Tuberculous meningitis is globally highly prevalent and is commoner in resource-limited countries and in patients with immunosuppression. Central nervous system tuberculosis is one of the severest forms of ext...
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Τετάρτη 28 Ιουνίου 2017
Tuberculous meningoencephalitis associated with brain tuberculomas during pregnancy: a case report
Fluorescein sodium-guided surgery of parotid gland tumors as a technical advance
Complete tumor removal and preservation of the facial nerve are essential in parotid gland surgery. A technical adjunct that potentially enhances the contrast between the facial nerve and the adherent tumor ti...
http://ift.tt/2tnbUKU
Febrile headache and leg weakness as the initial symptoms of tickborne encephalitis
Description
A 61-year-old woman presented to the emergency department (ED) with a 1-week fever associated with progressive headache. She also reported weakness and paraesthesias in both legs. In the ED, the patient had normal vital parameters and reported no other medical history. Clinical examination showed a slight neck stiffness; the rest of the examination was normal. Laboratory findings showed a mild inflammatory syndrome. The patient had a lumbar punction; the cerebrospinal fluid (CSF) showed moderate pleocytosis (140 leucocytes/μL with a mononuclear cell dominance). After a normal CT scan, an MRI examination was performed (figures 1and 2). Several days later, intrathecal IgM and IgG antibodies came back positive.
Figure 1
T2-weighted transverse MRI. Localised hyperintense band involving the tegmentum pontis (arrow heads) and the cerebellar vermis (arrow).
Figure 2
Coronal MRI, fluid attenuation inversion recovery...
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Critical Ischemia Times and The Effect of Novel Preservation Solutions HTK-N and TiPROTEC on Tissues of a Vascularized Tissue Isograft.
Background: We herein investigate critical ischemia times and the effect of novel preservation solutions HTK-N and TiProtec on the individual tissues of a rat limb isograft. Methods: Orthotopic hind-limb transplantations were performed in male Lewis rats following 2h, 6h or 10h of cold ischemia. Limbs were flushed and stored in either HTK-N, TiProtec, HTK or saline solution. Muscle, nerve, vessel, skin and bone samples were procured on day 10 for histology, immunohistochemistry, confocal and electron microscopy and RTqPCR analysis. Results: Histomorphology of the muscle showed a mainly perivascular inflammatory infiltrate, fibrotic degeneration and neovascularization after 6h and 10h of cold ischemia. However, centrally aligned nuclei observed in muscle fibers suggest for muscle regeneration in these samples. In addition to Wallerian degeneration, nerve injury was significantly (p=0.032) aggravated after prolonged cold ischemia. Proinflammatory and regulatory cytokines were most significantly upregulated after 2h cold ischemia. Our data suggest no superiority of novel perfusates HTK-N and TiProtec in terms of tissue preservation, compared to HTK and saline. Conclusions: Limiting cold ischemia time below 6h is the most significant factor to reduce tissue damage in vascularized tissue transplantation. Signs of muscle regeneration give rise that ischemic muscle damage in limb transplantation might be reversible to a certain extent. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.
http://ift.tt/2sTkCQ1
http://ift.tt/2sTkCQ1
Targeted Next-generation Sequencing in Brazilian Children With Nephrotic Syndrome Submitted to Renal Transplant.
Background: The aims of this study were to identify the genetic mutations profile in Brazilian children with nephrotic syndrome and to determine a genotype-phenotype correlation in this disease. Methods: Next generation sequencing (NGS) and mutation analysis were performed on 24 genes related to nephrotic syndrome in a cross-sectional study involving 95 children who underwent kidney transplantation due to nephrotic syndrome, excluding congenital cases. Results: A total of 149 variants were identified in 22 out of 24 sequenced genes. The mutations were classified as pathogenic, likely pathogenic, likely benign and benign per the chance of causing the disease. NPHS2 was the most common mutated gene. We identified 8 patients (8.4%) with hereditary NS and 5 patients (5%) with probably genetically caused NS. COL4A3-5 variants were found as well, but it is not clear whether they should be considered isolated FSGS or simply a misdiagnosed type of the Alport spectrum. Considering the clinical results, hereditary NS patients presented a tendency to early disease onset when compared to the other groups (p=0.06) and time to end stage renal disease (ESRD) was longer in this group (p=0.03). No patients from hereditary NS group had NS recurrence after transplantation. Conclusions: This is the first study in children with steroid resistant nephrotic syndrome who underwent kidney transplantation using NGS. Considering our results, we believe this study has shed some light to the uncertainties of genotype-phenotype correlation in NS, where several genes cooperate to produce or even to modify the course of the disease. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.
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http://ift.tt/2soWiCl
Pharmacokinetics and Clinical Outcomes of Generic Tacrolimus (Hexal) Versus Branded Tacrolimus in De Novo Kidney Transplant Patients: A Multicenter, Randomized Trial.
http://ift.tt/2sTvnSv
Tacrolimus Trough Concentration Variability and Disparities in African American Kidney Transplantation.
Background: Low tacrolimus concentrations have been associated with higher risk of acute rejection, particularly within African-American (AA) kidney transplant recipients; little is known about intrapatient tacrolimus variabilities impact on racial disparities. Methods: Ten year, single-center, longitudinal cohort study of kidney recipients. Intrapatient tacrolimus variability was assessed using the coefficient of variation (CV) measured between 1 month posttransplant and the clinical event, with a comparable period assessed in those without events. Pediatrics, nontacrolimus/mycophenolate regimens and nonrenal transplants were excluded. Multivariable Cox regression models were used to analyze data. Results: 1411 recipients were included (54.4% AA) with 39 521 concentrations utilized to assess intrapatient tacrolimus CV. Overall, intrapatient tacrolimus CV was higher in AAs vs non-AAs (39.9+/-19.8 % vs. 34.8+/-15.8% p40%) was a significant explanatory variable for disparities in AAs; the crude relative risk of acute rejection in AAs was reduced by 46% when including tacrolimus variability in modeling and reduced by 40% for graft loss. Conclusions: These data demonstrate that intrapatient tacrolimus variability is strongly associated with acute rejection in AAs and graft loss in all patients. Tacrolimus variability is a significant explanatory variable for disparities in AA recipients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.
http://ift.tt/2sToh0l
http://ift.tt/2sToh0l
New and cost-effective way of retracting orbital contents during repair of the orbital floor
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): N. Bhatti, S. Ali, S. Holmes
http://ift.tt/2ukDNAi
Necrotising coronaritis with fatal outcome
A 56-year-old woman presented with acute onset of typical chest pain. She was diagnosed with acute coronary syndrome with ST-segment elevation myocardial infarction. Although significant obstructive coronary artery disease was ruled out by coronary angiography, cardiac MRI showed transmural necrosis of the lateral free wall with extensive microvascular obstruction consistent with ischaemic heart disease. Within 48 hours after initial presentation, the patient suddenly arrested due to pulseless electrical activity with futile resuscitation efforts. Autopsy revealed myocardial perforation with extensive haematothorax due to pericardial laceration, caused by the mechanical chest compressions. Eventually, histology identified diffuse necrotising coronary vasculitis as a rare cause of ischaemic heart disease.
http://ift.tt/2ukuFeQ
Bilateral inner ear damage after electrical injury: A case report
Source:Auris Nasus Larynx
Author(s): George Psillas, Marios Stavrakas, Ioanna Petrou, Dimitrios Rachovitsas, Konstantinos Markou
Electrical injury occurs as a result of direct contact with an electrical source. We present the case of a 62-year-old male patient, an electrician by profession, who was hit by a high-voltage electrical current while working with cables in proximity to a wet floor. The patient suffered from immediate loss of consciousness and five days later he started complaining of slight hearing loss, persistent vertigo, instability and bilateral tinnitus. A thorough audiological and vestibular examination revealed an extensive bilateral vestibulocochlear dysfunction. The exact pathogenetic mechanisms of inner ear dysfunction after electrical injury have not been fully elucidated, although it is believed that there is significant improvement with time. Long-term follow-up, medical assistance and psychological support are crucial factors for the patient management.
http://ift.tt/2sSR0m8
Ultrasound Risk Categories for Thyroid Nodules and Cytology Results: A Single Institution’s Experience after the Adoption of the 2016 Update of Medical Guidelines by the American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi
Objectives. In 2016, the American Association of Clinical Endocrinologists (AACE) and Associazione Medici Endocrinologi (AME) released updated guidelines for the diagnosis and management of thyroid nodules. The aim of this study was to evaluate the AACE/AME recommendations for FNA in clinical practice, by comparing the (US) stratification risk and indications for FNA with cytologic results. Methods. From May to December 2016, we collected the cytologic results from FNAs of nodules that were classified using a three-tier US category system (low, intermediate, and high risk). Results. We obtained 859 FNAs from 598 patients: 341 (39.7%) from low, 489 (56.9%) from intermediate, and 29 (3.4%) from high risk nodules. Of these, 88.5% and 74.9% of low and intermediate risk nodules, respectively, were cytologically benign, whereas 84.6% of high risk nodules had a moderate-to-elevated risk of malignancy or were malignant. If FNAs had been limited to intermediate risk nodules >20 mm, we would have missed 13/17 (76.5%) nodules that had moderate-to-elevated risk of malignancy or were malignant (11/13 were malignant based on histology). Conclusions. A nonnegligible number of cytologically malignant nodules or nodules that were suspected to be malignant would be missed if intermediate US risk nodules
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Retrospective study of intranasal dexmedetomidine as a prophylactic against emergence delirium in pediatric patients undergoing ear tube surgery
Source:International Journal of Pediatric Otorhinolaryngology, Volume 100
Author(s): Lisgelia Santana, Katherine Mills
ObjectivesThis study evaluated the effect of intranasal dexmedetomidine on emergence delirium (ED) in pediatric patients who underwent ear tube surgeries. Due to the brief nature of the surgery and low levels of pain experienced, an IV is rarely needed, limiting the medications available to anesthesiologists to manage postoperative delirium that may arise during recovery from inhalational anesthesia. Intravenous dexmedetomidine is an alpha-2 agonist anesthetic that is used in pediatric patients for the management of ED in various surgical procedures. However, intranasal medication has not been evaluated specifically in ear tube surgeries for ED prevention.MethodsWe conducted a retrospective chart review of pediatric patients at Nemours Children's Hospital who had undergone ear tube insertion or removal surgery between 2013 and 2015, controlling for confounding variables such as age, surgery duration, and anesthesiologist. We used the post anesthesia emergence delirium (PAED) tool, an instrument created to assess ED in the clinical setting. We analyzed the data for significant differences in PAED score and time in the post anesthesia care unit (PACU) between patients treated with intranasal dexmedetomidine and the control group that did not receive the medication.ResultsWe found no significant difference between the PAED scores of those patients treated with intranasal dexmedetomidine prior to ear tube surgeries and those who did not receive the medication, and no difference in the duration of PACU stay.ConclusionThese results conflict with other research on intranasal dexmedetomidine and its potential to prevent ED in pediatric patients. This information should prompt further prospective investigation into the most efficacious use of dexmedetomidine for ED prevention, both in terms of timing and dosage required.
