Bullous pemphigoid following the replacement of vildagliptin with anagliptin

http://ift.tt/2uBsTaq

Replicon Particle Expressing the E2 Glycoprotein of Bovine Viral Diarrhea Virus Immunization and Evaluation of Antibody Response

Viral Immunology , Vol. 0, No. 0.


http://ift.tt/2szKo9F

Thymic Hyperplasia Associated with Graves' Disease: Pathophysiology and Proposed Management Algorithm

Thyroid , Vol. 0, No. 0.


http://ift.tt/2tAbC0U

Impact of the pretreatment Glasgow prognostic score on treatment tolerance, toxicities, and survival in patients with advanced head and neck cancer undergoing concurrent chemoradiotherapy

Abstract

Background

The purpose of this study was to evaluate the impact of the pretreatment Glasgow prognostic score on treatment-related toxicities, tolerance, and survival in patients with advanced head and neck cancers undergoing concurrent chemoradiotherapy (CRT).

Methods

We retrospectively analyzed and compared the clinical characteristics, toxicities, and survival of 143 patients with stages III, IVA, and IVB head and neck cancer treated with concurrent CRT according to their Glasgow prognostic score between 2007 and 2010.

Results

The Glasgow prognostic score was correlated with advanced tumor stage and T/N classification. Patients with a higher Glasgow prognostic score were less likely to tolerate concurrent CRT, experienced more weight loss, required tube feeding support more frequently, and had higher percentage of grade ≥3 hematological toxicities, sepsis, and toxic death. Patients with a Glasgow prognostic score of 0 had better overall and recurrence-free survival than those with a Glasgow prognostic score of 1 or 2.

Conclusion

Pretreatment Glasgow prognostic score predicts treatment tolerance, toxicity, and survival in patients with advanced head and neck cancer undergoing concurrent CRT.

http://ift.tt/2uUxinX

Using Simulation to Improve Systems

Attempts to understand and improve health care delivery often focus on the characteristics of the patient and the characteristics of the health care providers, but larger systems surround and integrate with patients and providers. Components of health care delivery systems can support or interfere with efforts to provide optimal health care. Simulation in situ, involving real teams participating in simulations in real care settings, can be used to identify latent safety threats and improve the work environment while simultaneously supporting participant learning. Thoughtful planning and skilled debriefing are essential.

http://ift.tt/2tWta9Y

Change in lip closing force in Classes II and III malocclusion before and after sagittal split ramus osteotomy with Le Fort I osteotomy

Many studies have shown that cranio-maxillofacial deformity patients have lower functioning than persons with normal skeleton and occlusion (Throckmorton et al., 2000). Improvement of that functioning is one of the purposes of orthognathic surgery.

http://ift.tt/2uUqGpC

Prospective comparison of 18F-NaF PET/CT versus 18F-FDG PET/CT imaging in mandibular extension of head and neck squamous cell carcinoma with dedicated analysis software and validation with surgical specimen. A preliminary study

: The aim of this study is to propose a new method to quantify radioactivity with PET/CT imaging in mandibular extension in head and neck squamous cell carcinoma (HNSCC), using innovative software, and to compare results with microscopic surgical specimens.

http://ift.tt/2tWIHX4

Clinical accuracy of waferless maxillary positioning using customized surgical guides and patient specific osteosynthesis in bimaxillary orthognathic surgery

Computer-assisted planning and surgery for the treatment of orthognathic deformities have been extensively documented over the last decade. Computerized and customized wafers have lacked to improve the accuracy of maxillary positioning, resulting in a draw back of computer-assisted orthognathic surgery. The aim of this study was to determine the accuracy of a new technique of waferless maxillary positioning using customized surgical guides and patient specific osteosynthesis implants in bimaxillary orthognathic surgery.

http://ift.tt/2uUIS2q

Total lower lip and chin reconstruction with radial forearm free flap: A novel approach

The management of large chin and lower lip defects is challenging due to this facial subunit's tremendous functional and aesthetic importance. Specific methods for total lower lip and mentum reconstruction are not well chronicled. Aesthetic and functional goals of this reconstruction include restoration of oral competence by maintaining lower lip height, vermilion reestablishment, color-matched skin introduction to the chin, sensation restoration, and ideally restoration of dynamic activity to the lower lip.

http://ift.tt/2tr3Sjy

Erratum to: Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy?

http://ift.tt/2tWyKJv

Use of yeast ( Pichia kudriavzevii ) as a novel feed additive to ameliorate the effects of aflatoxin B 1 on broiler chicken performance

