated hospital, or incomplete, improperly completed, or unavailable original federal consent forms among Medicaid-insured women. The federal requirement to wait 30 days after signing informed consent, and to retain the original signed document to be physically verified at time of the procedure, serves as a significant source of health care disparity for Medicaid-dependent mothers. This article reviews these larger issues of maternal health and comprehensive maternal care to broaden the anesthesiologist's appreciation of major benefits and potential risks of postpartum sterilization, including long-term effects, to promote an evidence-based, informed, and proactive role in delivering equitable, safe, and optimal care for these patients. (C) 2017 International Anesthesia Research Society

http://ift.tt/2sSjVbc

Investigation of Two Prototypes of Novel Noncontact Technologies for Automated Real-Time Capture of Incremental Drug Administration Data From Syringes.

BACKGROUND: An ideal electronic anesthesia recording system would be capable of not only recording physiological data but also injectable drug doses given, including those given incrementally from one syringe, without recourse to manual data entry. We compared 2 prototype devices which wirelessly recognized individual syringes and measured changes in their plunger positions via 2 different optical noncontact means, allowing calculation of incremental drug doses given. METHODS: Both devices incorporated a radio-frequency identification reader, which wirelessly read a unique code from a radio-frequency identification tag within syringe drug labels. A custom-designed cradle oriented any inserted 1-mL to 20-mL syringe in a repeatable position. The "laser" device had a moving laser beam broken by the end of the syringe plunger. The infrared (IR) device measured time of travel of IR light from a sender to a syringe plunger and back to a receiver. Both devices could therefore determine the drug and volume administered since the previous occasion when any syringe had been used. For each syringe size of 1, 2, 5, 10, and 20 mL, 121 plunger-length measurements were made over their full range, with each machine against a reference method of water filling and weighing using a randomized de Bruijn sequence. RESULTS: For every syringe size, the laser device showed greater accuracy and precision, lower bias, and narrower limits of agreement (95% confidence intervals = bias +/- 1.96 SD) than the IR device when compared to the reference method. For all syringe sizes, the range of bias was -0.05 to 0.32 mL for the laser and -2.42 to 1.38 mL for the IR. Lin concordance correlation coefficient values for the IR versus reference methods ranged from 0.6259 to 0.9255, with the lowest coefficients seen in syringes with the shortest distance of plunger travel (2 and 5 mL), while in laser versus reference comparisons, these coefficients were similar (0.9641-0.9981) over all syringe lengths. CONCLUSIONS: Both devices measured syringe volume changes, demonstrating potential for measuring incremental drug doses, recording these, and also the time of each measurement. The IR device had no moving parts, which would be advantageous in a clinical situation. However, the current embodiment was not deemed accurate enough for clinical use, potentially remediable through improvements in hardware and software design. The laser device showed high accuracy and precision over all syringe sizes and contained volumes, and was considered potentially accurate enough for clinical use with suitable development. (C) 2017 International Anesthesia Research Society

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Administration of Tetrahydrobiopterin (BH4) Protects the Renal Microcirculation From Ischemia and Reperfusion Injury.

BACKGROUND: Abdominal aortic aneurysm surgery with suprarenal cross-clamping is often associated with renal injury. Although the mechanism underlying such injury is unclear, tissue ischemia and reperfusion, which induces endothelial dysfunction and decreases the availability of tetrahydrobiopterin (BH4), may play a role. We evaluated whether BH4 administration prevents renal ischemia/reperfusion injury in an animal model of aortic cross-clamping. METHODS: Nineteen anesthetized, mechanically ventilated, and invasively monitored adult sheep were randomized into 3 groups: sham animals (n = 5) that underwent surgical preparation but no aortic clamping; an ischemia/reperfusion group (n = 7), where the aorta was clamped above the renal arteries for 1 hour, and a BH4 group (n = 7), in which animals received 20 mg/kg of BH4 followed by aortic cross-clamp for 1 hour. Animals were followed for a maximum of 6 hours after reperfusion. The renal microcirculation was evaluated at baseline (before clamping), and 1, 4, and 6 hours after reperfusion using side-stream dark field videomicroscopy. The renal lactate-to-pyruvate ratio was evaluated using microdialysis. The primary outcome was the change in proportion of small perfused vessels before and after injury. Secondary outcomes were renal tissue redox state and renal function. RESULTS: Ischemia/reperfusion injury was associated with increases in heart rate and mean arterial pressure, which were blunted by BH4 administration. From the first to the sixth hour after reperfusion, the small vessel density (estimated mean difference [EMD], 1.03; 95% confidence interval [CI], 0.41-1.64; P = .003), perfused small vessel density (EMD, 0.84; 95% CI, 0.29-1.39; P = .005), and proportion of perfused small vessels (EMD, 8.60; 95% CI, 0.85-16.30; P = .031) were altered less in the BH4 than in the ischemia/reperfusion group. The renal lactate-to-pyruvate ratios were lower in the cortex in the BH4 than in the ischemia/reperfusion group from the first to the sixth hour after reperfusion (EMD, -19.16; 95% CI, -11.06 to 33.16; P = .002) and in the medulla from the first to the fourth hour (EMD, -26.62; 95% CI, -18.32 to 38.30; P = .020; and EMD, -8.68; 95% CI, -5.96 to 12.65; P = .019). At the sixth hour, serum creatinine was lower in the BH4 than in the ischemia/reperfusion group (EMD, -3.36; 95% CI, -0.29 to 1.39; P = .026). CONCLUSIONS: In this sheep model of renal ischemia/reperfusion, BH4 pretreatment reduced renal microvascular injury and improved renal metabolism and function. Further work is needed to clarify the potential role of BH4 in ischemia/reperfusion injury. (C) 2017 International Anesthesia Research Society

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Perioperative Surgical Home: Evaluation of a New Protocol Focused on a Multidisciplinary Approach to Manage Children Undergoing Posterior Spinal Fusion Operation.

BACKGROUND: The concept of Perioperative Surgical Home has been gaining significant attention in surgical centers. This model is delivering and improving coordinated care in a cost-effective manner to patients undergoing surgical procedures. It starts with the decision for surgical intervention, continues to the intraoperative and postoperative periods, and follows into long-term recovery. Constant re-evaluation of outcomes and modifications of delivery provides a feedback loop for improvement. Children's Hospital Los Angeles initiated a new protocol in June 2014 to manage children undergoing Posterior Spinal Fusion (PSF) with the goal to improve patient experience and lower the hospital length of stay and cost. METHODS: A retrospective chart review identified patients who underwent a PSF for idiopathic scoliosis before and after initiation of a new treatment protocol designed by a team of anesthesiologists, surgeons, nurses, and physical therapists. The new protocol included preoperative teaching of parents and patients, intraoperative anesthetic and surgical management, and immediate to long-term postoperative medical management. In addition to demographics, we examined length of stay, cost of hospitalization, pain scores on discharge, length of patient-controlled analgesia use, time to first solid food intake, and time to ambulation. RESULTS: Thirty-six patients were identified preinitiation and postinitiation of the protocol (total n = 72). There was no statistically significant difference in age, sex, use of intrathecal morphine, or estimated blood loss. Patients enrolled in the new protocol had higher American Society of Anesthesiologists classification (P = .003), significantly lower duration of patient-controlled analgesia use, time to first solid food intake, and time to ambulation (P= .001). The pain scores were higher at the time of discharge, although the difference was not statistically significant. Length of stay was significantly shorter in the new protocol group (P = .001), accounting for $292,560 in cost savings for the hospital. CONCLUSIONS: These data show that the cooperation of different teams in designing new management guidelines for patients requiring a PSF can significantly decrease the total length of stay and cost of hospitalization without altering quality of care. (C) 2017 International Anesthesia Research Society

http://ift.tt/2ts3Mq3

Pupillary Unrest: Is It a Generalizable Finding?.

No abstract available

http://ift.tt/2sRWSgB

Platelet Counts and Postoperative Stroke After Coronary Artery Bypass Grafting Surgery.

BACKGROUND: Declining platelet counts may reveal platelet activation and aggregation in a postoperative prothrombotic state. Therefore, we hypothesized that nadir platelet counts after on-pump coronary artery bypass grafting (CABG) surgery are associated with stroke. METHODS: We evaluated 6 130 adult CABG surgery patients. Postoperative platelet counts were evaluated as continuous and categorical (mild versus moderate to severe) predictors of stroke. Extended Cox proportional hazard regression analysis with a time-varying covariate for daily minimum postoperative platelet count assessed the association of day-to-day variations in postoperative platelet count with time to stroke. Competing risks proportional hazard regression models examined associations between day-to-day variations in postoperative platelet counts with timing of stroke (early: 0-1 days; delayed: >=2 days). RESULTS: Median (interquartile range) postoperative nadir platelet counts were 123.0 (98.0-155.0) x 109/L. The incidences of postoperative stroke were 1.09%, 1.50%, and 3.02% for platelet counts >150 x 109/L, 100 to 150 x 109/L, and 150 x 109/L. Importantly, such thrombocytopenia, defined as a time-varying covariate, was significantly associated with delayed (>=2 days after surgery; adjusted HR, 2.83; 95% CI, 1.48.5.41; P = .0017) but not early postoperative stroke. CONCLUSIONS: Our findings suggest an independent association between moderate to severe postoperative thrombocytopenia and postoperative stroke, and timing of stroke after CABG surgery. (C) 2017 International Anesthesia Research Society

http://ift.tt/2trJJrv

In Response.

No abstract available

http://ift.tt/2sS6JTt

Epidemiologic Analysis of Elective Operative Procedures in Infants Less Than 6 Months of Age in the United States.

BACKGROUND: This study uses publicly available data to analyze the total number of elective, potentially deferrable operative procedures involving infants

http://ift.tt/2trozK1

A Shared Opportunity for Improving Electronic Medical Record Data.

With the recent rapid adoption of electronic medical records (EMRs), studies reporting results based on EMR data have become increasingly common. While analyzing data extracted from our EMR for a retrospective study, we identified various types of erroneous data entries. This report investigates the root causes of the incompleteness, inconsistency, and inaccuracy of the medical records analyzed in our study. While experienced health information management professionals are well aware of the many shortcomings with EMR data, the aims of this case study are to highlight the significance of the negative impact of erroneous EMR data, to provide fundamental principles for managing EMRs, and to provide recommendations to help facilitate the successful use of electronic health data, whether to inform clinical decisions or for clinical research. (C) 2017 International Anesthesia Research Society

http://ift.tt/2sSrqyP

Assessment of Postoperative Analgesic Drug Efficacy: Method of Data Analysis Is Critical.