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Comparison of home sleep apnea testing versus laboratory polysomnography for the diagnosis of obstructive sleep apnea in children
Source:International Journal of Pediatric Otorhinolaryngology, Volume 100
Author(s): Nicholas Scalzitti, Shana Hansen, Stephen Maturo, Joshua Lospinoso, Peter O'Connor
IntroductionObstructive sleep apnea (OSA) affects 1–5% of pediatric patients. Laboratory polysomnography is expensive, not always available, and is inconvenient for patients. Our study investigates the diagnostic ability of an unattended ambulatory monitor for the diagnosis of pediatric OSA.MethodsA prospective study was conducted in children, ages 2–17. Subjects completed in-lab polysomnography simultaneously with ambulatory monitoring. Caregivers attempted home studies on two subsequent nights to compare the home monitor and the laboratory polysomnogram (PSG).ResultsThirty-three subjects completed simultaneous laboratory polysomnogram with portable monitoring. Twenty patients completed home studies, with 16 completing 2 nights of monitoring. The measurement of AHI by the portable monitor was different than that obtained by the PSG with statistical significance for the comparisons of PSG vs. In-Lab (p = 0.0026), PSG vs. Home 1 (p = 0.033), and PSG vs. Home 2 (p = 0.033). The sensitivity of the portable monitor for diagnosing OSA was best for the In-lab use at 81%, but only 69% and 70% for the uses at home on the 2 nights respectively. Interestingly, the comparison of AHI and lowest oxygen saturation measurements from the home sleep test in children age 6 and older did not differ significantly from the PSG.ConclusionsThis pilot study demonstrated differences between home sleep testing and in-lab polysomnography for the diagnosis of pediatric sleep apnea. These differences were predominantly found to exist in younger children. Larger prospective studies are needed prior to widespread use, but home studies may alleviate issues of access to care and higher costs of laboratory polysomnography.
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Autoinflammatory keratinization diseases
Source:Journal of Allergy and Clinical Immunology
Author(s): Masashi Akiyama, Takuya Takeichi, John A. McGrath, Kazumitsu Sugiura
http://ift.tt/2sSvcqL
A clustering approach to identify and characterize the asthma and chronic obstructive pulmonary disease overlap phenotype
Abstract
Background
Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases. The phenotypes that have clinical features of both asthma and COPD are still incompletely understood.
Objective
To clarify the best discriminators of the asthma-COPD overlap phenotype from asthma and COPD subgroups using a clustering approach.
Methods
This study assessed pathophysiological parameters, including mRNA expression levels of T helper cell-related transcription factors, namely, TBX21 (Th1), GATA3 (Th2), RORC (Th17), and FOXP3 (Treg), in peripheral blood mononuclear cells in asthma patients (n = 152) and in COPD patients (n = 50). Clusters were determined using k-means clustering. Exacerbations of asthma and COPD were recorded during the 1-year follow-up period.
Results
The cluster analysis revealed four biological clusters: cluster 1, predominantly patients with COPD; cluster 2, patients with an asthma-COPD overlap phenotype; cluster 3, patients with non-atopic and late-onset asthma; and cluster 4, patients with early-onset atopic asthma. Hazard ratios for exacerbation were 2.5 (95% confidence interval [CI], 1.1–5.6) in cluster 1 and 2.3 (95% CI, 1.0–5.0) in cluster 2 compared with patients in other clusters. Cluster 2 was discriminated from other clusters by total serum IgE level ≥ 310 IU/mL, blood eosinophil counts ≥ 280 cells/μL, a higher ratio of TBX21/GATA3, FEV1/FVC ratio < 0.67, and smoking ≥ 10 pack-years with an area under the curve of 0.94 (95% CI, 0.90–0.98) in the receiver operating characteristic analysis.
Conclusions & Clinical Relevance
The asthma-COPD overlap phenotype was characterized by peripheral blood eosinophilia and higher levels of IgE despite the Th2-low endotype.
This article is protected by copyright. All rights reserved.
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Novel Somatic RET Mutation Questioning the Causality of the RET I852M Germline Sequence Variant in Multiple Endocrine Neoplasia 2A
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Double chin: Causes and how to get rid of one
Excess fat under the chin can be caused by a number of factors, including age, weight, and genetics. Learn how to reduce the appearance of a double chin.
http://ift.tt/2sn853P
Human Papillomavirus Vaccination and Keratinocyte Carcinomas—Reply
In Reply We appreciate Dr Mayer's interest in our article as well as his comments highlighting the inherent limitations of a small case series. We reported 2 cases of immunocompetent patients with a history of multiple keratinocyte carcinomas (KCs) and observed a substantial reduction of both squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs) subsequent to the quadrivalent human papillomavirus (HPV) vaccine.
http://ift.tt/2t1ydUa
http://ift.tt/2t1ydUa
Whitish Papules and Scars on a Patient With Bowel Perforation
A woman in her 30s with a 1-year history of unintentional weight loss, mild diffuse abdominal pain, and occasional episodes of vomiting after bowel perforation 3 years prior had a 24-hour history of intense abdominal pain, fever, and loose stools. What is your diagnosis?
http://ift.tt/2siiHWH
http://ift.tt/2siiHWH
Isotretinoin and Timing of Cutaneous Surgery Procedural Interventions
This systematic review analyzes the evidence behind the medical dictum prohibiting procedural interventions in the setting of isotretinoin therapy.
http://ift.tt/2t1AoXF
http://ift.tt/2t1AoXF
Human Papillomavirus Vaccination and Keratinocyte Carcinomas
To the Editor I enjoyed reading the article by Nichols et al on using the human papillomavirus (HPV) vaccine for the prevention of keratinocyte carcinomas (KCs). They found that 2 patients given the HPV vaccine had a large decrease in both squamous cell carcinomas (SCCs) (about 65%) and basal cell carcinomas (BCCs) (100%). However, further study details are needed to clarify whether the HPV vaccine is indeed a magic bullet or if the results are due to selection bias.
http://ift.tt/2siohZ5
http://ift.tt/2siohZ5
Misspelling of Coauthor Surname
In the article titled "Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Standard Reporting and Evaluation Guidelines: Results of a National Institutes of Health Working Group," published online March 15, 2017, Dr Tassaneeyakul's surname was misspelled in the byline. This article has been corrected online. This article was also corrected in April 2017 for typographical errors and missing table footnote.
http://ift.tt/2t1EtLi
http://ift.tt/2t1EtLi
Correlation Among Cancer Mortality Rates and Internet Searches
This cross-sectional analysis of Google seach volume index data investigates whether internet search volumes are correlated with registry recorded incidences and mortalities of common cancers
http://ift.tt/2sibaac
http://ift.tt/2sibaac
Immediate moxifloxacin hypersensitivity: is there more than currently meets the eye?
Abstract
Immediate drug hypersensitivity reactions (IDHR) to moxifloxacin constitute a pathomechanistic conundrum and a diagnostic challenge. Our objective was to study whether simultaneous phenotyping and quantification of histamine release might add to our knowledge about the basophil activation properties of moxifloxacin and constitute a reliable diagnostic aid. Fifteen patients with an IDHR to moxifloxacin and 9 moxifloxacin challenged controls were selected. All had a basophil activation test (BAT) with moxifloxacin. Flow cytometric analysis of basophil responses implied labeling for CD63, CD203c and intracellular histamine. Unlike tolerant challenged controls, basophilic upregulation of CD203c in response to moxifloxacin was observed in 7/15 patients. Only 2 of these 7 patients demonstrated appearance of CD63 and release of histamine. In the remainder 8 patients no basophil responses were demonstrable. In conclusion, immediate hypersensitivity to moxifloxacin might involve mechanisms difficult to capture by traditional CD63/CD203c-based BAT. Deciphering the complexity of quinolone IDHR seems mandatory.
This article is protected by copyright. All rights reserved.
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Delayed type hypersensitivity reactions induced by proton pump inhibitors: a clinical and in vitro T cell reactivity study
Abstract
Background
Proton pump inhibitors (PPI) has been known to induce type I hypersensitivity reactions. However, severe delayed type hypersensitivity reactions (DHR) induced by PPI, such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), or drug rash with eosinophilia and systemic symptoms (DRESS), are rarely reported. We conducted a study of a large series of PPI-related DHR, followed up their tolerability to alternative anti-ulcer agents, and investigated the T cell reactivity to PPI in PPI-related DHR patients.
Methods
We retrospectively analyzed patients with PPI-related DHR from multiple medical centers in Taiwan during the study period January 2003 to April 2016. We analyzed the causative PPI, clinical manifestations, organ involvement, treatment, and complications. We also followed up the potential risk of cross-hypersensitivity or tolerability to other PPI after their hypersensitivity episodes. Drug lymphocyte activation test (LAT) was conducted by measuring granulysin and interferon-γ to confirm the causalities.
Results
There were 69 cases of PPI-related DHR, including SJS/TEN (n=27) and DRESS (n=10). The LAT by measuring granulysin showed a sensitivity of 59.3% and specificity of 96.4%. Esomeprazole was the most commonly involved in PPI-related DHR (51%). Thirteen patients allergic to one kind of PPI could tolerate other structurally different PPI without cross-hypersensitivity reactions, whereas three patients developed cross-hypersensitivity reactions to alternative structurally similar PPI. The cross-reactivity to structurally similar PPI was also observed in LAT assay.
Conclusions
PPIs have the potential to induce life-threatening DHR. In patients when PPI is necessary for treatment, switching to structurally different alternatives should be considered.
This article is protected by copyright. All rights reserved.
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The in vitro mucolytic effect of xylitol and dornase alfa on chronic rhinosinusitis mucus
Background
The overproduction and stagnation of purulent mucus impair mucociliary clearance and exacerbate the symptoms of chronic rhinosinusitis (CRS). There is a clinical need for effective topical mucolytic agents to facilitate removal of mucus and improve postoperative outcomes.
Methods
The effects of xylitol (5%) and dornase alfa (1 mg/mL) on mucus and mucus crusts were investigated. Viscoelasticity and viscosity of wet mucus derived from 30 CRS patients was measured with a plate rheometer. Postoperative dried mucus crust dissolution was measured by examining peripheral transparency, central transparency, and border definition of treated crust samples from 17 CRS patients.