Abstract

The aim of this study was to evaluate the efficacy of autochthonous Pichia kudriavzevii as a novel bioadsorbent for aflatoxin B₁ (AFB₁). The selection of this yeast was based on the AFB₁ adsorption capacity previously demonstrated in vitro (Magnoli et al. 2016). One-day-old Cobb broilers (n = 160) were randomly assigned to four dietary treatments (T1: basal diet (B); T2: B + 0.1% yeast; T3: B + AFB₁, 100 μg/kg; T4: B + 0.1% yeast + AFB₁, 100 μg/kg). Performance parameters (average daily weight gain body, average daily consumption, feed conversion ratio, carcass weight, and dead weight), biochemical parameters (albumin, globulin, and albumin/globulin), liver pathological changes, and AFB₁ residual levels in the liver and excreta were evaluated. Significant differences (P < 0.05) in performance parameters were observed among treatments and controls: T3 group showed the lowest average daily body weight gain value while in T4 group, the value of this parameter increased significantly (P < 0.05). T3 and T4 groups showed the lowest and highest values for average daily feed consumption, respectively. The feed conversion ratio (FC) showed no significant differences among treatments. T3 group showed the lowest dead weight and carcass weight compared with T1 group. The biochemical parameters showed no significant differences among treatments. T3 group showed macroscopic and microscopic liver changes compared to the control. Aflatoxin B₁ levels (μg/g) were detected in broiler livers and showed significant differences among treatments (P < 0.05). In conclusion, native P. kudriavzevii incorporation (0.1%) in broiler diets containing AFB₁ was shown to be effective in ameliorating the adverse effects of AFB₁ on production.

http://ift.tt/2tSmU3z

Biphasic synovial sarcoma of the epiglottis: Case report and literature review

Publication date: Available online 6 July 2017
Source:Auris Nasus Larynx
Author(s): Marlene C. Wigand, Thomas K. Hoffmann, Thomas F.E. Barth, Johannes Veit
Synovial sarcomas are rare malignant tumors supposed to arise from pluripotent mesenchymal stem cells predominantly affecting the deep soft tissue of the lower and upper extremities in young adults. The occurrence of this tumor entity in the head and neck is very uncommon and hence, timely diagnosis and treatment of synovial sarcoma in this region remain a challenge.We describe the clinical and molecular pathological features of a biphasic synovial sarcoma of the epiglottis, a site where the primary manifestation of this tumor entity has not been documented to date. With this background the existing literature is being reviewed. Whilst wide excision of synovial sarcoma is considered as the primary mainstay of therapy, (neo)adjuvant treatment strategies have been proposed to increase local control and prolong disease-free survival.



http://ift.tt/2uUmMwW

Influence of bisphosphonates on the adherence and metabolism of epithelial cells and gingival fibroblasts to titanium surfaces

Abstract

Objectives

To evaluate the effects of sodium alendronate (SA) and zoledronic acid (ZA), on the adhesion and metabolism of epithelial cells and gingival fibroblasts to titanium surfaces considering cell functions related to an effective mucosal barrier around the implant.

Materials and methods

Cells were seeded onto titanium discs and incubated for 24 h. Then, serum-free DMEM containing selected bisphosphonates (0, 0.5, 1, or 5 μM) was added for 24 and 48 h. Factors related to the achievement of an effective mechanical and immunological barrier—cell adhesion, viability, collagen epidermal growth factor, and immunoglobulin synthesis—were evaluated. Data were analyzed by Kruskal-Wallis and Mann-Whitney tests as well as by ANOVA and Tukey's tests, (α = 0.05).

Results

The presence of bisphosphonates culminated in lower cell adhesion to the titanium discs, particularly for SA at 5 μM (40%) and ZA at all concentrations (from 30 to 50%, according to increased concentrations). Reduced cell viability occurred after exposing these cells to ZA (40%); however, only 5 μM SA-treated cells had decreased viability (30%). Reduced synthesis of growth factors and collagen was observed when cells were reated with ZA (20 and 40%, respectively), while about 70% of IgG synthesis was enhanced.

Conclusion

Bisphosphonates negatively affected the adhesion and metabolism of oral mucosal cells, and this effect was related to the type of bisphosphonate as well as to concentration and period of treatment.

Clinical relevance

The negative effects of bisphosphonates on oral mucosal cells can hamper the formation of an effective biological seal in osseointegrated implants.

http://ift.tt/2tr3tgV

Mechanical loading increases pro-inflammatory effects of nitrogen-containing bisphosphonate in human periodontal fibroblasts

Abstract

Objectives

There is increasing evidence that inflammation and biomechanical loading can influence the effects of bisphosphonates (BP). The aim of this study was to investigate the influence of tensile strain application combined with IL-1ß and clodronate or zoledronate on human periodontal ligament fibroblasts (HPdLF) in vitro.

Materials and methods

HPdLF were cultured with 10 nM IL-1ß and 5 μM clodronate or zoledronate for 48 h. Cells were applied to cyclic tensile strain (CTS; 3% elongation) for 12 h in vitro. Cell number was analyzed directly after CTS by MTT assay. Gene expression of receptor activator of cyclooxygenase-2 (COX-2) was investigated using real-time PCR. MMP-8, TIMP-1, and PGE2 were measured by ELISA. Statistics were performed with SPSS (ANOVA, p < 0.05).