BACKGROUND: Pain intensity ratings and opioid consumption (OC) are ubiquitous indicators of pain in postoperative trials of the efficacy of interventional procedures. Unfortunately, consensus on the appropriate statistical handling of these outcomes has not been reached. The aim of this article was, therefore, to reexamine original data obtained from a postoperative analgesic drug trial, applying a collection of standard statistical methods in analgesic outcome assessments. Furthermore, a modified integrated assessment method of these outcomes was evaluated. METHODS: Data from a randomized, double-blind, placebo-controlled study investigating the analgesic efficacy of a regional anesthetic block following a major elective surgical procedure were analyzed. The original data included measurements of pain intensity (visual analog scale [VAS]) at rest and during coughing (VAS0/2/4/6/12/18/24 hrs) and OC0-6/0-24 hrs administered by patient-controlled analgesia. The statistical analyses included comparisons of discrete pain intensity scores (VAS0/2/4/6/12/18/24 hrs), summary measures of pain intensity ratings (area under the curve [AUC]-VAS0-6/0-24 hrs; mean VAS0-6/0-24 hrs), and OC0-6/0-24 hrs. Finally, the analyses also included an integrated assessment of longitudinally measured pain intensity and opioid consumption (PIOC0-6/0-24 hrs). Also, estimation of effect size, generalized odds ratio of the individual analgesic outcome variables was performed. RESULTS: Sixty-one patients were included in the final data analysis. Discrete pain intensity ratings differed significantly between the treatment groups at specific postoperative time points, but appropriate correction for multiple comparisons eliminated some of these differences. AUC-VAS0-6 hrs differed significantly at rest and during coughing, while no difference was found for AUC-VAS0-24 hrs. In contrast, mean VAS0-6 hrs and VAS0-24 hrs differed significantly between treatment groups at rest and during coughing. OC0-6/0-24 hrs differed significantly between the treatment groups. Finally, also PIOC0-6/0-24 hrs differed significantly at rest and during coughing. CONCLUSIONS: Our analyses demonstrate that the applied statistical method may alter the statistical significance and estimates of effect size of analgesic outcome variables in postoperative pain trials. Our findings underline the importance of defining valid statistical methods for future analgesic drug trials. We propose an integrated assessment of longitudinally measured pain intensity and opioid consumption (PIOC). The method combines two interdependent analgesic outcomes, lowers the risk of mass significance, and provides more accurate representation of the dynamic nature of postoperative pain and analgesic drug efficacy. (C) 2017 International Anesthesia Research Society

http://ift.tt/2trJKM5

Hospital-Based Acute Care Within 7 Days of Discharge After Outpatient Arthroscopic Shoulder Surgery.

BACKGROUND: The rate of hospital-based acute care (defined as hospital transfer at discharge, emergency department [ED] visit, or subsequent inpatient hospital [IP] admission) after outpatient procedure is gaining momentum as a quality metric for ambulatory surgery. However, the incidence and reasons for hospital-based acute care after arthroscopic shoulder surgery are poorly understood. METHODS: We studied adult patients who underwent outpatient arthroscopic shoulder procedures in New York State between 2011 and 2013 using the Healthcare Cost and Utilization Project database. ER visits and IP admissions within 7 days of surgery were identified by cross-matching 2 independent Healthcare Cost and Utilization Project databases. RESULTS: The final cohort included 103,476 subjects. We identified 1867 (1.80%, 95% confidence interval [CI], 1.72%-1.89%) events, and the majority of these encounters were ER visits (1643, or 1.59%, 95% CI, 1.51%-1.66%). Direct IP admission after discharged was uncommon (224, or 0.22%, 95% CI, 0.19%-0.24%). The most common reasons for seeking acute care were musculoskeletal pain (23.78% of all events). Nearly half of all events (43.49%) occurred on the day of surgery or on postoperative day 1. Operative time exceeding 2 hours was associated with higher odds of requiring acute care (odds ratio [OR], 1.28; 99% CI, 1.08-1.51). High-volume surgical centers (OR, 0.67; 99% CI, 0.58-0.78) and regional anesthesia (OR, 0.72; 99% CI, 0.56-0.92) were associated with lower odds of requiring acute care. CONCLUSIONS: The rate of hospital-based acute care after outpatient shoulder arthroscopy was low (1.80%). Complications driving acute care visits often occurred within 1 day of surgery. Many of the events were likely related to surgery and anesthesia (eg, inadequate analgesia), suggesting that anesthesiologists may play a central role in preventing acute care visits after surgery. (C) 2017 International Anesthesia Research Society

http://ift.tt/2trNcGK

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital.

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service. (C) 2017 International Anesthesia Research Society

http://ift.tt/2sScaSj

Stroke Volume Variation-Guided Versus Central Venous Pressure-Guided Low Central Venous Pressure With Milrinone During Living Donor Hepatectomy: A Randomized Double-Blinded Clinical Trial.

BACKGROUND: We previously demonstrated the usefulness of milrinone for living donor hepatectomy. However, a less-invasive alternative to central venous catheterization and perioperative contributors to good surgical outcomes remain undetermined. The current study evaluated whether the stroke volume variation (SVV)-guided method can substitute central venous catheterization during milrinone-induced profound vasodilation. METHODS: We randomly assigned 42 living liver donors to receive either SVV guidance or central venous pressure (CVP) guidance to obtain milrinone-induced low CVP. Target SVV of 9% was used as a substitute for CVP of 5 mm Hg. The surgical field grade evaluated by 2 attending surgeons on a 4-point scale was compared between the CVP- and SVV-guided groups (n = 19, total number of scores = 38 per group) as a primary outcome variable. Multivariable analysis was performed to identify independent factors associated with the best surgical field as a post hoc analysis. RESULTS: Surgical field grades, which were either 1 or 2, were not found to be different between the 2 groups via Mann-Whitney U test (P = .358). There was a very weak correlation between SVV and CVP during profound vasodilation such as CVP

http://ift.tt/2tro0jt

Improving Outcomes in Emergency General Surgery Patients: What Evidence Is Out There?.

No abstract available

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Cardiac cycle efficiency and dicrotic pressure variations: new parameters for fluid therapy: A pilot observational study.

BACKGROUND: During a fluid challenge, the changes in cardiac performance and peripheral circulatory tone are closely related to the position of the ventricle on the Frank-Starling curve. Some patients have a good haemodynamic response to a fluid challenge, others hardly any response. The early haemodynamic effects of a fluid challenge could predict the final response before the entire fluid volume has been administered. OBJECTIVE: To assess whether a multivariate logistic regression model, including pulse pressure variation (PPV), cardiac cycle efficiency (CCE), arterial elastance and the difference between the dicrotic pressure and both systolic and mean arterial pressure (SAP - Pdic and MAP - Pdic) can predict cardiac responsiveness early during a fluid challenge in comparison with the standard procedure described elsewhere. DESIGN: Observational pilot study. SETTING: Elective surgical patients undergoing laparotomy, enrolled in two Italian University Hospitals. PATIENTS: Fifty adult surgical patients, ventilated with a lung protective strategy, were enrolled and data from 46 were analysed. INTERVENTIONS: A fluid challenge consisting of 500 ml of crystalloid infused over 10 min. MAIN OUTCOME MEASURES AND ANALYSIS: The changes in CCE, arterial elastance, SAP - Pdic and MAP - Pdic were compared using analysis of variance. A multivariate logistic regression analysis utilising baseline values and the first minute measuring a variation statistically significant for the considered variables. RESULTS: At baseline, PPV correctly identified 70% of patients (89% of non-responders; 42% of responders). The model, including baseline PPV, [DELTA]CCE and [DELTA]SAP - Pdic, correctly identified the efficiency of fluid challenge in 87% of patients (84.2% of responders; 92.5 of non-responders) after 5 min from fluid challenge infusion. CONCLUSION: In this pilot study conducted in a population of surgical patients mechanically ventilated with a VT less than 8 ml kg-1, a dynamic model of fluid challenge assessment, including PPV, [DELTA]CCE and [DELTA]SAP - Pdic, enhances the prediction of fluid challenge response after 5 min of a 10-min administration. TRIAL REGISTRATION: ACTRN12616001479493. (C) 2017 European Society of Anaesthesiology

http://ift.tt/2sOKLAe

Pulse photoplethysmographic amplitude and heart rate variability during laparoscopic cholecystectomy: A prospective observational study.

BACKGROUND: Surgical stress affects the autonomic nervous system by increasing sympathetic outflow. One method of monitoring sympathetic activity is pulse photoplethysmographic analysis. From this two indices can be derived - autonomic nervous system state (ANSS) and ANSS index (ANSSi). It has recently been claimed that these indices can be used to measure sympathetic activity in anaesthetised patients, but their validity has not yet been demonstrated. OBJECTIVE: To measure changes in pulse photoplethysmographic indices and determine any agreement with autonomic nervous system modulation of the cardiovascular system in healthy study participants during surgery under general anaesthesia. DESIGN: Prospective observational study. SETTING: Single-centre study based at a tertiary care centre in Milan, Italy. PATIENTS: Healthy patients undergoing general anaesthesia for elective laparoscopic cholecystectomy. INTERVENTIONS: ANSS, ANSSi, and heart rate variability (HRV) were analysed at three main times: baseline, after induction of general anaesthesia, and after pneumoperitoneum insufflation. MAIN OUTCOME MEASURES: The magnitude of changes in photoplethysmographic and HRV indices was measured. The agreement between pulse photoplethysmographic and HRV-derived indices was assessed by Bland-Altman plots. RESULTS: In total, 52 patients were enrolled and their data analysed. Both pulse photoplethysmographic and HRV indices changed during the study phases. An agreement was found between ANSSi and low frequency spectral components of HRV [bias 10.2nu, 95% confidence interval (CI) -13 to 33.4], high frequency spectral components of HRV (bias 6.1 nu, 95% CI -16.3-28.6), and low frequency/high frequency ratio (bias 16.1nu, 95% CI -1.4-33.5). The agreement was weaker between ANSSI and HRV indices. CONCLUSION: The study endorses the use of pulse photoplethysmographic indices ANSS and ANSSi as surrogates to estimate changes of autonomic modulation of the cardiovascular system in healthy adults during surgery under general anaesthesia. Orcid ID: http://ift.tt/2tMAaTr. (C) 2017 European Society of Anaesthesiology

http://ift.tt/2sOK3mq

The relative effects of dexmedetomidine and propofol on cerebral blood flow velocity and regional brain oxygenation: A randomised noninferiority trial.