Results
Xylitol and dornase alfa reduced wet mucus viscoelasticity at a frequency of 0.1 Hz significantly more than the saline control. Treatments also produced significantly lower viscosities than saline at a shear rate of 10 and 100 seconds−1. Xylitol and dornase alfa significantly decreased mucus crust border definition relative to saline.
Conclusion
Xylitol and dornase alfa may be efficacious mucolytics, encouraging the breakdown of postoperative mucus crusts and the reduction of viscoelasticity and viscosity of wet mucus. In vivo study is required to evaluate the potential of these agents in treating recalcitrant CRS.
http://ift.tt/2tYiZPz
Assessment of acquired mucociliary clearance defects using micro-optical coherence tomography
Background
Dehydration of airway surface liquid (ASL) disrupts normal mucociliary clearance (MCC) in sinonasal epithelium, which may lead to chronic rhinosinusitis (CRS). Abnormal chloride (Cl−) transport is one such mechanism that contributes to this disorder and can be acquired secondary to environmental perturbations, such as hypoxia at the tissue surface. The objective of this study was to assess the technological feasibility of the novel micro-optical coherence tomography (μOCT) imaging technique for investigating acquired MCC defects in cultured human sinonasal epithelial (HSNE) cells.
Methods
Primary HSNE cell cultures were subjected to a 1% oxygen environment for 12 hours to induce acquired cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction. Ion transport characteristics were assessed with pharmacologic manipulation in Ussing chambers. ASL, periciliary fluid (PCL), and ciliary beat frequency (CBF) were evaluated using μOCT.
Results
Amiloride-sensitive transport (ΔISC) was greater in cultures exposed to hypoxia (hypoxia: −13.2 ± 0.6 μA/cm2; control: −6.5 ± 0.1 μA/cm2; p < 0.01), whereas CFTR-mediated anion transport was significantly diminished (hypoxia: 28.6 ± 0.3 μA/cm2; control: 36.2 ± 1.6 μA/cm2; p < 0.01), consistent with acquired CFTR dysfunction and sodium hyperabsorption. Hypoxia diminished all markers of airway surface function microanatomy as observed with μOCT, including ASL (hypoxia: 5.0 ± 0.4 μm; control: 9.0 ± 0.9 μm; p < 0.01) and PCL depth (hypoxia: 2.5 ± 0.1 μm; control: 4.8 ± 0.3 μm; p < 0.01), and CBF (hypoxia: 8.7 ± 0.3 Hz; control: 10.2 ± 0.3 Hz; p < 0.01).
Conclusion
Hypoxia-induced defects in epithelial anion transport in HSNE led to predictable effects on markers of MCC measured with novel μOCT imaging. This imaging method represents a technological leap forward and is feasible for assessing acquired defects impacting the airway surface.
http://ift.tt/2tpAVFZ
Platelet activation by crushed and uncrushed muscle: a flow cytometry analysis
Background
Crushed autologous muscle is used in skull base surgery in the acute phase of major arterial hemorrhage to stop bleeding. The mechanism of this is not yet clear, but is thought to involve the formation of a platelet plug, which seals the vessel wall defect but still allows ongoing blood flow to the brain.
Methods
In this study we use flow cytometry to replicate the in-vivo actions of crushed muscle on platelets in whole blood. We compare the ratio of activation of platelets exposed to crushed and uncrushed muscle supernatant in control patients and in patients on antiplatelet agents.
Results
Crushed muscle activated platelets to a higher degree than uncrushed muscle: 5.18-fold greater in control blood (p = 0.002); 6.53-fold greater in aspirin-exposed blood (p < 0.0001); and 9.4-fold greater in clopidogrel-exposed blood (p < 0.0001).
Conclusion
Crushed muscle caused a consistently increased ratio of platelet activation when compared with uncrushed muscle across all groups, adding to the evidence that at least part of its clinical effect is the result of platelet activation.
http://ift.tt/2uj3nFM
Expression of Metabolic Syndrome in Women with Severe Obesity
Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.
http://ift.tt/2s2fOoS
Quality metrics: hard to develop, hard to validate
In this issue of the British Journal of Anaesthesia, Epstein and colleagues1 report their findings surrounding the proposed use of intraoperative hypotension as a quality metric for comparison of anaesthetists. The authors analysed a retrospective data set derived from 10 yr of data from their anaesthesia information management system, focusing specifically on a cohort of patients undergoing surgery at an increased risk of postoperative myocardial injury. The availability of electronic health records has enabled big data approaches for quality improvement and outcomes research in anaesthesia.23 Anaesthetists performing these procedures were compared based on the time-weighted area under the curve for postinduction hypotension (defined as a mean arterial pressure of <65 mm Hg) over 2 month intervals. Recent evidence reviewed by Epstein and colleagues1 has implicated intraoperative hypotension in adverse outcomes after cardiac and non-cardiac surgery, and additional relevant studies will appear in the British Journal of Anaesthesia.45 The authors showed, convincingly, that because of the wide distribution of hypotension across providers and time epochs, intraoperative hypotension cannot be used alone as a quality metric to compare anaesthetists.
http://ift.tt/2s2r8kM
http://ift.tt/2s2r8kM
Predicting postoperative morbidity in adult elective surgical patients using the Surgical Outcome Risk Tool (SORT)
Abstract
Background. The Surgical Outcome Risk Tool (SORT) is a risk stratification instrument used to predict perioperative mortality. We wanted to evaluate and refine SORT for better prediction of the risk of postoperative morbidity.Methods. We analysed prospectively collected data from a single-centre cohort of adult patients undergoing major elective surgery. The data set was split randomly into derivation and validation samples. We used logistic regression to construct a model in the derivation sample to predict postoperative morbidity as defined using the validated Postoperative Morbidity Survey (POMS) assessed at 1 week after surgery. Performance of this 'SORT-morbidity' model was then tested in the validation sample and compared against the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM).Results. The SORT-morbidity model was constructed using a derivation sample of 1056 patients and validated in a further 527 patients. SORT-morbidity was well calibrated in the validation sample, as assessed using calibration plots and the Hosmer–Lemeshow test (χ2=4.87, P=0.77). It showed acceptable discrimination by receiver operating characteristic curve analysis [area under the receiver operating characteristic curve (AUROC)=0.72, 95% confidence interval: 0.67–0.77]. This compared favourably with POSSUM (AUROC=0.66, 95% confidence interval: 0.60–0.71), whilst being simpler to use. Linear shrinkage factors were estimated, which allow the SORT-morbidity model to predict a range of alternative morbidity outcomes with greater accuracy, including low- and high-grade morbidity, and POMS at later time points.Conclusions. SORT-morbidity can be used before surgery, with clinical judgement, to predict postoperative morbidity risk in major elective surgery.http://ift.tt/2s27yF9
Sleep deprived and unprepared
Recent UK government policy initiatives concerning 24/7 care have once again put the spotlight on work after hours. The unavoidable night shift confronts us on a regular basis with the physical, psychological, social, and emotional impacts of acute sleep deprivation and fatigue. Although the function of sleep is still not fully understood, it is undoubtedly vital for our good health and well-being. Regardless, on average we are sleeping less now than we ever did before. As a result, there is endless debate about the dangers of long working hours vs the benefits of continuity of care. Intriguingly, very little is actually known about the impact of delaying sleep on our behaviour as a team member in an unpredictable environment such as the emergency room, operating room, or intensive care unit.
http://ift.tt/2tlbULq
http://ift.tt/2tlbULq
Predictor of fluid responsiveness in the ‘grey zone’: augmented pulse pressure variation through a temporary increase in tidal volume
Abstract
Background: Pulse pressure variation (PPV) is widely used as a predictor of fluid responsiveness. However, a previous study has suggested a 'grey zone' between 9 and 13% in which PPV would be inconclusive to predict fluid responsiveness. Considering PPV is based on cardiopulmonary interactions, we evaluated whether an augmented PPV using a temporary increase in tidal volume (VT) from 8 to 12 ml kg−1 has the predictability for fluid responsiveness in patients within the grey zone.Methods: Adult patients requiring general anaesthesia were enrolled. During the period when PPV was within the range of 9–13%, haemodynamic variables such as stroke volume index (SVI) and PPV with an 8 ml kg−1 tidal volume ventilation (PPV8) were obtained before and after volume expansion (6 ml kg−1) under mechanical ventilation. Augmented PPV induced by 2-min ventilation with a VT of 12 ml kg−1 (PPV12) was also recorded immediately before volume loading. The patients whose SVI increased ≥10% after volume expansion were considered responders.Results: In 38 enrolled patients, 20 were responders. Receiver operating characteristic curve analysis showed PPV12 had an excellent predictability for fluid responsiveness {area under the curve [AUC]=0.935 [95% confidence interval (CI) 0.805–0.989]; sensitivity 95%; specificity 72%; P<0.0001}. The optimal threshold for PPV12 was >17%. However, PPV8 failed to show significant predictability [AUC=0.668 (95% CI 0.497–0.812); sensitivity 65%; specificity 61%; P=0.06].Conclusion: In mechanically ventilated patients, our augmented PPV successfully predicted fluid responsiveness in the previously suggested grey zone.Clinical trial registration: ClinicalTrials.gov, NCT02653469.http://ift.tt/2s2pxLR
Supplemental oxygen and surgical site infection: getting to the truth
Surgical site infection (SSI) remains one of the most serious and expensive postoperative complications.1 Infected patients are twice as likely to need admission to critical care and twice as likely to die.2 The primary defence against SSI is oxidative killing by neutrophils, and molecular oxygen is the substrate.3 Resistance to infection is thus a strong function of tissue oxygen partial pressure over the clinical range. One might thus expect that supplemental perioperative oxygen (∼80%) would reduce infection risk when compared with more traditional inspired oxygen concentrations (∼30%) during anaesthesia and surgery. Despite some early evidence supporting the role of supplemental oxygen in reducing the risk of SSI,4 there have since been conflicting results from numerous randomized clinical trials. The most compelling data come from the PROXI trial,5 a large, multicentre, randomized trial enrolling 1400 patients undergoing abdominal surgery. This trial found no evidence of any beneficial effect of supplemental oxygen; SSI occurred in 131 of 685 patients (19%) receiving 80% oxygen and in 141 of 701 (20%) receiving 30% oxygen [odds ratio 0.94 (95% confidence interval 0.72–1.22), P=0.64]. Indeed, a long-term follow-up study (median 2.3 years after surgery) found poorer survival in the supplemental oxygen group.6
http://ift.tt/2tl2G1M
http://ift.tt/2tl2G1M
Continuous monitoring and feedback of quality of recovery indicators for anaesthetists: a qualitative investigation of reported effects on professional behaviour
Abstract
Background: Research suggests that providing clinicians with feedback on their performance can result in professional behaviour change and improved clinical outcomes. Departments would benefit from understanding which characteristics of feedback support effective quality monitoring, professional behaviour change and service improvement. This study aimed to report the experience of anaesthetists participating in a long-term initiative to provide comprehensive personalized feedback to consultants on patient-reported quality of recovery indicators in a large London teaching hospital.Methods: Semi-structured interviews were conducted with 13 consultant anaesthetists, six surgical nursing leads, the theatre manager and the clinical coordinator for recovery. Transcripts were qualitatively analysed for themes linked to the perceived value of the initiative, its acceptability and its effects upon professional practice.Results: Analysis of qualitative data from participant interviews suggested that effective quality indicators must address areas that are within the control of the anaesthetist. Graphical data presentation, both longitudinal (personal variation over time) and comparative (peer-group distributions), was found to be preferable to summary statistics and provided useful and complementary perspectives for improvement. Developing trust in the reliability and credibility of the data through co-development of data reports with clinical input into areas such as case-mix adjustment was important for engagement. Making feedback specifically relevant to the recipient supported professional learning within a supportive and open collaborative environment.Conclusions: This study investigated the requirements for effective feedback on quality of anaesthetic care for anaesthetists, highlighting the mechanisms by which feedback may translate into improvements in practice at the individual and peer-group level.http://ift.tt/2s2msex
Intraoperative fraction of inspired oxygen: bringing back the focus on patient outcome
Over the last two decades, several randomized controlled trials (RCTs) have investigated the clinical impact of a higher fraction of inspired oxygen (FiO2) administered in the perioperative period. Setting FiO2 in the operating theatre and after surgery is one of the daily tasks of every anaesthetist, and in elective surgery in uncomplicated patients is often based on the clinician's habits, training, and local clinical practice, rather than on evidence-based guidelines.
http://ift.tt/2tl8TLj
http://ift.tt/2tl8TLj
Supraglottic jet oxygenation and ventilation enhances oxygenation during upper gastrointestinal endoscopy in patients sedated with propofol: a randomized multicentre clinical trial
Abstract
Background. Hypoventilation is the main reason for hypoxia during upper gastrointestinal endoscopy procedures with sedation. The key to preventing hypoxia is to maintain normal ventilation during the procedure. We introduced supraglottic jet oxygenation and ventilation (SJOV) through a new Wei nasal jet tube (WNJ) to reduce the incidence of hypoxia in patients sedated with propofol during upper gastrointestinal endoscopy procedures.Methods. In a multicentre, prospective randomized single-blinded study, 1781 outpatients undergoing routine upper gastrointestinal endoscopy who were sedated with propofol by an anaesthetist were randomized into the following three groups: the supplementary oxygen via nasal cannula group [nasal cannula oxygen: O2 (2 litres min−1) was administered via a nasal cannula]; the supplementary oxygen via WNJ group [WNJ oxygen: O2 (2 litres min−1) was administered through a WNJ]; and the SJOV via WNJ group (WNJ SJOV: SJOV was administered via WNJ) at three centres from March 2015 to July 2016. The primary outcome of interest was the incidence of hypoxia (peripheral oxygen saturation of 75–89%). Other adverse events were also recorded.Results. Supraglottic jet oxygenation and ventilation decreased the incidence of hypoxia from 9 to 3% (P<0.0001). No severe hypoxia occurred in the WNJ SJOV group, one instance occurred in the WNJ oxygen group, and two instances were observed in the nasal cannula oxygen supply control group. Supraglottic jet oxygenation and ventilation-related minor adverse events increased significantly within 1 min after the procedure but decreased 30 min later.Conclusions. The use of SJOV during upper gastrointestinal endoscopy for patients who are sedated with propofol reduces the incidence of hypoxia, with minor and tolerable adverse events. Supraglottic jet oxygenation and ventilation has a favourable risk-to-benefit ratio and may improve patient safety.Clinical trial registration. NCT02436018.http://ift.tt/2s2BFMK
Methodology in systematic reviews of goal-directed therapy: improving but not perfect
There has been a recent tsunami of articles on goal-directed (fluid) therapy, haemodynamic optimization and validation of cardiovascular monitoring devices. This has been followed by a wave of systematic reviews, in particular over the last five years, trying to summarize and derive conclusions and recommendations from many of these studies.1–19 Terminology for systematic reviews and meta-analyses is frequently used incorrectly. A systematic review refers to a rigorous scientific process of reviewing relevant literature whereas meta-analysis refers to a statistical method of pooling data from multiple studies to derive a summary effect estimate. Any well-conducted scientific process needs to comply with quality standards. Likewise, systematic reviews need to meet quality criteria before qualifying for the highest level of evidence (http://ift.tt/17HmMli, accessed May 29, 2017), including a sufficiently detailed published protocol, full search strategy in multiple databases, outcome selection following GRADE20 (http://ift.tt/YgVdNI, accessed May 29, 2017), assessment of risks of bias, assessment of risks of random errors, and reporting results following PRISMA21 and GRADEpro. Producing pooled estimates is always tempting whereas frequently not pooling data because of large heterogeneity might be much wiser. Eventually, only a few systematic reviews qualify for Level 1A evidence.
http://ift.tt/2tlpvTj
http://ift.tt/2tlpvTj
Association between preoperative pulse pressure and perioperative myocardial injury: an international observational cohort study of patients undergoing non-cardiac surgery
Abstract
Background. The management of elevated blood pressure before non-cardiac surgery remains controversial. Pulse pressure is a stronger predictor of cardiovascular morbidity in the general population than systolic blood pressure alone. We hypothesized that preoperative pulse pressure was associated with perioperative myocardial injury.Methods. This is a secondary analysis of the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation (VISION) international cohort study. Participants were aged ≥45 yr and undergoing non-cardiac surgery at 12 hospitals in eight countries. The primary outcome was myocardial injury, defined using serum troponin concentration, within 30 days after surgery. The sample was stratified into quintiles by preoperative pulse pressure. Multivariable logistic regression analysis explored associations between pulse pressure and myocardial injury. We accounted for potential confounding by systolic blood pressure and other co-morbidities known to be associated with postoperative cardiovascular complications.Results. One thousand one hundred and ninety-one of 15 057 (7.9%) patients sustained myocardial injury, which was more frequent amongst patients in the highest two preoperative pulse pressure quintiles {63–75 mm Hg, risk ratio (RR) 1.14 [95% confidence interval (CI): 1.01–1.28], P=0.03; >75 mm Hg, RR 1.15 [95% CI: 1.03–1.29], P=0.02}. After adjustment for systolic blood pressure, preoperative pulse pressure remained the dominant predictor of myocardial injury (63–75 mm Hg, RR 1.20 [95% CI: 1.05–1.37], P<0.01; >75 mm Hg, RR 1.25 [95% CI: 1.06–1.48], P<0.01). Systolic blood pressure >160 mm Hg was not associated with myocardial injury in the absence of pulse pressure >62 mm Hg (RR 0.67 [95% CI: 0.30–1.44], P=0.31).Conclusions. Preoperative pulse pressure >62 mm Hg was associated with myocardial injury, independent of systolic blood pressure. Elevated pulse pressure may be a useful clinical sign to guide strategies to reduce perioperative myocardial injury.http://ift.tt/2s27u8n
Some light in the grey zone?
Treatment of shock is not a new concern in intensive care medicine. The highest priority in patients with shock is the restoration of oxygen delivery. Fluid resuscitation is the very first goal of increasing cardiac output and oxygen delivery in patients with acute circulatory insufficiency. First, based on the simple physiology of the Frank–Starling mechanism, fluid loading should increase cardiac output (CO) by increasing preload and subsequently increasing left ventricular (LV) stroke volume.1 However, fluid overload, especially in patients with pre-existing or developing cardiac failure, can end in only a fractional increase of stroke volume and negative effects like pulmonary venous congestion can predominate. It is therefore a daily task for each intensivist to identify those patients who will respond to and benefit from volume expansion (e.g. acute shock) and to avoid fluid overload in those who are no longer fluid responsive but are at risk for increased mortality by further fluid therapy (e.g. protracted sepsis, acute respiratory distress syndrome, acute kidney injury). Thus the therapeutic conflict between hypovolaemia and hypervolaemia needs to be addressed wisely. Consequently, precise monitoring of preload could be helpful in this clinical scenario (Fig. 1).
http://ift.tt/2tlbzIT
http://ift.tt/2tlbzIT
Hypotension during induction of anaesthesia is neither a reliable nor a useful quality measure for comparison of anaesthetists’ performance
Abstract
Background. Identification of statistically reliable outcomes for comparison among anaesthetists is challenging. Time-weighted intraoperative mean arterial pressure <65 mm Hg (AUC65) is associated with increased odds for myocardial damage. We explored retrospectively whether such hypotension before incision was statistically reliable for peer comparison.Methods. We retrieved electronic data between 2006 and 2015 at a tertiary care, academic hospital in the USA for patients at risk for myocardial damage (inpatient after surgery, ASA physical status ≥III, ≥50 yr of age, and case duration ≥60 min). We determined the percentage of anaesthetists comparable based on caseload and case-mix. The AUC65 was compared amongst anaesthetists supervising ≥100 cases involving at-risk patients during the last 12 months.Results. Only 14.1% [95% confidence interval (CI) 13.6–14.5%] of cases involved patients who were 'at risk' during the 10 yr study period. A yearly average of 49 (sd 6) anaesthetists supervised ≥100 cases of any type, of whom only 52% (95% CI 47.1–56.0%) supervised ≥100 cases involving at-risk patients. Thus, nearly half the anaesthetists would have been excluded from peer comparison. During the last 12 months, there were two outliers among 34 evaluable anaesthetists (P<0.05, controlling for false discovery). However, their contribution to total hypotension amongst cases for all patients was small, because hypotension was widely distributed (e.g. 80% of hypotension attributable to 61.8% of anaesthetists, 95% CI 59.8–63.7%). There was no relationship between the AUC65 and propofol induction dose.Conclusions. The AUC65 of time-weighted pre-incision hypotension is not a suitable metric for comparing anaesthetists. There were few at-risk patients, half the anaesthetists were not evaluable because of their case-mix and caseload, and hypotension was widely distributed.http://ift.tt/2s2gzhB
The Goldilocks principle as it applies to perioperative blood pressure: what is too high, too low, or just right?