BACKGROUND: Dexmedetomidine constricts cerebral blood vessels without a concomitant reduction in cerebral metabolic oxygen consumption. Its safety as a sedative in patients with neurological diseases thus remains uncertain. OBJECTIVE: Our primary objective was to test the hypothesis that dexmedetomidine is noninferior to propofol as regards cerebral blood flow (CBF) velocity and brain oxygenation. DESIGN: Unblinded randomised trial. SETTING: Cleveland Clinic Hospital, Cleveland, from November 2010 to July 2013. PATIENTS: Forty-four patients scheduled for insertion of a deep-brain stimulating electrodes. INTERVENTIONS: Patients were randomised to receive either dexmedetomidine or propofol sedation during deep-brain stimulating electrode insertion. MAIN OUTCOME MEASURES: Intraoperative CBF velocity was measured with transcranial Doppler, and brain oxygenation was assessed with near-infrared spectroscopy. Noninferiority of dexmedetomidine to propofol was defined as a less than 20% difference in means. RESULTS: Twenty-three patients were given dexmedetomidine and 21 propofol. Baseline characteristics and operative management were similar in each group. Dexmedetomidine was noninferior to propofol on both CBF and brain oxygenation, confirming our primary hypothesis. For cerebral flood flow, the estimated ratio of means (dexmedetomidine/propofol) was 0.94 [90% CI: 0.84 to 1.05], P = 0.011 for noninferiority. For brain oxygenation, the estimated ratio of means was 0.99 [90% CI: 0.96 to 1.02], P

http://ift.tt/2sOmPg7

Achalasia leading to diagnosis of adenocarcinoma of the oesophagus

A 50-year-old male with a 7 month history of progressive dysphagia to solids then subsequently to liquids. He underwent a diagnostic gastroscopy which was normal. A further barium swallow suggested achalasia. He was referred to a tertiary centre, where he underwent pH and manometry studies which confirmed a diagnosis of achalasia. He was referred for a laparoscopic cardiomyotomy, and at surgery there was a suspected tumour at the gastro-oesophageal junction. A follow-up endoscopy with biopsies was normal. Following this, a positron emission tomography scan showed T3 distal oesophageal cancer with no nodal involvement or distal metastasis. An attempt at oesophagectomy was performed, but at operation there was locally advanced carcinoma infiltrating the coeliac axis. He is currently undergoing palliative chemotherapy.

http://ift.tt/2rBuFX3

Racial disparity in mycosis fungoides: An analysis of 4495 cases from the US National Cancer Database

Studies have shown contradictory results regarding the survival outcomes among white, African American, and Asian patients with mycosis fungoides (MF).

http://ift.tt/2tLD22Z

Association of bullous pemphigoid with malignancy: A systematic review and meta-analysis

Studies evaluating whether malignancy rate is increased in patients with bullous pemphigoid (BP) have reached conflicting results.

http://ift.tt/2sOl2YE

Per Operative Study of Relation of Zuckerkandl Tubercle with Recurrent Laryngeal Nerve in Thyroid Surgery

Abstract

To identify Zuckerkandl tubercle and to determine relationship between the recurrent laryngeal nerve and Zuckerkandl tubercle (ZT). Peroperative study. Intraoperatively Zuckerkandl tubercle was identified. Size of the thyroid lobe and Zuckerkandl tubercle were co-related and direction of tubercle in relation to recurrent laryngeal nerve was examined. Grading of tubercle on the basis of size was done. We studied its direction and relation with recurrent laryngeal nerve. ZT was identified in 87.86% (179 out of 206) of cases. In the study amongst the 179 cases in whom ZT could be identified, ZT was found on the right side (85.41% i.e. 123 out of 144), 81.41% (92 out of 113) to the left side and 15.68% (8 out of 51) were B/L. ZT was found posterior to the tubercle in 97.22%(175 out of 179) cases and anterior to the tubercle in 2.77% (5 out of 179) cases. The relationship between recurrent laryngeal nerve and ITA was studied. ITA was anterior to RLN (in 70.89%) and posterior to RLN in 29.10%. Thus, ZT is an important landmark for identification of RLN during thyroidectomy (p value 0.001).

Level of evidence III

http://ift.tt/2sndA61

Odontogenic orbital cellulitis associated with cavernous sinus thrombosis and pulmonary embolism: a case report

This case illustrates the importance of prompt assessment and treatment of orbital cellulitis. In fact the ocular signs and symptoms may be associated with systemic complications which should be investigated a...

http://ift.tt/2snz6aI

Conservative management of oral submucous fibrosis in early and intermediate stage

Publication date: Available online 19 June 2017
Source:Journal of Oral Biology and Craniofacial Research
Author(s): Sachin Rai, Vidya Rattan, Akshat Gupta, Praveen Kumar
Aims & objectiveTo evaluate the efficacy of combined intralesional injection of Hyaloronidase and Triamcinolone with third molar removal in early and intermediate stage (Stage II & III) of Oral Submucous Fibrosis (OSMF) for improvement in mouth opening and hypersensitivity to food.Study design48 patients in stage II & III OSMF were selected for the study. All the third molars were extracted in each patient followed by 6 to 8 doses of combined intralesional injection of Hyaloronidase and triamcinolone at 10days interval targeting the fibrotic bands. Mouth opening and improvement in hypersensitivity to food was noted by numerical grading. The patients were followed for one year at regular intervals. The data was expressed as mean ±SD, and a probability (p) value of < 0.05 was considered significant.ResultsThe initial mouth opening in Stage II patients (n=27) was 30±3.0mm and in Stage III patients (n=21) was 19±3.5mm and the increase in mouth opening at the end of treatment was 11.3±1.9mm and 10.2±2.3mm respectively. The mean improvement in hypersensitivity to food in both the groups was 2.9 and 2.2 respectively.ConclusionThere is significant improvement in grade II patients in mouth opening and hypersensitivity to food. Grade III patients show variable improvement or no improvement wherein surgery becomes the only option. Third molar extraction helps in reducing inflammation and fibrosis in the retromolar region thus easing in mouth opening. This combined approach for moderately staged OSMF can be proposed as a viable conservative modality.



http://ift.tt/2tKGTx3

Characterization of slow-cycling cells in the mouse cochlear lateral wall

by Yang Li, Kotaro Watanabe, Masato Fujioka, Kaoru Ogawa

Cochlear spiral ligament fibrocytes (SLFs) play essential roles in the physiology of hearing including ion recycling and the generation of endocochlear potential. In adult animals, SLFs can repopulate after damages, yet little is known about the characteristics of proliferating cells that support SLFs' self-renewal. Here we report in detail about the characteristics of cycling cells in the spiral ligament (SL). Fifteen P6 mice and six noise-exposed P28 mice were injected with 5-bromo-2′-deoxyuridine (BrdU) for 7 days and we chased BrdU retaining cells for as long as 60 days. Immunohistochemistry revealed that the BrdU positive IB4 (an endotherial marker) negative cells expressed an early SLF marker Pou3f4 but negative for cleaved-Caspase 3. Marker studies revealed that type 3 SLFs displayed significantly higher percentage of BrdU⁺ cells compared to other subtypes. Notably, the cells retained BrdU until P72, demonstrating they were dividing slowly. In the noise-damaged mice, in contrast to the loss of the other types, the number of type 3 SLFs did not altered and the BrdU incorporating- phosphorylated Histone H3 positive type 3 cells were increased from day 1 to 14 after noise exposure. Furthermore, the cells repopulating type 1 area, where the cells diminished profoundly after damage, were positive for the type 3 SLF markers. Collectively, in the latral wall of the cochlea, type 3 SLFs have the stem cell capacity and may contribute to the endogenous regeneration of lateral wall spiral ligament. Manipulating type 3 cells may be employed for potential regenerative therapies.

http://ift.tt/2sSYgiI

Per Operative Study of Relation of Zuckerkandl Tubercle with Recurrent Laryngeal Nerve in Thyroid Surgery

Abstract

To identify Zuckerkandl tubercle and to determine relationship between the recurrent laryngeal nerve and Zuckerkandl tubercle (ZT). Peroperative study. Intraoperatively Zuckerkandl tubercle was identified. Size of the thyroid lobe and Zuckerkandl tubercle were co-related and direction of tubercle in relation to recurrent laryngeal nerve was examined. Grading of tubercle on the basis of size was done. We studied its direction and relation with recurrent laryngeal nerve. ZT was identified in 87.86% (179 out of 206) of cases. In the study amongst the 179 cases in whom ZT could be identified, ZT was found on the right side (85.41% i.e. 123 out of 144), 81.41% (92 out of 113) to the left side and 15.68% (8 out of 51) were B/L. ZT was found posterior to the tubercle in 97.22%(175 out of 179) cases and anterior to the tubercle in 2.77% (5 out of 179) cases. The relationship between recurrent laryngeal nerve and ITA was studied. ITA was anterior to RLN (in 70.89%) and posterior to RLN in 29.10%. Thus, ZT is an important landmark for identification of RLN during thyroidectomy (p value 0.001).

Level of evidence III

http://ift.tt/2sndA61

Atopic dermatitis is associated with anxiety, depression, and suicidal ideation, but not with hospitalization or suicide

Abstract

Background

Atopic dermatitis (AD) has been linked with psychiatric disease in adults. However, the exact relationship and its consequences have been insufficiently studied. Our aim in this study was to assess the association between depression, anxiety and AD in adults, and examine the risk of hospitalization and suicide.

Methods

We utilized questionnaire data from a large general population study with data on social habits and psychiatric symptoms to compare prevalences of depression, anxiety, suicidal ideation, and anxiety attacks, in adults with and without a history of AD. Additionally we used nationwide hospital/clinic registry and prescription data to examine the risk of anxiety and depression in Danish adults with mild and moderate-severe AD, as well as the risk of hospitalization and suicide.

Results

In the general population study, those with AD reported clinician-diagnosed depression and anxiety more often than non-AD subjects, and had an increased prevalence of suicidal ideation and depressive symptoms. In the health registry study, moderate-severe AD patients had increased risk of antidepressant and anxiolytic medication use, while patients with mild AD only had increased risk of anxiolytic medication use. There was no increased risk of hospitalization or outpatient contacts due to depression or anxiety, or risk of suicide in AD patients.

Conclusions

Depression, anxiety, and suicidal ideation are more common among AD individuals, but do not to lead to psychiatric consultations, hospitalization, or suicide.

This article is protected by copyright. All rights reserved.