In this issue of the British Journal of Anaesthesia, Professor Venkatesan and colleagues,1 using data from the large UK Clinical Practice Research Datalink (CPRD) database, found a significant association between low preoperative arterial blood pressure (BP) values and increased postoperative mortality, but only in an elderly population of patients. The risk thresholds started at a preoperative systolic BP of 119 mm Hg and diastolic BP of 63 mm Hg compared with a reference BP of 120 mm Hg. Elevated diastolic, but not systolic BP, was also associated with increased mortality in the entire cohort of patients. These BP readings are considered within the normal, in fact optimal, ranges of acceptable BP for long-term control. Readers should not be surprised that elevated BP was associated with adverse outcomes. However, the findings that only elevated diastolic readings, not systolic hypertension, and 'low' (though the adjective 'lower' would likely be more descriptive of the actual findings) BP are associated with mortality are novel findings. The findings regarding low BP add weight to a growing body of observational data suggesting intraoperative hypotension is associated with adverse outcome. This article challenges us to perhaps be as concerned about low BP readings as we are about elevated BP in the preoperative as well as intraoperative periods.
http://ift.tt/2tkTsTb
http://ift.tt/2tkTsTb
Impact of sleep deprivation on anaesthesia residents’ non-technical skills: a pilot simulation-based prospective randomized trial
Abstract
Background. Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills.Methods. Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n=10] or after a night of rest [rested (R) group, n=10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists' non-technical skills (ANTS) assessed by two blinded evaluators.Results. Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5–13)] compared with the R group [14.5 (14–15), P<0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills.Conclusions. In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario.Trial registration. NCT02622217.http://ift.tt/2tliNwC
Rising sudden death among anaesthesiologists in China
Editor—Anaesthesiologists in China are currently suffering from work overload, and sudden death is increasing dramatically. A recent sudden death of a young anaesthesiologist in a local hospital followed an overnight of on-duty work; the second sudden death of a young anaesthesiologist this spring. In 2014, a young anaesthesiologist had a cardiac arrest after working 70 hours per week before the incident. More than 10 anaesthesiologists aged 30–45 yr had a cardiac arrest due to a heavy workload in China from 2013 to 2014.1 Sadly, this number has been increasing in recent years.2 The occupational status of anaesthesiologists was recently examined in a survey conducted by the New Youth Anaesthesia Forum, the largest web site of anaesthesiologists in China.3 The survey was also supported by the Chinese Society of Anaesthesiology and the Chinese Association of Anaesthesiology.
http://ift.tt/2s2qRhA
http://ift.tt/2s2qRhA
Premedication with salbutamol prior to surgery does not decrease the risk of perioperative respiratory adverse events in school-aged children
Abstract
Background: Perioperative respiratory adverse events (PRAE) remain the leading cause of morbidity and mortality in the paediatric population. This double-blinded randomized control trial investigated whether inhaled salbutamol premedication decreased the occurrence of PRAE in children identified as being at high risk of PRAE.Methods: Children with at least two parentally reported risk factors for PRAE undergoing elective surgery were eligible for recruitment. They were randomized to receive either salbutamol (200 µg) or placebo prior to their surgery and PRAE (bronchospasm, laryngospasm, airway obstruction, desaturation, coughing and stridor) were recorded.Results: Out of 470 children (6–16 yr, 277 males, 59%) recruited, 462 were available for an intention-to-treat analysis. Thirty-two (14%) and 27 (12%) children from the placebo and salbutamol groups experienced PRAE. This difference was not significant [odds ratio (OR): 0.83, 95% confidence interval (CI): 0.48–1.44, P: 0.51]. Oxygen desaturation [14/232 (6%) vs 14/230 (6%), OR: 1.01, 95% CI: 0.47–2.17, P: 0.98] and severe coughing [12/232 (5%) vs 10/230 (4%), OR: 0.83, 95% CI: 0.35–1.97, P: 0.68] were the most common PRAE, but did not significantly differ between the groups. The occurrence of PRAE was slightly lower in children with respiratory symptoms who received salbutamol compared with placebo [16/134 (12%) vs 21/142 (15%), OR: 0.93, 95% CI: 0.38–2.26, P: 0.87], but was not significantly different.Conclusions: Premedication with salbutamol to children aged between 6 and 16 years and at high risk of PRAE prior to their surgery did not reduce their risk of PRAE.Trial registration number: ACTRN12612000626864 (www.anzctr.org.au).http://ift.tt/2s27mWy
ISO (Infraclavicular–SubOmohyoid) block: a single-puncture technique for diaphragm- and opioid-sparing shoulder anaesthesia
Editor—The shoulder joint and its muscles are entirely supplied by the brachial plexus and can be anaesthetized simply using the interscalene block. However, this proximal placement of local anaesthetic results in spread to many crucial neural structures (especially the phrenic nerve). To bypass this complication, distal block of the shoulder innervation is recommended.1 Distally, the shoulder nerves are discrete, so multiple injections are usually required to achieve adequate analgesia. Blocking the axillary nerve and suprascapular nerve can provide adequate analgesia for minor shoulder surgery, but for major surgery both infraclavicular and suprascapular nerve blocks are required.1 To minimize block time and patient discomfort, we perform both infraclavicular and suprascapular nerve blocks through a single-puncture technique (the ISO block).
http://ift.tt/2s2wyfq
http://ift.tt/2s2wyfq
Prolonged concurrent hypotension and low bispectral index (‘double low’) are associated with mortality, serious complications, and prolonged hospitalization after cardiac surgery
Abstract
Background: Low bispectral index (BIS) and low mean arterial pressure (MAP) are associated with worse outcomes after surgery. We tested the hypothesis that a combination of these risk factors, a 'double low', is associated with death and major complications after cardiac surgery.Methods: We used data from 8239 cardiac surgical patients from two US hospitals. The primary outcomes were 30-day mortality and a composite of in-hospital mortality and morbidity. We examined whether patients who had a case-averaged double low, defined as time-weighted average BIS and MAP (calculated over an entire case) below the sample mean but not in the reference group, had increased risk of the primary outcomes compared with patients whose BIS and/or MAP were at or higher than the sample mean. We also examined whether a prolonged cumulative duration of a concurrent double low (simultaneous low MAP and BIS) increased the risk of the primary outcomes.Results: Case-averaged double low was not associated with increased risk of 30-day mortality {odds ratio [OR] 1.73 [95% confidence interval (CI) 0.94–3.18] vs reference; P=0.01} or the composite of in-hospital mortality and morbidity [OR 1.47 (95% CI 0.98–2.20); P=0.01] after correction for multiple outcomes. A prolonged concurrent double low was associated with 30-day mortality [OR 1.06 (95% CI 1.01–1.11) per 10-min increase; P=0.001] and the composite of in-hospital mortality and morbidity [OR 1.04 (95% CI 1.01–1.07), P=0.004].Conclusions: A prolonged concurrent double low, but not a case-averaged double low, was associated with higher morbidity and mortality after cardiac surgery.http://ift.tt/2s2qUKs
Lip, tooth, and pharyngeal injuries during tracheal intubation at a teaching hospital
Editor—A non-negligible number of patients suffer injury to the lips, teeth, or pharynx during tracheal intubation,12 but the incidence of such injuries at teaching hospitals has not been clarified. This prospective observational study surveyed the occurrence of lip, tooth, and pharyngeal injuries associated with tracheal intubation by trainee doctors at a teaching hospital (Osaka Medical College, Japan) to compare incidence rates during the early and late training stages.
http://ift.tt/2tlkGJp
http://ift.tt/2tlkGJp
Reports of Adverse Reactions With Cosmetics Increasing
Reuters Health Information
http://ift.tt/2tTUXFB
Large Study Finds No Link Between Eczema, Cardiovascular Disease
Atopic dermatitis (AD) is unlikely to be associated with cardiovascular disease, new research shows.
Reuters Health Information
http://ift.tt/2sn25rQ
An Unusually Large Carbuncle of the Temporofacial Region
How was this extensive carbuncle over the temporofacial region effectively managed?
Wounds
http://ift.tt/2thg737
Fluorescein sodium-guided surgery of parotid gland tumors as a technical advance
Abstract
Background
Complete tumor removal and preservation of the facial nerve are essential in parotid gland surgery. A technical adjunct that potentially enhances the contrast between the facial nerve and the adherent tumor tissue and allows to identify residual tumor tissue could be Fluorescein Sodium.
Methods
Retrospective chart analysis on 7 patients with benign parotid gland lesions that were operated using Fluorescein Sodium intravenously and the application of the YELLOW 560 nm filter of the operating microscope. Safety and feasibility were evaluated.
Results
All tumors showed fluorescence and the rating ´contrast-enhancing´ was assigned in all cases. In 2 patients, satellite nodules were identified and resected meaning that the fluorescence staining of the tumor margins was significantly better than under white light.
Conclusion
The use of Fluorescein Sodium in parotidectomy is promising. In two cases residual tumor was detected that would have been left behind under white light. Further research in parotid gland surgery and other head and neck tumor procedures is warranted.
http://ift.tt/2shLjzf
Granulome annulaire élastolytique à cellules géantes : étude anatomoclinique
Publication date: Available online 27 June 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): F. Margerin, B. Cribier
IntroductionLe rare granulome annulaire élastolytique à cellules géantes (GAECG), décrit en 1979, est très proche du granulome actinique (GA) de O'Brien, décrit en 1975. Depuis, de nombreux cas ont été publiés sous l'un ou l'autre nom. Nous avons effectué une étude anatomoclinique monocentrique afin d'en préciser les caractéristiques et de déterminer s'il existait une différence entre GAECG et GA.Matériel et méthodesLes cas classés GAECG ou GA au laboratoire de dermatopathologie de Strasbourg ont été inclus et analysés avec les colorations hématoxyline-éosine, orcéine et bleu alcian. Le diagnostic était retenu lorsqu'il existait un granulome riche en cellules géantes multinucléées et une diminution ou une disparition du tissu élastique. Les renseignements cliniques ont été collectés à partir des demandes d'analyse et des dossiers cliniques.RésultatsNous avons retenu 73 cas : 12 classés GAECG et 61 GA. L'âge moyen était de 60,5 ans et le sex-ratio de 0,55. La durée d'évolution variait de 8jours à 17 ans. Il s'agissait d'une lésion unique dans 52 % des cas et de lésions multiples dans les autres cas. Leur taille variait de 0,3 à 10cm. Elles siégeaient avec prédilection dans les zones photo-exposées, majoritairement la tête, le cou et les membres supérieurs. Il s'agissait le plus souvent de lésions à bordure érythémateuse annulaire et à centre clair, de croissance centrifuge lente. Le diagnostic n'avait été proposé que dans 5,5 % des cas par le clinicien. Ces granulomes étaient de siège dermique superficiel et moyen, rarement profond, comportaient de nombreuses cellules géantes avec un contingent lymphocytaire constant, mais aussi plasmocytaire dans la moitié des cas. La coloration à l'orcéine montrait une diminution nette ou une disparition totale du tissu élastique au sein de la zone granulomateuse et presque toujours des images d'élastophagocytose. De manière plus rare, des images de nécrobiose, d'organisation palissadique de granulome, d'atteinte vasculaire ou encore de corps astéroïdes orcéinophiles étaient observées. Il n'y avait pas de différence clinique ou histologique notable entre les cas initialement classés comme GAECG ou GA.DiscussionLe GAECG est une entité unique distincte du granulome annulaire, qui doit être assimilée au granulome actinique d'O'Brien. Le rôle central des fibres élastiques semble clair mais celui des ultraviolets est plus débattu. Le terme de granulome annulaire élastolytique à cellules géantes apparaît plus approprié car plus descriptif et sans implication physiopathologique. Le lien avec une sarcoïdose ou un diabète semble significatif dans une minorité de cas, justifiant leur dépistage.BackgroundAnnular elastolytic giant cell granuloma (AEGCG), a rare entity first described in 1979, is very similar to O'Brien actinic granuloma (AG), first described in 1975. Since then, many cases have been published under one or other of the two names. We performed a single-centre histopathology study to identify the distinguishing features and determine whether there was any objective difference between AEGCG and AG.Patients and methodsCases classed as AEGCG or AG at the dermatopathology laboratory in Strasbourg were included and analysed using haematoxylin-eosin, orcein and Alcian blue staining. The diagnosis was made in the event of granuloma rich in multi-nucleated giant cells and reduction or disappearance of elastic tissue. Clinical data were collected from the analysis requests and clinical files.ResultsWe identified 73 cases: 12 classed as AEGCG and 61 classed as AG. Mean age was 60.5 years with a sex ratio of 0.55. The duration of the disease ranged from 8 days to 17 years. A single lesion was seen in 52% of cases with multiple lesions in the remaining cases. Lesions measured between 0.3 and 10cm and exhibited a predilection for photo-exposed areas, chiefly on the head, neck and upper limbs. In most cases, an annular erythematous edge was seen together with a light centre, and slow centrifugal spread. The diagnosis was made by a clinician in only 5.5% of cases. These granulomas were chiefly in the superficial and mid dermis and only rarely deep, and contained numerous giant cells with a constant contingent of lymphocytes, but plasma cells were also seen in half of the cases. Orcein staining revealed marked decrease or total disappearance of elastic tissue within the granulomatous area together with elastophagocytosis in practically all images. More rarely, there was evidence of necrobiosis, palisading granuloma, vascular involvement or orcein-stained asteroid bodies. There were no notable clinical or histological differences between the cases initially classed as AEGCG or AG.DiscussionAEGCG is a separate entity from annular granuloma that must be assimilated with O'Brien actinic granuloma. The central role of elastic fibres seems clear, but that of ultraviolet radiation remains more controversial. The term annular elastolytic giant cell granuloma seems more appropriate since it is more descriptive and carries no physiopathological implications. There appears to be a significant association with sarcoidosis and with diabetes in a minority of cases, thus warranting screening for these diseases.
http://ift.tt/2t0XhKM
Evaluation of high-fidelity simulation as a training tool in transoral robotic surgery
Objectives/Hypothesis
To develop and evaluate a high-fidelity training simulator for transoral robotic posterior hemiglossectomy.
Study Design
Prospective observational study.
Methods
We constructed a transoral robotic surgery (TORS) simulator using porcine tongue in a modified airway mannequin. Twenty-nine surgeons performed transoral robotic posterior hemiglossectomy on the simulator. The 20 resident subjects completed six trials each, and the five fellows and four attending surgeons completed two trials each. In addition to instrument vibrations, surgical video was recorded for each trial and was blindly rated using the Global Evaluative Assessment of Robotic Skill (GEARS), a validated instrument for assessing robotic surgical skill.
Results
Attending surgeons were faster (P = .004) and demonstrated greater technical skill than fellows or residents (P < .001). Resident completion time generally decreased over the study, becoming significantly faster by the fifth trial (P = .02). A similar trend was seen in resident GEARS scores, which generally increased and were significantly improved by the fourth trial (P = .008). Instrument vibrations were not significantly different between subject groups. Finally, subjects highly rated the realism and training value of the TORS simulator (mean 4.4 and 4.7 out of 5, respectively).
Conclusions
The reported findings support using the described simulator as a training tool for TORS. Residents significantly improved in speed and technical skill over the course of six trials but did not achieve the performance levels of attending surgeons. These results demonstrate that high-fidelity simulation is a valuable tool for training novice surgeons in transoral robotic surgery.
Level of Evidence
NA Laryngoscope, 2017
http://ift.tt/2tkmkLj
Systemic bevacizumab for recurrent respiratory papillomatosis: A national survey
Objectives/Hypothesis
Aggressive laryngeal, tracheal, and pulmonary papilloma is an extremely challenging clinical problem without proven treatment options. A recent German report documented promising results with systemic bevacizumab. The objective of this study is to report the initial experience of this novel treatment in the United States for recurrent respiratory papillomatosis (RRP).
Study Design
Cases series.
Methods
Electronic survey of the RRP Task Force of the American Society of Pediatric Otolaryngology, American Broncho-Esophagological Association, and physicians known to the authors to have used systemic bevacizumab for RRP.
Results
Eleven completed surveys were obtained. In three cases, systemic bevacizumab was considered clinically but not administered. Eight patients were treated with systemic bevacizumab, all for aggressive papillomatosis uncontrolled by surgical and adjuvant therapy, including seven of eight with pulmonary disease. Treatment dosing ranged from 5 to 10 mg/kg every 2 to 4 weeks, with all patients responding (7/8 partial response, 1/8 complete response). In four patients who had postbevacizumab chest imaging, three demonstrated improvement of disease and one stabilization. Treatment interval could be lengthened in seven patients and clinical response maintained. One patient with long-standing pulmonary disease (>10 years) was diagnosed with malignant transformation while on treatment, and bevacizumab was discontinued in lieu of other chemotherapeutic agents. All other patients continue on systemic bevacizumab with minimal complications (hemoptysis n = 1, proteinuria n = 1).
Conclusions
Systemic bevacizumab appears to have significant promise in the most treatment-resistant and aggressive forms of papillomatosis with a low complication profile. These results suggest bevacizumab should be studied in a formal clinical trial for RRP.
Level of Evidence
4. Laryngoscope, 2017
http://ift.tt/2s1S2cm
The Diagnosis of Nasopharyngeal Carcinomas Through the Probe-based Confocal Laser Endomicroscopy
Conditions: Nasopharyngeal Carcinoma; Squamous Cell Carcinoma of the Head and Neck
Intervention: Diagnostic Test: 10% fluorescein
Sponsor: Eye & ENT Hospital of Fudan University
Recruiting - verified June 2017
http://ift.tt/2shj8AB
Intervention: Diagnostic Test: 10% fluorescein
Sponsor: Eye & ENT Hospital of Fudan University
Recruiting - verified June 2017
http://ift.tt/2shj8AB
The clinical efficacy of first-generation carcinoembryonic antigen (CEACAM5)-specific CAR T cells is limited by poor persistence and transient pre-conditioning-dependent respiratory toxicity
Abstract
The primary aim of this clinical trial was to determine the feasibility of delivering first-generation CAR T cell therapy to patients with advanced, CEACAM5+ malignancy. Secondary aims were to assess clinical efficacy, immune effector function and optimal dose of CAR T cells. Three cohorts of patients received increasing doses of CEACAM5+-specific CAR T cells after fludarabine pre-conditioning plus systemic IL2 support post T cell infusion. Patients in cohort 4 received increased intensity pre-conditioning (cyclophosphamide and fludarabine), systemic IL2 support and CAR T cells. No objective clinical responses were observed. CAR T cell engraftment in patients within cohort 4 was significantly higher. However, engraftment was short-lived with a rapid decline of systemic CAR T cells within 14 days. Patients in cohort 4 had transient, acute respiratory toxicity which, in combination with lack of prolonged CAR T cell persistence, resulted in the premature closure of the trial. Elevated levels of systemic IFNγ and IL-6 implied that the CEACAM5-specific T cells had undergone immune activation in vivo but only in patients receiving high-intensity pre-conditioning. Expression of CEACAM5 on lung epithelium may have resulted in this transient toxicity. Raised levels of serum cytokines including IL-6 in these patients implicate cytokine release as one of several potential factors exacerbating the observed respiratory toxicity. Whilst improved CAR designs and T cell production methods could improve the systemic persistence and activity, methods to control CAR T 'on-target, off-tissue' toxicity are required to enable a clinical impact of this approach in solid malignancies.
http://ift.tt/2tnOplq
The history and composition of the identified human skeletal collection of the Certosa Cemetery (Bologna, Italy, 19th -20th century)
Abstract
The purpose of this paper is to present the identified skeletal collection (by age, sex, cause of death, occupation, preservation state) from the Certosa Cemetery of Bologna (Italy), which was reviewed and checked through a consultation of the cemetery archives. The collection consists of 425 skeletons of individuals (from newborn to 91 years old) who died in Bologna between 1898 and 1944. The personal details associated with the skeletons were crosschecked with the data contained in the cemetery and municipal archives. For each skeleton, the biological profile was assessed using current anthropological methods in order to confirm its correct identification. Four hundred and eighteen skeletons (98.4%), mostly complete and well preserved, are identified at least for sex, and for 95% of these the age is known. The distribution of sexes in the various age groups is fairly well balanced. The cause of death is known in 93% of the individuals. Approximately 30% of the individuals died from infectious diseases. The occupation is known for more than 92% of the individuals. Most of the women were housewives, while the males were employed in various jobs. The crosscheck between archival data with the anthropological analysis of the remains, enabled a reliable identification of the skeletons. The sexes and various age groups are well represented, and the sample is substantially uniform as far as geographical origin and socioeconomic conditions (lower social classes) are concerned. Thanks to the reliability of the information collected, the Certosa collection is an excellent anthropological tool for the development and validation of osteobiographic methods.