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A prospective microbiome-wide association study of food sensitization and food allergy in early childhood

Abstract

Background

Alterations in the intestinal microbiome are prospectively associated with the development of asthma; less is known regarding the role of microbiome alterations in food allergy development.

Methods

Intestinal microbiome samples were collected at age 3-6 months in children participating in the follow-up phase of an interventional trial of high dose Vitamin D given during pregnancy. At age 3, sensitization to foods (milk, egg, peanut, soy, wheat, walnut) was assessed. Food allergy was defined as caretaker report of healthcare provider-diagnosed allergy to the above foods prior to age 3 with evidence of IgE sensitization. Analysis was performed using Phyloseq and DESeq2; p-values were adjusted for multiple comparisons.

Results

Complete data were available for 225 children; there were 87 cases of food sensitization and 14 cases of food allergy. Microbial diversity measures did not differ between food sensitization and food allergy cases and controls. The genera Haemophilus (log₂ fold change -2.15, p=0.003), Dialister (log₂ fold change -2.22, p=0.009), Dorea (log₂ fold change -1.65, p=0.02) and Clostridium (log₂ fold change -1.47, p=0.002) were underrepresented among subjects with food sensitization. The genera Citrobacter (log₂ fold change -3.41, p=0.03), Oscillospira (log₂ fold change -2.80, p=0.03), Lactococcus (log₂ fold change -3.19, p=0.05) and Dorea (log₂ fold change -3.00, p=0.05) were underrepresented among subjects with food allergy.

Conclusions

The temporal association between bacterial colonization and food sensitization and allergy suggests that the microbiome may have a causal role in the development of food allergy. Our findings have therapeutic implications for the prevention and treatment of food allergy.

This article is protected by copyright. All rights reserved.

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Critical biological parameters modulate affinity as a determinant of function in T-cell receptor gene-modified T-cells

Abstract

T-cell receptor (TCR)-pMHC affinity has been generally accepted to be the most important factor dictating antigen recognition in gene-modified T-cells. As such, there is great interest in optimizing TCR-based immunotherapies by enhancing TCR affinity to augment the therapeutic benefit of TCR gene-modified T-cells in cancer patients. However, recent clinical trials using affinity-enhanced TCRs in adoptive cell transfer (ACT) have observed unintended and serious adverse events, including death, attributed to unpredicted off-tumor or off-target cross-reactivity. It is critical to re-evaluate the importance of other biophysical, structural, or cellular factors that drive the reactivity of TCR gene-modified T-cells. Using a model for altered antigen recognition, we determined how TCR–pMHC affinity influenced the reactivity of hepatitis C virus (HCV) TCR gene-modified T-cells against a panel of naturally occurring HCV peptides and HCV-expressing tumor targets. The impact of other factors, such as TCR–pMHC stabilization and signaling contributions by the CD8 co-receptor, as well as antigen and TCR density were also evaluated. We found that changes in TCR–pMHC affinity did not always predict or dictate IFNγ release or degranulation by TCR gene-modified T-cells, suggesting that less emphasis might need to be placed on TCR–pMHC affinity as a means of predicting or augmenting the therapeutic potential of TCR gene-modified T-cells used in ACT. A more complete understanding of antigen recognition by gene-modified T-cells and a more rational approach to improve the design and implementation of novel TCR-based immunotherapies is necessary to enhance efficacy and maximize safety in patients.

http://ift.tt/2rRDQBU

Peritumoral Cuffing by T cell Tumor Infiltrating Lymphocytes Distinguishes HPV-Related Oropharyngeal Squamous Cell Carcinoma from Oral Cavity Squamous Cell Carcinoma

Abstract

Background

It is unclear why human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) has improved clinical behavior compared to HPV-negative HNSCC. We sought to better characterize the immune microenvironment of tongue cancers by examining the CD3 and CD8 TIL pattern in HPV-positive and -negative tumors.

Methods

Histologic sections from 40 oral tongue and oropharyngeal cases were analyzed (n= 21 HPV DNA-positive, n= 19 HPV DNA-negative). CD3 and CD8 T cell immunostaining was performed on whole slide sections to quantify tumor infiltrating lymphocyte (TIL) density and assess its morphology.

Results

A subset of cases (HPV-positive), displayed a unique TIL pattern consisting of circumferential peritumoral population T cells, which was absent in the HPV-negative cases. The presence of peritumoral cuffing was strongly predictive of improved recurrence free survival compared to cases that lacked this morphologic pattern of immune infiltrate. Four HPV-positive cases lacked the pattern, including two cases with disease recurrence.

Conclusions

For the first time, we show an architectural pattern of immune infiltrate in HNSCC is seen exclusively in HPV-positive patients with improved recurrence free survival and suggests an organized host immunological response contributes to disease control.

This article is protected by copyright. All rights reserved.

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Improve endotracheal intubation with First and TEN approach

Taking the time to prepare for intubation success on the First pass and following the Tongue, Epiglottis and arytenoid Notch landmarks will stack the cards in your favor during both routine and difficult airway scenarios. When attempting endotracheal intubation, most paramedics focus on quickly visualizing the vocal cords so I developed the First and TEN approach to slow the process to improve first ...

http://ift.tt/2sx6qur

Effect of C1-INH on ischemia/reperfusion injury in a porcine limb ex vivo perfusion model

Publication date: August 2017
Source:Molecular Immunology, Volume 88
Author(s): Mai M. Abdelhafez, Jane Shaw, Damian Sutter, Jonas Schnider, Yara Banz, Hansjörg Jenni, Esther Voegelin, Mihai A. Constantinescu, Robert Rieben
Revascularization of an amputated limb within 4–6h is essential to avoid extensive ischemia/reperfusion (I/R) injury leading to vascular leakage, edema and tissue necrosis. I/R injury is a pathological inflammatory condition that occurs during reperfusion of an organ or tissue after prolonged ischemia. It is characterized by a complex crosstalk between endothelial cell activation and the activation of plasma cascades. Vasculoprotective pharmacological intervention to prevent I/R injury might be an option to prolong the time window between limb amputation and successful replantation. We used C1-easterase inhibitor (C1-INH) in this study because of its known inhibitory effects on the activation of the complement, coagulation and kinin cascades. Forelimbs of 8 large white pigs were amputated, subjected to ischemia, and then reperfused with autologous whole blood. All limbs were exposed to 9h of cold ischemia at 4°C. After 2h of cold ischemia the limbs were either perfused with of C1-INH (1U/ml in hydroxyethyl starch, n=8) or hydroxyethyl starch alone (n=7). After completion of the 9-h ischemia period, all limbs were ex vivo perfused with heparinized autologous whole blood for 12h using a pediatric heart lung machine to simulate in vivo revascularization. Our results show that I/R injury in the control group led to a significant elevation of tissue deposition of IgG and IgM, complement C3b/c, C5b-9 and MBL. Also, activation of the kinin system was significantly increased, namely bradykinin in plasma, and expression of bradykinin receptors 1 and 2 in tissue. In addition, markers for endothelial integrity like expression of CD31, VE-cadherin and heparan sulfate proteoglycans were decreased in reperfused tissue. Limb I/R injury also led to activation of the coagulation cascade with a significant elevation of fibrin and thrombin deposition and increased fibrinogen-like protein-2 expression. C1-INH treated limbs showed much less activation of plasma cascades and better protection of endothelial integrity compared to the reperfused control limbs. In conclusion, the use of the cytoprotective drug C1-INH significantly reduced I/R injury by protecting the vascular endothelium as well as the muscle tissue from deposition of immunoglobulins, complement and fibrin.



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RAG2 involves the Igκ locus demethylation during B cell development

Publication date: August 2017
Source:Molecular Immunology, Volume 88
Author(s): Caijun Wu, Yanying Dong, Xiaohui Zhao, Ping Zhang, Mingzhe Zheng, Hua Zhang, Shichang Li, Yaofeng Jin, Yunfeng Ma, Huixun Ren, Yanhong Ji
The genes encoding the immunoglobulin κ light chain are assembled during B cell development by V(D)J recombination. For efficient rearrangement, the Igκ locus must undergo a series of epigenetic changes. One such epigenetic mark is DNA methylation. The mechanism that the Igκ locus is selectively demethylated at the pre-B cell stage has not previously been characterized. Here, we employed bisulfite DNA-modification assays to analyze the methylation status of the Igκ locus in primary pre-B cells from RAG-deficient mice with pre-rearranged Igh knock-in allele. We observed that the Igκ locus was hypermethylated in RAG2-deficient pre-B cells but hypomethylated in RAG1-deficient pre-B cells, indicating that wild-type (WT) RAG2 involves the Igκ locus demethylation in a RAG1-independent manner prior to rearrangement. We generated a series of RAG2 mutants between residue 350 and 383. We showed that these mutants mediated the Igκ rearrangement but failed to regulate the Igκ gene demethylation. We further analyzed that these mutants could increase RAG recombinase activity in vivo. We conclude that residues 350–383 region are responsible for endogenous Igκ locus demethylation at pre-B cells. We propose that WT RAG2 has an intrinsic function to regulate the Igκ locus demethylation.



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IL-18/IL-15/IL-12 synergy induces elevated and prolonged IFN-γ production by ex vivo expanded NK cells which is not due to enhanced STAT4 activation

Publication date: August 2017
Source:Molecular Immunology, Volume 88
Author(s): Evan Lusty, Sophie M. Poznanski, Karen Kwofie, Talveer S. Mandur, Dean A. Lee, Carl D. Richards, Ali A. Ashkar
The synergistic effect of IL-18/IL-15/IL-12 stimulation potently activates NK cells, inducing high levels of IFN-γ production. As a result of this potent stimulatory effect, NK cell pre-activation with IL-18/IL-15/IL-12 is being developed as a cancer immunotherapy. Ex vivo expansion of NK cells enables the efficient generation of large numbers of NK cells for wide-scale and repeated therapeutic use, and is thus an important source of NK cells for clinical application. However, the effects of IL-18/IL-15/IL-12 stimulation on ex vivo expanded NK cells have not yet been assessed. Thus, the present study assessed the effects of IL-18/IL-15/IL-12 stimulation on NK cells expanded ex vivo using K562-based artificial antigen presenting cells expressing membrane-bound IL-21. We report that ex vivo expanded NK cells stimulated with IL-18/IL-15/IL-12 produce high levels of IFN-γ and TNFα, have potent cytotoxicity, and maintain prolonged IFN-γ production following removal of stimulation. IL-18/IL-15/IL-12 stimulation induces a phenotypically unique IFN-γ-producing population with reduced CD16 expression and greater CD25 expression as compared to stimulated IFN-γ- NK cells and unstimulated NK cells. We elucidate that the mechanism of synergy for induction and maintenance of IFN-γ production is not due to a further enhancement of STAT4 activation compared to stimulation with IL-12 alone. Furthermore, we demonstrate that the synergistic increase in IFN-γ is not solely under translational regulation, as elevated levels of IFN-γ mRNA contribute to the synergistic increase in IFN-γ. Overall, this study characterizes the response of ex vivo expanded NK cells to IL-18/IL-15/IL-12 stimulation and supports the use of ex vivo expanded NK cells as a feasible and efficient source of IL-18/IL-15/IL-12 pre-activated NK cells for adoptive transfer in cancer immunotherapies.



http://ift.tt/2sxLVOk

Advantages of targeting B cell receptor complex to treat B-cell derived autoimmune diseases and lymphomas

Publication date: August 2017
Source:Molecular Immunology, Volume 88
Author(s): Jemal Adem, Mine Eray, Jonna Eeva, Ulla Nuutinen, Jukka Pelkonen
Antibodies produced by B-cells provide protection from infectious agents. However, impaired cell death signaling pathways in B-cells can lead to cancer, immunodeficiency or autoimmune diseases. B-cell signaling molecules such as CD20, CD19, Btk, and BAFF-R are targeted by therapeutic drugs and used to treat B-cell derived lymphomas or autoimmune diseases. Nevertheless, B-cells could develop resistance to these therapeutic drugs or the therapeutic drugs may have off-target effects. For instance, repeated rituximab (anti-CD20 antibody) treatment may lead to the loss of its target cell surface molecule, CD20. In addition, in B-cell malignancies, loss of CD19 expression has been observed. Another target molecule, Btk is expressed not only in B-cells but also in mast cells, macrophages, and dendritic cells. Thus, targeting Btk could negatively regulate the functions of innate immunity. The expression of BAFF-R is thought to be restricted to B-cells but it is also expressed on T-cells. Targeting BAFF-R, therefore, may lead to depletion of T-cells in addition to B-cells. B cell receptor (BCR) expression and signaling, however, are critically important for development, differentiation and survival of B-cells. Moreover, BCR is exclusively expressed on B-cells, which makes it an excellent target to avoid off-target effects.



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Comparison of endocranial morphology according to age in one-piece fronto-orbital advancement using a distraction in craniosynostotic plagiocephaly

Publication date: Available online 17 June 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Woo Shik Jeong, Ersin Altun, Jong Woo Choi, Young Shin Rah
The capacity for cranial remodelling is known to be better at younger ages. The timing of cranioplasty could affect the axis of the skull base. We investigated whether age at the time of distraction is related to the outcome of endocranial morphology correction. In this retrospective study, we investigated the surgical outcome of 14 patients with unilateral craniosynostotic plagiocephaly who underwent one-piece fronto-orbital advancement without bandeau by using a distraction technique between April 2005 and December 2015. Satisfactory results were achieved in all 14 patients with unilateral coronal suture craniosynostosis. An average distraction of 27.3 mm was obtained without detachment from the dura mater. The endocranial angulation of the anteroposterior axis was reduced from 165.4° to 173.5° on average, and the average total change was 8.1°. Between patients aged <1 year and those >1 year, there was a statistically significant difference in the postoperative endocranial angulation of the anteroposterior axis after 3 months (p = 0.003). The distraction techniques resulted in better correction of endocranial morphology. This indicates that the changes in the skull base axis after one-piece fronto-orbital advancement without bandeau are related to the remodelling capacity of the skull base in growing children based on the dura mater.



http://ift.tt/2rRs6ze

BOTOX® (Botulinum Toxin Type A) as Headache Prophylaxis in Chinese Participants With Chronic Migraine

Condition:   Migraine Disorders
Interventions:   Biological: botulinum toxin Type A;   Drug: placebo (sodium chloride 0.9 mg)
Sponsor:   Allergan
Not yet recruiting - verified June 2017

http://ift.tt/2tp5FUe

Open Label Study of BOTOX® (Botulinum Toxin Type A) as Headache Prophylaxis in Chinese Patients With Chronic Migraine

Condition:   Migraine Disorders
Intervention:   Biological: botulinum toxin Type A
Sponsor:   Allergan
Not yet recruiting - verified June 2017

http://ift.tt/2toWzqD

Apatinib Combined With Docetaxel in the Treatment of Advanced Esophageal Squamous Cell Carcinoma

Condition:   Advanced Esophageal Squamous Carcinoma
Intervention:   Drug: Apatinib
Sponsor:   The First Affiliated Hospital of Zhengzhou University
Recruiting - verified June 2017

http://ift.tt/2sPhk1A

First reported case of paratesticular seminoma in a postpubertal cryptorchid testis

Abstract

Cryptorchidism is a very common anomaly, affecting 2–4% of male infants and is more common in premature infants. The long-term outcome despite orchidopexy still remains problematic and controversial with a risk of developing cancer 5–10 times greater than normal. Paratesticular tumors are mostly benign and very rare in children however malignant paratesticular tumors do arise, the most common being rhabdomyosarcoma. Primary paratesticular seminoma is extremely rare by itself and in most cases is associated with foci of seminoma within the testis. To the best of our knowledge, our case represents the fourth reported case of paratesticular seminoma in the published literature and being the first one in cryptorchid testis.

http://ift.tt/2sx8O4g

Single-stage reconstruction for buccal mucosa tumor resection including the labial commissure using a facial artery musculomucosal flap and a vermilion advancement flap

Abstract

Resection of buccal mucosa tumors may occasionally involve the labial angle and peripheral skin. Reconstruction is required when the resection involves more than one-third of the lip. We describe a single-stage reconstruction using a facial artery musculomucosal (FAMM) flap and a vermilion advancement flap after buccal mucosa resection including the labial angle. A 62-year-old woman with carcinoma in situ of the buccal mucosa underwent tumor resection. The resection included the right labial angle and peripheral skin. The resection did not lead to a massive lip defect, but a wide defect resulted on the mucosal side. The defect on the mucosal side was reconstructed using a FAMM flap, while the vermilion defect was covered using a vermilion advancement flap. Reconstruction performed using the FAMM flap and vermilion advancement flap produced aesthetically and functionally satisfactory outcomes.

http://ift.tt/2sx8N0c

Complete cricotracheal transection due to blunt neck trauma without significant symptoms

Abstract

Laryngotracheal injuries are relatively rare but their mortality rate is fairly high. Complete disruption of trachea is extremely rare and a systematic approach is needed for early diagnosis and favourable outcome. The patients symptoms and physical signs do not necessarily correlate with the severity of the injuries and this case report highlights it. This is a case report of 25-year-old man who arrived to the emergency department 8 h after a motor accident in which a rope was wrapped around his neck. Because of the good general and respiratory condition of the patient on admission, the pathognomonic signs of laryngeal injury were not noticed. A computed tomographic scan showed distortion of cricotracheal framework. Flexible bronchoscopy showed cricotracheal transaction. Immediately, the endotracheal tube was advanced distal to the transection site under bronchoscopic guide and then after neck exploration primary end-to-end cricotracheal anastomosis was performed.

http://ift.tt/2swYYzx

Biological activity of glatiramer acetate on Treg and anti-inflammatory monocytes persists for more than 10years in responder multiple sclerosis patients

Publication date: Available online 19 June 2017
Source:Clinical Immunology
Author(s): Michela Spadaro, Francesca Montarolo, Simona Perga, Serena Martire, Federica Brescia, Simona Malucchi, Antonio Bertolotto
Glatiramer acetate (GA) is a widely used treatment for multiple sclerosis (MS), with incompletely defined mechanism of action. Short-term studies suggested its involvement in the modulation of anti-inflammatory cytokines and regulatory T cells (Treg), while long-term effect is still unknown.To investigate this aspect, we analyzed by flow-cytometry peripheral-blood Treg, natural killer (NK), CD4 and CD8 T-cells and anti-inflammatory CD14⁺CD163⁺ monocytes from 37 healthy donor and 90 RRMS patients divided in untreated, treated with GA for 12months and from 34 to 192months.While NK, CD4 and CD8 T-cells did not show any significant differences among groups over time, we demonstrated that GA increased the anti-inflammatory monocytes and restored the Treg level in both GA-treated groups. Both these effects are a characteristic of responder patients and are observed not just in short-term but even after as long as a decade of GA treatment.



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Paediatric airway infections

1C022D013D00

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Kindler syndrome complicated by invasive squamous cell carcinoma of the palate

Publication date: Available online 20 June 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): H. Souldi, M.Y. Bajja, M. Mahtar
IntroductionKindler syndrome is a very rare, autosomal recessive genodermatosis characterized by skin fragility and photosensitivity in infancy with progressive poikiloderma.Case reportWe report the case of a young woman with a history of Kindler syndrome predominantly characterized by extensive involvement of the oropharyngeal mucosa. The patient presented with an ulcerative lesion of the palate. Computed tomography and biopsy concluded on unresectable invasive squamous cell carcinoma of the hard palate. Neoadjuvant chemotherapy was proposed, but the patient died after the first course of chemotherapy in a context of severe gastrointestinal mucositis and generalized sepsis.DiscussionMucosal manifestations of Kindler syndrome have been described in the literature, but very few cases of malignant transformation to squamous cell carcinoma have been reported, although it is a very well known, long-term complication of this disease. To our knowledge, this is the second reported case of Kindler syndrome complicated by invasive squamous cell carcinoma of the hard palate.



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Is Aggregatibacter actinomycetemcomitans the missing link between periodontitis and rheumatoid arthritis?

Abstract

The impact of chronic conditions on the modern population is even more evident in view of a prolonged human life span. In addition, most individuals will probably simultaneously suffer from more than one chronic condition. As such, unveiling the pathogenesis of chronic diseases, as well as the causal factors that crosstalk between different conditions, is one of the greatest challenges faced by modern medicine. Two such conditions are periodontitis and rheumatoid arthritis (RA).