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Tubercular Ulcer of Tongue in an Elderly Patient Masquerading as a Traumatic Ulcer
Tuberculosis is still one of the most prevalent diseases in developing countries like Nepal. However, due to the effectiveness of DOTS therapy, vaccination, and education, the prevalence of tuberculosis has fallen in recent years. Although the pulmonary and extrapulmonary tuberculosis, especially the tubercular lymphadenitis, is still very common in our country, the tuberculosis of oral cavity is an uncommon condition. We present a case of an elderly male who presented with the complaint of nonhealing ulcer of lateral border of tongue for 2-month duration which was masquerading as a traumatic ulcer due to sharp teeth adjacent to the lesion. Deep biopsy was taken under local anesthesia. Histopathological examination revealed that it was tuberculosis. Antitubercular therapy was then started which cured the lesion.
http://ift.tt/2tX2qUs
Insidious perforation of the rectum by a fallopian tube: the need to keep 'an open mind' when dealing with deep infiltrating endometriosis (DIE)
Endometriosis is a benign chronic disease which can have different degrees of severity and can potentially affect any organ. Intestinal endometriosis occurs in 3%â"37% of the cases, being more frequent in the rectosigmoid transition. Transmural involvement of intestinal endometriosis is extremely rare and is usually associated with recurrent abdominal pain. Due to the cyclical hormone influence, endometriosis implants may infiltrate the deeper layers of the intestinal wall and may lead to bowel obstruction or perforation. We present a case of transmural perforation of the rectum wall by an adjacent organ (left fallopian tube) that occurred insidiously in a patient with deep infiltrative endometriosis. A complete set of images is presented, regarding the preoperative, intraoperative and postoperative findings.
http://ift.tt/2t0doIA
Vibrio vulnificus tonsillitis after swimming in the Gulf of Mexico
Description
A 55-year-old man with decompensated cirrhosis secondary to Laennec's (alcoholic) cirrhosis and insulin-dependent diabetes mellitus presented with acute dysphagia and left-sided neck pain within hours of swimming in the Florida Gulf of Mexico. He did not ingest raw seafood, eat raw vegetables washed with fresh water or intentionally drink sea water prior to the presentation. He reported no gastrointestinal complaints. On examination, temperature was 39.1°C, and heart rate was 109 beats per minute with normal blood pressure. He appeared generally toxic and had an inflamed, ulcerated left tonsil; later, an axillary skin lesion developed with no trauma to the axillary area (figure 1). Neck CT showed submucosal tonsillar oedema, enlarged left palatine tonsil and reactive lymphadenopathy, consistent with acute tonsillitis (figure 2).
Figure 1
Tonsillar and pharyngeal lesions which appear ulcerated, inflamed and necrotic (A, B). Erythematous, slightly tender axillary lesion that appeared after the...
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Acute cor pulmonale due to pulmonary tumour thrombotic microangiopathy from renal cell carcinoma
We report the case of a previously healthy man who presented with subacute dyspnoea after a long drive. He developed hypoxic respiratory failure, thought secondary to a massive pulmonary embolism and was treated with tissue plasminogen activator but died in the hospital despite aggressive medical measures. Autopsy revealed pulmonary tumour thrombotic microangiopathy (PTTM) from papillary renal cell carcinoma. PTTM is a rare clinicopathological syndrome that clinically results in symptoms of dyspnoea and right heart failure. Pathologically, a localised paraneoplastic process evolves from tumour microemboli in the pulmonary arterioles, resulting in fibrocellular proliferation and narrowing of the vessels, causing subacute right heart failure. To our knowledge, this is the first case of PTTM due to papillary renal cell carcinoma.
http://ift.tt/2t0xkuW
Mild androgen insensitivity syndrome (MAIS): the identification of c.1783C>T mutation in two unrelated infertile men
Two unrelated men complaining of primary male infertility presented to Orient Hospital in Damascus city. Physical examination showed moderate hypoandrogenic features. Both men were azoospermic. Hormone profiles revealed an elevation of follicle-stimulating hormone in one patient, but all the other hormones tested were within normal limits for both patients. Further genetic analyses, including karyotype and microdeletions in the AZF region of the Y chromosome, were normal in both patients. Mild androgen insensitivity syndrome was expected in the two patients. Sequencing analysis of the first exon in the androgen receptor (AR) gene have shown c.1783C>T mutation in the two patients with azoospermia. This paper sheds light on the need to screen for mutations in the AR gene, causing male infertility whenever mild hypoandrogenic features are present with unexplained male infertility.
http://ift.tt/2sh3l4O
Presacral mass in the setting of an ovarian cyst and abdominal pain
Tailgut cysts, also known as retrorectal hamartomas, are very rare neoplasms located in the presacral/retrorectal space that originate from the embryonic hindgut. Although a majority of lesions in this location are benign, 30% of the reported cases in the literature were found to be malignant. This report describes a case of a presacral mass found on CT of a 37-year-old woman who initially presented with worsening abdominal pain and a history of ovarian cyst rupture. This patient's clinical picture was complicated by an enlarging ovarian cyst. The risk of progression to malignancy warranted excision. She recovered well with resolution of her presenting symptoms. We report this case along with a brief review of the literature with a focus on the surgical considerations.
http://ift.tt/2t0dmQY
Spontaneous rupture of the bladder during vomiting
A 46-year-old woman with no urological history or comorbidities presented with an acute abdomen with haematuria after a spell of protracted vomiting. The initial cystogram was negative; however, CT imaging highly suggested an intraperitoneal bladder perforation, which was confirmed during laparotomy and subsequently repaired. Cystoscopic evaluation prior to laparotomy revealed no concurrent bladder pathology, and the ureteric orifices were intact. A cystogram 2 weeks after repair demonstrated no leaks, and her catheters were removed. She recovered well, with expectant postoperative pain and lower urinary tract symptoms settling on 3-month review. Spontaneous bladder rupture is a rare entity, with very few reports in the literature.
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Successful repeat ECMO in a patient with AIDS and ARDS
Veno-venous extracorporeal membrane oxygenation (ECMO) is being more commonly used in patients with acute respiratory distress syndrome (ARDS) due to potentially reversible illnesses. Survival from ARDS using ECMO has been reported even in patients with AIDS. However, the indications for ECMO for ARDS due to immune reconstitution inflammatory syndrome (IRIS) in patients with AIDS are unknown. A 23-year-old man with AIDS and Pneumocystis jirovecii pneumonia was admitted to the intensive care unit with severe ARDS refractory to mechanical ventilator support requiring ECMO. Although ECMO was discontinued, a second treatment with ECMO was necessary due to IRIS-associated ARDS, resulting in an excellent patient outcome. This patient's clinical course suggests two important messages. First, ECMO is a reasonable option for the treatment of patients with ARDS even in a patient with AIDS. Second, ECMO may be effective for the treatment of patients with IRIS.
http://ift.tt/2t0thib
When your patient clicks: a loud clicking sound as a key sign to the diagnosis
A 19-year-old male patient was referred by his general practitioner with a new 'cardiac murmur'. For 1 week, he had been able to provoke a clicking sound, which was in time with his heart beat and originated from his chest. The physical examination and laboratory tests were normal. The sound was initially interpreted as most likely due to a valve condition such as mitral valve prolapse, but a transthoracic echocardiogram was normal. A cardiac CT was obtained, which showed left-sided ventral pneumothorax.
The Hamman's sign is a loud precordial pulse synchronous sound, which is often postural. It is pathognomonic for left-sided pneumothorax or pneumomediastinum. Hamman's sign as a presenting symptom is rare, but if present is key to diagnosis. The awareness of rare clinical findings is important and will prevent unnecessary diagnostic tests.
http://ift.tt/2sgC1Uk
Heroin-induced acute myelopathy with extreme high levels of CSF glial fibrillar acidic protein indicating a toxic effect on astrocytes
A man aged 33 years with previous heroin substance abuse was found unconscious lying in a bush. The patient had been without heroin for some time but had just started to use intravenous heroin again, 0.5–2 g daily. The patient had almost complete paraplegia and a sensory loss for all modalities below the mamillary level and a urine retention of 1.5 L. Acute MRI of the spine revealed an expanded spinal cord with increased intramedullary signal intensity, extending from C7–T9. The cerebrospinal fluid showed extremely high levels of nerve injury markers particularly glial fibrillar acidic protein (GFAP): 2 610 000/ng/L (ref. <750). The patient was empirically treated with intravenous 1 g methylprednisolone daily for 5 days and improved markedly. Very few diseases are known to produce such high levels of GFAP, indicating a toxic effect on astrocytes. Measuring GFAP could possibly aid in the diagnosis of heroin-induced myelopathy.
http://ift.tt/2t0yFle
Fever and asplenia: a dangerous association
Description
A 77-year-old splenectomised woman presented with temperatures reaching 38.5°C in the last 24 hours. The clinical presentation was non-specific and blood tests came back normal: a diagnosis of acute gastroenteritis was made. The patient's clinical state then deteriorated rapidly; she developed septic shock, acute renal failure, disseminated intravascular coagulation and purpura fulminans with peripheral necrosis of toes and fingers (figure 1 A,B), as complications of a pneumococcaemia. Following appropriate antibiotic therapy and supportive care, the patient recovered but had to undergo transmetatarsal and finger amputations(figure 1 C,D).
Figure 1
Necrosis of the (A) toes and (B) fingers in the context of disseminated intravascular coagulation. Clinical evolution following (C) transmetatarsal and (D) finger amputations.
Fever in patients with asplenia can be the initial, and sometimes sole, sign of a severe infection. It should never be trivialised. Moreover, other clinical...
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Giant lipoma of the hand causing median nerve compression
Lipomas are benign neoplasms derived from adipose tissue composed of mature adipocytes. They account for almost 50% of all soft-tissue neoplasms and occur in up to 2% of the population. They usually present asymptomatically as solitary discrete mobile lumps found most commonly on the neck, upper back, proximal limbs and chest. In less than 1% of cases, they can be found in the distal extremities.
We discuss the case of a 65-year-old man who presented with a 2-year history of a slowly enlarging left palm swelling, with recent-onset numbness and loss of power in the distribution of the median nerve. MRI studies showed that the 5x4x2.7 cm lipoma had a component extending into the distal aspect of the carpal tunnel, compressing the median nerve. It was successfully excised, and at follow-up the patient reported complete resolution of his symptoms.
http://ift.tt/2t0y57r
Urine fluorescence in antifreeze poisoning
Description
A 48-year-old man with diabetes mellitus and alcohol abuse presented to the emergency room (ER) with altered mental status, vomiting and abdominal pain. On examination, he was confused and uncooperative with a blood pressure of 70/40 mm Hg, heart rate of 66 beats/min, respiratory rate of 30 breaths/min and oxygen saturation of 95% on room air. Initial venous blood gas showed a 6.57 pH and PaCO2 of 33 mm Hg. Laboratory investigation showed serum bicarbonate of 5 mEq/L, serum creatinine of 2.5 mg/dL (baseline creatinine 1.1 mg/dL), blood sugar of 200 mg/dL, anion gap of 29 mmol/L, delta ratio of 0.9, lactic acid of 21 mmol/L, a serum osmolality of 360 mOsm/kg and an osmolar gap of 44 mOsm; blood alcohol level was 0.053 g/dL, and urine was negative for ketones. Bedside examination of a urine samples (figure 1) and mouth under Wood's lamp showed blue–green fluorescence, which raised suspicion of ethylene glycol poisoning secondary to antifreeze ingestion. Serum level...