This article is protected by copyright. All rights reserved.

http://ift.tt/2rz1oMD

A novel technique for ultrasound-guided central venous catheterization under short-axis out-of-plane approach: “stepwise flashing with triangulation”

Abstract

In ultrasound-guided central venous catheterization, there is no standard technique either for the needle tip visualization or for the adequate needle angle and entry to the skin with short-axis view under out-of-plane technique. In the present study, we propose a novel technique named "stepwise flashing with triangulation", and the efficacy of this technique is assessed. Before and after a didactic session in which the technique was explained, 12 novice residents were asked to position the needle tip on or into the imitation vessels and to avoid deeper penetration by using an agar tissue phantom with ultrasound guidance. "Stepwise flashing" technique was for stepwise visualization of the needle tip, and "triangulation" technique was for adequate needle angle and entry to the skin. After the session, the success rate was increased and a deeper penetration rate was decreased. This technique will help us to facilitate vascular access and to avoid complications in clinical settings.

http://ift.tt/2toffH3

Oxidative stress and psychiatric morbidity in patients with facial acne

Summary

Background

Acne vulgaris is a common cosmetic problem that is frequently associated with psychosocial disturbances as well as increased oxidative stress. However, oxidative stress and psychological aspects have been studied separately in acne.

Objective

To evaluate the relationships between oxidative stress, anxiety, depression, and quality of life in acne patients.

Methods

Sixty patients with facial acne and 40 age- and sex-matched healthy individuals were included in the study. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS), and quality of life (QoL) was measured by the Cardiff Acne Disability Index. Disease severity was assessed using the Combined Acne Severity Classification. The serum levels of zinc and malondialdehyde (MDA) and total antioxidant capacity (TAC) were measured in patients and healthy subjects.

Results

The mean HADS scores for anxiety and depression were higher in patients than controls (P<.001 for both). Acne patients showed higher serum MDA and lower TAC and serum zinc levels compared with control subjects (P=.019, P<.001, and P=.028, respectively). Anxiety and depression scores did not correlate with oxidative stress parameters. Patients with moderate/severe acne had worse anxiety scores than mild acne (P=.048), and higher anxiety scores were associated with poorer quality of life (r=.436, P=.001).

Conclusion

Our results indicate that the high levels of anxiety and depression in patients with facial acne were not related to oxidative stress. Anxiety was more common than depression and was directly related to QoL impairment.

http://ift.tt/2sLsqnC

La dirofilariose cutanée

Publication date: Available online 19 June 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): M. Benzaquen, E. Marmottant, P. Parola, P. Berbis
La dirofilariose est une zoonose ubiquitaire touchant rarement l'Homme, liée à la transmission par un moustique d'un nématode du genre Dirofilaria. La dirofilariose cutanée, due à D. repens, se manifeste par des plaques inflammatoires évoluant vers la formation de nodules sous-cutanés ; ce tableau clinique peut faire évoquer une cellulite de Wells. La mise en évidence du nématode lors de l'exérèse du nodule, associée à son identification macroscopique, histologique et moléculaire par PCR, permet de confirmer le diagnostic. L'exérèse chirurgicale du nodule reste le traitement de référence. Le nombre de cas de dirofilariose cutanée humaine rapportés ces dernières années a augmenté, rendant nécessaire la connaissance de ce diagnostic.Dirofilariasis is a worldwide zoonotic infection that rarely affects humans and is caused by filarial nematodes of the genus Diroflaria transmitted by mosquitoes. Cutaneous dirofilariasis, due to D. repens, presents as inflammatory lesions that develop into subcutaneous nodules. These clinical symptoms may be consistent with Wells' cellulitis. Diagnosis of dirofilariasis involves demonstration of the presence of the nematode during skin biopsy and identification of the worm through macroscopic, histological and PCR analysis. Surgical resection of the nodule remains the gold standard treatment. The number of cases of human cutaneous dirofilariasis has increased in the recent years and the disease must not be misdiagnosed.



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Bristle splaying and its effect on pre-existing gingival recession—a 12-month randomized controlled trial

Abstract

Objective

The link between bristle splaying and gingival recession is unclear.

Methods

In a 12-month, parallel group, randomized, controlled clinical trial, 110 systemically healthy participants with pre-existing gingival recessions (pre-GR) were assigned to brush their teeth with either a manual (MT) or a powered toothbrush (PT). Every 3 months, toothbrushes and brush heads were replaced. Wear was measured using the Bristle-Splaying-Index (BSI), matched between groups and correlated to the change of pre-GR.

Results

Data from 109 subjects (PT, 55; MT, 54) were analyzed. The overall mean BSI was found to be significantly lower (p < 0.001) in the PT group (median 5.5; second and third quartile 1.9–10.0) as compared to the MT group (21.5; 15.0–30.5). After 12 months, pre-GR decreased significantly in the PT group (∆0.2 ± 0.1 mm; p < 0.001) and remained stable in the MT group (∆0.1 ± 0.1 mm; p > 0.05). In the MT group, higher BSI values were associated with a higher risk for increasing or stable recession over 12 months: odds ratio (95 % CI) = 27.9 (1.7; 452.9); p = 0.019.

Conclusion

After a mean using time of 3 months, the PT group demonstrated a lower BSI than the MT group, and the greater bristle splaying was associated with a higher risk of increased (or stable) GR in subjects using a MT but not a PT.

Clinical relevance

Compared to a manual toothbrush, powered toothbrushes seem to be utilized with less force and can be considered safe to use in patients with pre-existing gingival recession.

http://ift.tt/2sRBd7L

Chair-side generated posterior monolithic lithium disilicate crowns: clinical survival after 6 years

Abstract

Objectives

The objective of this prospective clinical study was to evaluate the clinical performance of chair-side generated monolithic lithium disilicate crowns after 72 months.

Materials and methods

Forty-one posterior full contour crowns made of lithium disilicate ceramic were inserted in 34 patients with a chair-side CAD/CAM technique. One crown per patient was randomly selected for evaluation at baseline, 6, 12, 24, 36, 48, 60 and 72 months according to the modified US Public Health Service criteria.

Results

After a mean examination time of 73.2 months (SD ± 1.7 months), 25 crowns were available for re-examination. Within the observation period, three failures occurred due to one crown fracture after 2.9 years, an abutment fracture after 6.0 years, and one severe endodontic problem after 6.1 years. One lithium disilicate crown showed a loss of retention after 2 years but could be reinserted. There were two events of caries below the crown margin, one after 24 and another one after 48 months. Both teeth received cervical adhesive composite fillings. Two abutment teeth changed their sensibility perception from positive to negative within the first 13 months. The failure-free rate was 87.6%, and the complication-free rate was 70.1% after 6 years according to the Kaplan-Meier analysis.

Conclusions

Due to the fact that there was only one severe technical complication and the severe biological complications were in a normal range, the clinical performance of monolithic lithium disilicate crowns in the posterior region was completely satisfying.

Clinical relevance

The chair-side application of monolithic lithium disilicate crowns can be recommended.

http://ift.tt/2ryHUrB

Management and outcomes of obstructive sleep apnea in children with Robin sequence, a cross-sectional study

Abstract

Objective

The objective of this cross-sectional study is to assess the prevalence, course, and management of obstructive sleep apnea (OSA) in children with Robin sequence (RS) aged 1–18 years.

Materials and methods

A cross-sectional study was conducted in 63 children aged 1 to18 years with RS. Patient data were collected on baseline characteristics and management. OSA was evaluated by polysomnography.

Results

Sixty-three children with RS were included (median age 8.0 years) and divided into two groups based on the initial treatment: prone positioning or respiratory support. Respiratory support was more often indicated in children with a non-isolated RS (p < 0.05). At cross section, in the prone positioning group (n = 32), one child was diagnosed with OSA. In the respiratory support group (n = 31), 13 children (42 %) had respiratory problems of whom 10 needed respiratory support.

Conclusions

Between the age of 1 and 18 years, almost one out of four children with RS still has respiratory problems. Children with RS, who can be treated with prone positioning only as an infant, are not likely to develop obstructive airway problems at a later age. In contrast, children who need respiratory support early after birth are at risk of continuing or re-developing OSA after the age of 1 year.

Clinical relevance

This study shows that those who need respiratory support at an early age need careful monitoring until adulthood.

http://ift.tt/2sS8mQD

Clinical performance of screw-retained and cemented implant-supported zirconia single crowns: 36-month results

Abstract

Objectives

The objective of this clinical study was to evaluate the clinical performance of implant-supported zirconia crowns with a sintered veneering cap. Furthermore, the influence of the type of retention (screw-retained vs cemented single crowns) was analysed.

Materials and methods

Fifty-eight patients were accommodated with 114 implants, inserted in the molar and premolar regions. Zirconia-based crowns with a sintered veneering cap were either screw-retained (n = 53) or cemented (n = 61) on the implant. Recalls were performed every 6 months. The state of soft tissue was documented by the modified plaque and gingiva index (mPI) and sulcus bleeding index (mSBI). The restorations were evaluated for technical failures like veneering porcelain fractures, surface qualities and marginal fitting.

Results

Neither implant loss nor crown fractures occurred. After a mean clinical service time of 36.9 months, fractures of the veneering porcelain were registered in 1.8 % of the cases. The Kaplan-Meier survival probability regarding eventless restorations was 98.2 %. Chipping of the veneering porcelain was registered in two cemented crowns without statistical influence of the type of retention. The indices showed healthy soft periimplant tissues in both groups.

Conclusions

Implant-supported zirconia crowns with a sintered veneering cap demonstrated good clinical performance. The type of retention had no influence on technical complications.

http://ift.tt/2rz0oIe

Secretomes from mesenchymal stem cells participate in the regulation of osteoclastogenesis in vitro

Abstract

Objectives

The receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors are novel clinically effective agents that inhibit osteoclast differentiation, function, and survival by binding to RANKL. Medication-related osteonecrosis of the jaw (MRONJ), caused as a result of treatment using denosumab, is a newly emerging type of bone necrosis, the exact pathogenesis of which is unknown. Several studies recently showed that the intravenous administration of mesenchymal stem cells (MSCs) improved the osteonecrosis of the jaw, and it was hypothesized that paracrine effects by secretomes from MSCs are the main constituent. Our aim was to investigate the effects of serum-free conditioned media from human MSCs (MSC-CM) and RANKL inhibitors on osteoclast differentiation.

Materials and methods

Cytokines included in MSC-CM were identified using the cytokine array analysis. MSC-CM was added to the culture medium of rat osteoclast precursors containing RANKL inhibitor. Osteoclast differentiation assays, immunohistochemistry, real-time reverse-transcriptase polymerase chain reaction (RT-PCR) analysis, and pit formation assays were performed.

Results

MSC-CM included various cytokines such as the recruitment of cell osteogenesis angiogenesis and cell proliferation. MSC-CM promoted osteoclast differentiation and expression of master regulatory transcriptional factors for osteoclastogenesis. In addition, MSC-CM showed function maintenance in osteoclasts despite the presence of RANKL inhibitors.

Conclusions

Our findings suggest that secretomes in MSC-CM were related to the regulation of osteoclast differentiation, which may reduce the effect of RANKL inhibitors.

Clinical relevance

New combinations of drugs using factors included in MSC-CM have effective therapeutic modality for treating patients with MRONJ.

http://ift.tt/2sRQC8e

Retrospective case-control study of correlation between MTHFR gene and OSCC risk in North India

Abstract

Background

Oral squamous cell carcinoma (OSCC) occurrence appears to be the number one among all cancers in India. Folate is a methyl donor during DNA methylation, as it provides substrate for methylenetetrahydrofolate reductase (MTHFR) to convert 5,10-MTHF to 5-MTHF and subsequently metabolizes it to methionine. The purpose of this study was to identify MTHFR C677T gene polymorphism in patients with OSCC.

Materials and methods

A total of 350 OSCC cases and 350 healthy controls participated in this study. MTHFR C677T single-nucleotide polymorphism was evaluated by PCR-RFLP.

Results

In the present study, MTHFR gene 677CC, CT, and TT genotype frequencies of the total OSCC cases were 74.8; 19.4 and 5.71; and 88.5, 9.42, and 2.0 % in controls. The average frequency of the MTHFR 677T allele was 15.4 % in OSCC cases compared to 6.71 % in the controls. The CT genotype occurrence prevailed more in patients than controls in contrast to TT genotype, although both the genotypes were statistically significant for OSCC. Moreover, we found that T allele was significant in cases of smoking and tobacco chewing.

Conclusions

In this study, we found that the homozygous mutant T allele appeared to have significantly higher risk of OSCC especially in late stages and therefore supporting in OSCC susceptibility and its progression.

http://ift.tt/2ryVqeI

The randomized shortened dental arch study: influence of two different treatments on interdental spacing over 5 years

Abstract

Objectives

Being a secondary outcome in a multicenter randomized controlled trial, the present analysis focused on interdental spacing in the shortened dental arch (SDA). The aim was to evaluate changes in interdental spacing in dependence of two different treatments after an observation period of up to 5 years.

Material and methods

Patients were either treated with a partial removable dental prosthesis (PRDP) for molar replacement (PRDP group) or according to the SDA concept aiming at a premolar occlusion (SDA group) in a randomized manner. Interdental spacing in the anterior region was measured with gauges and categorized as "0" (<0.1 mm), "1" (<0.5 mm), "2" (0.5–1 mm), and "3" (>1 mm). The statistical analysis was performed with analysis of variance models followed by linear contrast.

Results

Ninety-one patients (SDA n = 41, PRDP n = 50) were included. Changes of interdental spacing were detected in 70.7 % of all cases. A significant difference between the mean score changes was found in the mandible comparing the PRDP group and the SDA group. The respective mean score changes from baseline to 5 years were 0.23 (SD 0.49) for the PRDP group and 0.02 (SD 0.30) for the SDA group (p = 0.023).

Conclusions

Major interdental spacing could be observed in neither of the groups. The SDA concept resulted in a slightly better outcome.

Clinical relevance

When deciding whether to replace missing molars, the present results give further support to the SDA concept.

http://ift.tt/2ryOX3A

Obstructive sleep apnoea in craniofacial microsomia: analysis of 755 patients

Publication date: Available online 19 June 2017
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): C.J.J.M. Caron, B.I. Pluijmers, B.D.P.J. Maas, Y.P. Klazen, E.S. Katz, F. Abel, M.P. van der Schroeff, I.M.J. Mathijssen, D.J. Dunaway, C. Mills, D.S. Gill, N. Bulstrode, B.L. Padwa, E.B. Wolvius, K.F.M. Joosten, M.J. Koudstaal
A retrospective cohort study was set up to analyse the prevalence and treatment of obstructive sleep apnoea (OSA) in relation to the severity of the deformity in patients with craniofacial microsomia (CFM). This study included a population of 755 patients with CFM from three craniofacial centres. Medical charts were reviewed for severity of the deformity, types of breathing difficulty, age at which breathing difficulty first presented, treatment for OSA, and treatment outcome. In total, 133 patients (17.6%) were diagnosed with OSA. Patients with Pruzansky IIB/III classification or bilateral craniofacial microsomia were significantly more often diagnosed with OSA than unilaterally affected patients of Pruzansky I/IIA classification. The initial treatment of OSA consisted of adenotonsillectomy, tracheotomy, or non-invasive positive pressure ventilation. Thirty-seven patients received more than one treatment (range 1–3). In this study, the prevalence of OSA in patients with CFM was higher than the prevalence in the healthy population described in the literature. Although several treatment modalities are available for the treatment of OSA in patients with CFM, treatment should be individualized and based on clinical symptoms, the severity of the deformity, and comorbidities.



http://ift.tt/2sL7LjA

Temporomandibular joint disc perforation: a retrospective study

Publication date: Available online 20 June 2017
Source:International Journal of Oral and Maxillofacial Surgery





http://ift.tt/2tJ28j1

Sclerosing odontogenic carcinoma: current diagnostic and management considerations concerning a most unusual neoplasm

Publication date: Available online 20 June 2017
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): M. Hanisch, D. Baumhoer, S. Elges, L.F. Fröhlich, J. Kleinheinz, S. Jung
Sclerosing odontogenic carcinoma (SOC) is a primary intraosseous carcinoma of the jaws that has been listed as a separate entity for the first time in the latest version of the World Health Organization classification of Head and Neck Tumours (2017). The aim of this study was to analyse and interpret the existing literature on SOC in the context of a clinical case treated in the authors' department. A systematic search of the PubMed database was performed in accordance with the PRISMA guidelines, yielding nine cases of SOC reported so far. In summary, characteristic clinical and radiological features of SOC include asymptomatic swelling, location predominantly in the mandible, tumour primarily lytic in appearance, presence of cortical bone destruction, and lack of metastatic spread. Due to the rarity of the disease, close collaboration between oral/maxillofacial surgeons and pathologists is crucial to avoid misdiagnosis. With complete excision, no recurrence of SOC should be expected.



http://ift.tt/2sL6GIq

Synovial chondromatosis of the temporomandibular joint with intracranial extension—report of two cases

Publication date: Available online 20 June 2017
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): J.N. Khanna, Radhika Ramaswami
Synovial chondromatosis of the temporomandibular joint is a rare condition, and only 10 cases with intracranial extension have been reported in the literature. Two cases of synovial chondromatosis with intracranial extension, followed up for 3 to 9 years, are reported here. The surgical treatment modality is described for each case.



http://ift.tt/2tIMl3E

Biomechanical evaluation of different osteosynthesis methods after mandibular sagittal split osteotomy in major advancements

Publication date: Available online 19 June 2017
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): G.B.G. Klein, G.C.B. Mendes, P.D. Ribeiro Junior, A. Viswanath, M. Papageorge
The aim of this study was to assess the biomechanical stability of six different osteosynthesis methods after sagittal split osteotomy. Sixty polyurethane hemimandibles were divided into two groups, with six subgroups in each. After 10-mm advancement of the distal segment (group 1) and 10-mm advancement combined with 20° counterclockwise rotation (group 2), the bone segments were fixed using 2.0-mm plates/screws as follows: subgroup A, one conventional straight plate; subgroup B, two conventional straight plates; subgroup C, one conventional sagittal plate; subgroup D, one locking straight plate; subgroup E, two locking straight plates; subgroup F, one locking sagittal plate. The hemimandibles were tested for compressive strength by three-point biomechanical test, until there was 3mm of displacement between the segments. The fixations showed better performance in group 1 than in group 2 in all cases, with statistical significance for subgroups A, C, and D. In both groups, the use of two straight miniplates showed the most resistance, followed by the sagittal miniplates. However, in counterclockwise rotations, no statistically significant difference was found between two conventional straight plates and the sagittal locking plate. This study shows that the use of two plates is the form of fixation with the minimum displacement. If the clinician opts to use one plate, a sagittal plate is the best alternative.



http://ift.tt/2sLpc3r

Incidental Thrombus in Transit Causing Embolic Stroke

Thrombus in transit leading to paradoxical systemic arterial embolism is a rare echocardiographic finding in patients presenting with embolic stroke. We present a case of a patient who had an atrial thrombus in transit discovered incidentally and later suffered a fatal stroke. Etiologies of cardioembolic stroke and the use of echocardiography in diagnosis and management are briefly discussed.

http://ift.tt/2sRDRdF

Primary Prevention of Food Allergy

Abstract

Purpose of Review

This article summarises recent developments on the prevention of food allergy in terms of the 5 D's of the development of food allergy: dry skin, diet, dogs, dribble, and vitamin D.

Recent Findings

While several advances have improved our understanding of the development of food allergy, few preventive strategies have been implemented beyond changes in infant feeding guidelines. These now state that the introduction of allergenic solids such as peanuts should occur in the first year of life.

Summary

Results from randomised controlled trials on other allergenic solids, vitamin D supplementation, BCG immunisation at birth and eczema prevention are eagerly anticipated in order to inform further preventative strategies.

http://ift.tt/2sL0IaD

Review of Physical Urticarias and Testing Methods

Abstract

Purpose of Review

This review aims to update the information available on the prevalence, clinical picture, diagnostic methods, and treatment of urticarias induced by external physical stimuli.

Recent Findings

Physical urticarias are present in up to 5% of the general population, and in 10 to 50% of patients with chronic urticaria. Recent investigations have provided evidence that the presence of physical urticaria alone or when comorbid with chronic spontaneous urticaria is associated with a worse prognosis and duration.

Summary

Most frequent subtypes of physical urticaria are dermographism and delayed pressure urticaria. The diagnosis is established through specific provocation tests and the management encompasses avoidance measures, pharmacologic therapy with nonsedating antihistamines, and alternative medications in refractory cases.

http://ift.tt/2tIhxzZ

Role of Obesity in Asthma: Mechanisms and Management Strategies

Abstract

Purpose of Review

Obesity is a commonly reported comorbidity in asthma, particularly in severe asthma. Obese asthmatics are highly symptomatic with a poor quality of life, despite using high-dose inhaled corticosteroids. While the clinical manifestations have been documented, the aetiologies of obese-asthma remain unclear.

Recent Findings

Several potential mechanisms have been proposed, including poor diet quality, physical inactivity and consequent accrual of excess adipose tissue. Each of these factors independently activates inflammatory pathways, potentially exerting effects in the airways. Because the origins of obesity are multifactorial, it is now believed there are multiple obese-asthma phenotypes, with varied aetiologies and clinical consequences.