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An Objective Drug-Induced Sedation Endoscopy Data Capture and Analysis System.
| Related Articles |
An Objective Drug-Induced Sedation Endoscopy Data Capture and Analysis System.
JAMA Otolaryngol Head Neck Surg. 2017 Jun 22;:
Authors: Dijemeni E, D'Amone G, Gbati I
PMID: 28655062 [PubMed - as supplied by publisher]
http://ift.tt/2to6yQe
Evaluating Surgeon-Specific Performance for Endoscopic Sinus Surgery.
| Related Articles |
Evaluating Surgeon-Specific Performance for Endoscopic Sinus Surgery.
JAMA Otolaryngol Head Neck Surg. 2017 Jun 22;:
Authors: Rudmik L, Xu Y, Alt JA, Deconde A, Smith TL, Schlosser RJ, Quan H, Soler ZM
Abstract
Importance: Several identified factors have raised questions concerning the quality of care for endoscopic sinus surgery (ESS), including the presence of large geographic variation in the rates and extent of surgery, poorly defined indications, and lack of ESS-specific quality metrics. Combined with the risk of major complications, ESS represents a high-value target for quality improvement.
Objective: To evaluate differences in surgeon-specific performance for ESS using a risk-adjusted, 5-year ESS revision rate as a quality metric.
Design, Setting, and Participants: This retrospective study used a population-based administrative database to study adults (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent primary ESS in Alberta, Canada, between March 1, 2007, and March 1, 2010. The study period ended in 2015 to provide 5 years of follow-up.
Interventions: Endoscopic sinus surgery for CRS.
Main Outcomes and Measures: Primary outcomes were the 5-year observed and risk-adjusted ESS revision rate. Logistic regression was used to develop a risk adjustment model for the primary outcome.
Results: A total of 43 individual surgeons performed primary ESS in 2168 patients with CRS. Within 5 years after the primary ESS procedure, 239 patients underwent revision ESS, and the mean crude 5-year ESS revision rate was 10.6% (range, 2.4%-28.6%). After applying the risk adjustment model and 95% CI to each surgeon, 7 surgeons (16%) had lower-than-expected performance and 2 surgeons (5%) had higher-than-expected performance. Three variables had significant associations with surgeon-specific, 5-year ESS revision rates: presence of nasal polyps (odds ratio [OR], 2.07; 95% CI, 1.59-2.70), more annual systemic corticosteroid courses (OR, 1.33; 95% CI, 1.19-1.48), and concurrent septoplasty (OR, 0.70; 95% CI, 0.55-0.89).
Conclusions and Relevance: Evaluating surgeon-specific performance for ESS may provide information to assist in quality improvement. Although most surgeons had comparable risk-adjusted, 5-year ESS revision rates, 16% of surgeons had lower-than-expected performance, indicating a potential to improve quality of care. Future studies are needed to evaluate more surgeon-specific variables and validate a risk adjustment model to provide appropriate feedback for quality improvement.
PMID: 28655057 [PubMed - as supplied by publisher]
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Objective and Subjective Measures of Simultaneous vs Sequential Bilateral Cochlear Implants in Adults: A Randomized Clinical Trial.
| Related Articles |
Objective and Subjective Measures of Simultaneous vs Sequential Bilateral Cochlear Implants in Adults: A Randomized Clinical Trial.
JAMA Otolaryngol Head Neck Surg. 2017 Jun 22;:
Authors: Kraaijenga VJC, Ramakers GGJ, Smulders YE, van Zon A, Stegeman I, Smit AL, Stokroos RJ, Hendrice N, Free RH, Maat B, Frijns JHM, Briaire JJ, Mylanus EAM, Huinck WJ, Van Zanten GA, Grolman W
Abstract
Importance: To date, no randomized clinical trial on the comparison between simultaneous and sequential bilateral cochlear implants (BiCIs) has been performed.
Objective: To investigate the hearing capabilities and the self-reported benefits of simultaneous BiCIs compared with those of sequential BiCIs.
Design, Setting, and Participants: A multicenter randomized clinical trial was conducted between January 12, 2010, and September 2, 2012, at 5 tertiary referral centers among 40 participants eligible for BiCIs. Main inclusion criteria were postlingual severe to profound hearing loss, age 18 to 70 years, and a maximum duration of 10 years without hearing aid use in both ears. Data analysis was conducted from May 24 to June 12, 2016.
Interventions: The simultaneous BiCI group received 2 cochlear implants during 1 surgical procedure. The sequential BiCI group received 2 cochlear implants with an interval of 2 years between implants.
Main Outcomes and Measures: First, the results 1 year after receiving simultaneous BiCIs were compared with the results 1 year after receiving sequential BiCIs. Second, the results of 3 years of follow-up for both groups were compared separately. The primary outcome measure was speech intelligibility in noise from straight ahead. Secondary outcome measures were speech intelligibility in noise from spatially separated sources, speech intelligibility in silence, localization capabilities, and self-reported benefits assessed with various hearing and quality of life questionnaires.
Results: Nineteen participants were randomized to receive simultaneous BiCIs (11 women and 8 men; median age, 52 years [interquartile range, 36-63 years]), and another 19 participants were randomized to undergo sequential BiCIs (8 women and 11 men; median age, 54 years [interquartile range, 43-64 years]). Three patients did not receive a second cochlear implant and were unavailable for follow-up. Comparable results were found 1 year after simultaneous or sequential BiCIs for speech intelligibility in noise from straight ahead (difference, 0.9 dB [95% CI, -3.1 to -4.4 dB]) and all secondary outcome measures except for localization with a 30° angle between loudspeakers (difference, -10% [95% CI, -20.1% to 0.0%]). In the sequential BiCI group, all participants performed significantly better after the BiCIs on speech intelligibility in noise from spatially separated sources and on all localization tests, which was consistent with most of the participants' self-reported hearing capabilities. Speech intelligibility-in-noise results improved in the simultaneous BiCI group up to 3 years following the BiCIs.
Conclusions and Relevance: This study shows comparable objective and subjective hearing results 1 year after receiving simultaneous BiCIs and sequential BiCIs with an interval of 2 years between implants. It also shows a significant benefit of sequential BiCIs over a unilateral cochlear implant. Until 3 years after receiving simultaneous BiCIs, speech intelligibility in noise significantly improved compared with previous years.
Trial Registration: trialregister.nl Identifier: NTR1722.
PMID: 28655036 [PubMed - as supplied by publisher]
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An Objective Drug-Induced Sedation Endoscopy Data Capture and Analysis System-Reply.
| Related Articles |
An Objective Drug-Induced Sedation Endoscopy Data Capture and Analysis System-Reply.
JAMA Otolaryngol Head Neck Surg. 2017 Jun 22;:
Authors: Baiardi S, Gobbi R, Sorrenti G
PMID: 28654936 [PubMed - as supplied by publisher]
http://ift.tt/2t0h9h2
Excitability of the masseter inhibitory reflex after high frequency rTMS over the motor cortex: A study in healthy humans
Source:Archives of Oral Biology, Volume 82
Author(s): Congcong Cui, Yuhan Song, Xiao Fan, Qian Guo, Jijun Wang, Weicai Liu
ObjectiveWe aimed to investigate the influence of high frequency repetitive transcranial magnetic stimulation (rTMS) of the motor cortex on excitability of the masseter inhibitory reflex (MIR) in healthy subjects. Our goal in conducting this study was to obtain a better understanding of the subcortical and cortical networks related to the excitability of the central masticatory pathway.MethodsTwenty healthy volunteers participated in this study. MIRs were evaluated both before and after high frequency rTMS to elicit motor evoked potentials (MEPs) using single- and double-shock techniques over the motor cortex. During measurements, the latency and duration of silent periods (SPs) with single magnetic stimulation, and the recovery of SP2 with the double-shock technique, were recorded in basal conditions and immediately after high frequency rTMS. The "real" rTMS condition consisted of 20 stimulus trains delivered at 10Hz with a 5-s stimulation duration and an intensity of 70% of the active motor threshold (AMT) over the right optimal motor spot for the masseter muscle.Resultswere also compared to those obtained after "sham" rTMS 1 week laterResultsUsing the double-shock technique, SP2 recovery time was significantly shorter after high frequency rTMS compared to the basal condition (from 100 to 400ms; p<0.001), while at ISIs of 500 and 600ms, no significant effect was observed (p=0.084, p=0.948). There was also no significant change in the SP latency or duration between groups (p>0.05).ConclusionsHigh frequency, sub-threshold rTMS of the motor cortex had a facilitative after-effect on the excitability of the MIR. This effect was likely mediated through increased cortical drive to brainstem reflex pathways, which would ultimately accelerate MIR recovery.
http://ift.tt/2sQBd7i
Excitability of the masseter inhibitory reflex after high frequency rTMS over the motor cortex: A study in healthy humans
Source:Archives of Oral Biology, Volume 82
Author(s): Congcong Cui, Yuhan Song, Xiao Fan, Qian Guo, Jijun Wang, Weicai Liu
ObjectiveWe aimed to investigate the influence of high frequency repetitive transcranial magnetic stimulation (rTMS) of the motor cortex on excitability of the masseter inhibitory reflex (MIR) in healthy subjects. Our goal in conducting this study was to obtain a better understanding of the subcortical and cortical networks related to the excitability of the central masticatory pathway.MethodsTwenty healthy volunteers participated in this study. MIRs were evaluated both before and after high frequency rTMS to elicit motor evoked potentials (MEPs) using single- and double-shock techniques over the motor cortex. During measurements, the latency and duration of silent periods (SPs) with single magnetic stimulation, and the recovery of SP2 with the double-shock technique, were recorded in basal conditions and immediately after high frequency rTMS. The "real" rTMS condition consisted of 20 stimulus trains delivered at 10Hz with a 5-s stimulation duration and an intensity of 70% of the active motor threshold (AMT) over the right optimal motor spot for the masseter muscle.Resultswere also compared to those obtained after "sham" rTMS 1 week laterResultsUsing the double-shock technique, SP2 recovery time was significantly shorter after high frequency rTMS compared to the basal condition (from 100 to 400ms; p<0.001), while at ISIs of 500 and 600ms, no significant effect was observed (p=0.084, p=0.948). There was also no significant change in the SP latency or duration between groups (p>0.05).ConclusionsHigh frequency, sub-threshold rTMS of the motor cortex had a facilitative after-effect on the excitability of the MIR. This effect was likely mediated through increased cortical drive to brainstem reflex pathways, which would ultimately accelerate MIR recovery.
http://ift.tt/2sQBd7i
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