Summary

In this review, we will describe the clinical implications of obesity in people with asthma, our current understanding of the mechanisms driving this association and describe recently proposed obese-asthma phenotypes. We will then discuss how asthma management is complicated by obesity, and provide graded recommendations for the management of obesity in this population.

http://ift.tt/2sL0ArF

Accumulated evidence on Helicobacter pylori infection and the risk of asthma

Publication date: Available online 19 June 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Cheng Chen, Pengcheng Xun, Cari Tsinovoi, Ka He
BackgroundHelicobacter pylori (H pylori) infection has been suggested to be related to a decreased risk of asthma, but findings in the literature are inconsistent.ObjectiveTo quantitatively summarize the existing evidence on the association between H pylori infection and asthma risk.MethodsThe PubMed database was searched for observational studies of H pylori infection in relation to the risk of asthma published in English through May 2017. Measurements of association were pooled using a meta-analytic approach and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs).ResultsTwenty-four studies were identified in this meta-analysis, including 8 case-control studies composed of 1,247 cases and 2,410 controls, and 16 cross-sectional studies composed of 50,290 participants (4,185 cases and 46,105 noncases). The average H pylori infection rates were 40.01% and 48.74% in case-control and cross-sectional studies, respectively. Five studies subcategorized H pylori infection according to CagA status, in which 59.37% of H pylori–infected participants were identified as having CagA positivity. Helicobacter pylori infection was significantly inversely associated with the risk of asthma in case-control studies (OR 0.83, 95% CI 0.71–0.98) but was borderline significant in cross-sectional studies (OR 0.88, 95% CI 0.76–1.02). The observed inverse association persisted for CagA-positive H pylori infection (OR 0.77, 95% CI 0.63–0.93, P for interaction = .03) but not for CagA-negative strains (OR 1.08, 95% CI 0.66–1.78). No significant difference was observed across age or region subgroups.ConclusionThe accumulated evidence supports that H pylori infection, especially CagA-positive H pylori infection, is inversely associated with the risk of asthma.



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Distribution, subtype population, and IgE positivity of mast cells in chronic rhinosinusitis with nasal polyps

Publication date: Available online 19 June 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Shintaro Baba, Kenji Kondo, Maho Suzukawa, Ken Ohta, Tatsuya Yamasoba
BackgroundChronic rhinosinusitis with nasal polyps (CRSwNP) has been categorized into 2 subtypes in the Asian population: eosinophilic chronic rhinosinusitis (ECRS; similar to CRSwNP in Western countries) and non-ECRS (characterized by inflammation dominated by T-helper cell type 1). The pathogenesis of CRSwNP and the role of mast cells are poorly understood.ObjectiveTo investigate the distribution, phenotypes, and immunoglobulin E (IgE) positivity of mast cells in these 2 subtypes of CRSwNP.MethodsWe collected nasal tissue from patients with CRSwNP and control subjects. The mRNA for mast cell proteases tryptase and chymase was measured using real-time polymerase chain reaction, and the distribution of each type of protease-positive mast cell was examined using immunohistochemistry and immunofluorescence. IgE distribution on mast cells was determined using double-immunofluorescent staining for IgE and tryptase.ResultsExpression of tryptase mRNA was significantly increased in nasal polyps from patients with the 2 subtypes of CRSwNP compared with controls. Immunohistochemistry showed increased numbers of tryptase-positive mast cells in the epithelium, glands, and submucosa of ECRS polyps, whereas the number of tryptase- and chymase-positive mast cells was increased in the glands and submucosa of non-ECRS polyps. IgE-positive mast cells were abundant in the epithelial, glandular, and submucosal regions of ECRS polyps but few were detected in non-ECRS polyps.ConclusionThe present study demonstrates that the distribution, subtype population, and IgE positivity of mast cells is different between ECRS and non-ECRS nasal polyps. Our results suggest a role for IgE-mediated mast cell activation in the pathogenesis of ECRS.



http://ift.tt/2sRuwCx

Mycoplasma pneumoniae and health outcomes in children with asthma

Publication date: Available online 19 June 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Pamela R. Wood, Jordan C. Kampschmidt, Peter H. Dube, Marianna P. Cagle, Paola Chaparro, Norma S. Ketchum, Thirumalai R. Kannan, Harjinder Singh, Jay I. Peters, Joel B. Baseman, Edward G. Brooks
BackgroundAcute infections with Mycoplasma pneumoniae (Mp) have been associated with worsening asthma in children. Mp can be present in the respiratory tract for extended periods; it is unknown whether the long-term persistence of Mp in the respiratory tract affects long-term asthma control.ObjectiveTo determine the effect of Mp on asthma control.MethodsWe enrolled 31 pediatric subjects 3 to 10 years of age with persistent asthma who completed up to 8 visits over a 24-month period. We detected Mp by antigen capture and polymerase chain reaction. Primary outcome measurements included symptom scores, quality of life, medication scores, oral corticosteroid use, health care usage, school absences, and exhaled breath condensate pH.ResultsLow levels of Mp community-acquired respiratory distress syndrome toxin were detected in 20 subjects (64.5%) at enrollment. Subjects with Mp positivity at a given visit had a .579 probability of remaining Mp positive at the subsequent visit, whereas those with Mp negativity had a .348 probability of becoming Mp positive at the following visit. The incidence of Mp overall was higher in the spring and summer months. Overall, we found no significant relation between the detection of Mp and worse outcome measurements at the same visit or at subsequent visits.ConclusionThe long-term persistence of Mp in the respiratory tract is common in children with asthma. However, the detection of Mp was not associated significantly with worse asthma symptoms, quality of life, health care usage, school absences, or exhaled breath condensate pH in this pediatric asthma cohort.



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Economic evaluation of epinephrine auto-injectors for peanut allergy

Publication date: Available online 19 June 2017
Source:Annals of Allergy, Asthma & Immunology
Author(s): Marcus Shaker, Katherine Bean, Marylee Verdi
BackgroundThree commercial epinephrine auto-injectors were available in the United States in the summer of 2016: EpiPen, Adrenaclick, and epinephrine injection, USP auto-injector.ObjectiveTo describe the variation in pharmacy costs among epinephrine auto-injector devices in New England and evaluate the additional expense associated with incremental auto-injector costs.MethodsDecision analysis software was used to evaluate costs of the most and least expensive epinephrine auto-injector devices for children with peanut allergy. To evaluate regional variation in epinephrine auto-injector costs, a random sample of New England national and corporate pharmacies was compared with a convenience sample of pharmacies from 10 Canadian provinces.ResultsAssuming prescriptions written for 2 double epinephrine packs each year (home and school), the mean costs of food allergy over the 20-year model horizon totaled $58,667 (95% confidence interval [CI] $57,745–$59,588) when EpiPen was prescribed and $45,588 (95% CI $44,873–$46,304) when epinephrine injection, USP auto-injector was prescribed. No effectiveness differences were evident between groups, with 17.19 (95% CI 17.11–17.27) quality-adjusted life years accruing for each subject. The incremental cost per episode of anaphylaxis treated with epinephrine over the model horizon was $12,576 for EpiPen vs epinephrine injection, USP auto-injector. EpiPen costs were lowest at Canadian pharmacies ($96, 95% CI $85–$107). There was price consistency between corporate and independent pharmacies throughout New England by device brand, with the epinephrine injection, USP auto-injector being the most affordable device.ConclusionCost differences among epinephrine auto-injectors were significant. More expensive auto-injector brands did not appear to provide incremental benefit.



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Identification of allergens by IgE-specific testing improves outcomes in atopic dermatitis

Abstract

Introduction

IgE quantitative assaying of allergens (IgEQAA) has long been implemented by allergists in determining patients' reactivities for allergic rhinitis and asthma, two of the three diagnoses in atopic syndrome. This test operates by measuring the patient's IgE response to different allergens and can identify potential triggers for a patient's symptoms. Despite this, IgEQAA has yet to see the same widespread use in the field of dermatology, specifically in the treatment of patients with atopic dermatitis (AD).

Materials and Methods

The affected body surface area (BSA) at first presentation, IgEQAA classes, and total immunoglobulin E (IgE) concentration were taken retrospectively for 54 patients with AD.

Results

Of the 54 patients observed, 41 had an abnormally high total IgE concentration (76%). Additionally, it was observed that nine (17%) of our patients significantly improved after making lifestyle changes.

Conclusion

Knowledge of the identified specific antigens can guide patients to make lifestyle modifications that may improve disease outcomes. IgEQAA and avoidance of allergens may help some patients with AD.

http://ift.tt/2sRyGdO

Incidence of melanoma and keratinocytic carcinomas in patients evaluated by store-and-forward teledermatology vs. dermatology clinic

Abstract

Background

It is unclear whether incidence of detected skin cancer in patients evaluated by store-and-forward teledermatology (SAF) vs. face-to-face consultation (F2F) significantly differs, and whether such differences are because of variations in patient demographics, diagnostic accuracy, or both.

Methods

This retrospective cohort study compares patient skin cancer risk profile, pre-post biopsy diagnostic accuracy, and detection rates of any skin cancer, melanoma, and keratinocytic carcinoma between all SAF teledermatology patients and a subset of randomly selected F2F consultations at VA-Boston Healthcare System in 2014.

Results

Patients in the teledermatology (n = 434) and F2F visit cohorts (n = 587) had similar baseline demographics except a higher proportion of F2F patients had prior history of skin cancer, 22% (131/587) vs. 10% (45/434), P < 0.001, and received biopsies, 27.2% (160/587) vs. 11.5% (50/434), P < 0.001. When adjusted for age, immunosuppression, and personal and family history of skin cancer, there were no significant differences between the two cohorts in detection rates for any skin cancer (9.5% vs. 5.8%, P = 0.3), melanoma (0.6% vs. 0%, P = N/A), or keratinocytic carcinoma (8.5% vs. 5.5%, P = 0.7). The two cohorts also had similar pre-post biopsy perfect diagnostic concordance, time from initial consult request to biopsy (45.5 d vs. 47.3 d, P = 0.8), and time from biopsy to definitive treatment (67.5 d vs. 65.4 d, P = 0.8).

Conclusion

F2F patients were more likely to have prior history of skin cancer and receive biopsies. When adjusted for presence of skin cancer risk factors, incidence of detected melanoma, keratinocytic carcinoma, and any skin cancer was similar between SAF teledermatology and F2F patients.

http://ift.tt/2rySxdM