Results

Zoledronate reduced the cell number of HPdLF (60.3 vs. 100%), which was significant when combined with IL-1ß. Combined with 3% CTS, this effect was voided and cell number increased over the level of the control cells. IL-1ß led to a 10-fold increase of COX-2 gene expression. Combined with CTS and zoledronate, this increase was enhanced to a gene expression 70-fold that of control cells with related PGE2 synthesis. Clodronate neither reduce the cell number nor enhanced the COX-2 gene expression. CTS increased MMP-8 protein synthesis. Combined with BP, this increase was voided. TIMP-1 protein synthesis was increased at all conditions under CTS.

Conclusions

Mechanical loading might activate cell metabolism and abolish BP- and inflammation-induced reduction of viability. Combination of mechanical loading, inflammation, and nitrogen-containing bisphosphonates can cause pro-inflammatory effects.

Clinical relevance

Periodontal inflammation should be treated initially before BP intake to prevent decreased cell viability of the periodontium and increased inflammation, which might be enhanced by the addition of mastication forces.

http://ift.tt/2tqJzCO

Prognostic score in patients with recurrent or metastatic carcinoma of the head and neck treated with cetuximab and chemotherapy

by Teresa Magnes, Thomas Melchardt, Lukas Weiss, Christof Mittermair, Daniel Neureiter, Eckhard Klieser, Simon Gampenrieder, Gerhard Moser, Alexander Gaggl, Richard Greil, Alexander Egle

Despite modern treatment approaches, survival of patients with recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) remains low and it is difficult to identify patients who derive optimal benefit from treatment. We therefore analyzed which commonly available laboratory and clinical parameters may help improve the prognostication in this patient group. This retrospective monocenter analysis includes 128 patients with recurrent or metastatic SCCHN treated with cetuximab alone or in combination with polychemotherapy as first line therapy. Factors with independent prognostic power in the multivariate analysis were used to build up a score separating patient groups with different survival. Patients had a median age of 61 years and 103 patients were treated with polychemotherapy plus cetuximab. An ECOG score above 1, high CRP and leukocyte levels, less intensive treatment and a time below 12 months from primary diagnosis to relapse remained as independent negative prognostic factors in multivariate analysis. Patients with 0 to 1 risk factors had a median OS of 13.6 months compared to a median OS of less than one month for patients 4 to 5 risk factors (p

http://ift.tt/2u0rT2o

Assessment of circulating copy number variant detection for cancer screening

by Bhuvan Molparia, Eshaan Nichani, Ali Torkamani

Current high-sensitivity cancer screening methods, largely utilizing correlative biomarkers, suffer from false positive rates that lead to unnecessary medical procedures and debatable public health benefit overall. Detection of circulating tumor DNA (ctDNA), a causal biomarker, has the potential to revolutionize cancer screening. Thus far, the majority of ctDNA studies have focused on detection of tumor-specific point mutations after cancer diagnosis for the purpose of post-treatment surveillance. However, ctDNA point mutation detection methods developed to date likely lack either the scope or analytical sensitivity necessary to be useful for cancer screening, due to the low (

http://ift.tt/2tVbNq7

Pembrolizumab, Chemotherapy, and Radiation Therapy With or Without Surgery in Treating Patients With Anaplastic Thyroid Cancer

Condition:   Thyroid Gland Undifferentiated (Anaplastic) Carcinoma
Interventions:   Drug: Docetaxel;   Drug: Doxorubicin Hydrochloride;   Radiation: Intensity-Modulated Radiation Therapy;   Other: Laboratory Biomarker Analysis;   Biological: Pembrolizumab;   Procedure: Therapeutic Conventional Surgery
Sponsors:   Mayo Clinic;   National Cancer Institute (NCI)
Not yet recruiting - verified July 2017

http://ift.tt/2uTDEnC

Effects of Voluntary Neck Extension on Cerebral Blood Flow, in Breath-hold Divers Ending an Apnoea of Two Minutes or More.

Condition:   Healthy Amateur Apneists
Intervention:   Other: apnea performing
Sponsor:   Nantes University Hospital
Not yet recruiting - verified July 2017

http://ift.tt/2tVxvu7

Use of Intra-Operative Shear Wave Ultrasound Vibrometry for Characterization of Esophageal Malignant Tumors

Condition:   Esophageal Cancer
Intervention:   Device: General Electric LOGIQ E9 ultrasound system
Sponsor:   Mayo Clinic
Recruiting - verified July 2017

http://ift.tt/2tVF0RJ

NCI-MATCH: Targeted Therapy Directed by Genetic Testing in Treating Patients With Advanced Refractory Solid Tumors, Lymphomas, or Multiple Myeloma

Conditions:   Advanced Malignant Solid Neoplasm;   Bladder Carcinoma;   Breast Carcinoma;   Cervical Carcinoma;   Colon Carcinoma;   Colorectal Carcinoma;   Endometrial Carcinoma;   Esophageal Carcinoma;   Gastric Carcinoma;   Glioma;   Head and Neck Carcinoma;   Kidney Carcinoma;   Liver and Intrahepatic Bile Duct Carcinoma;   Lung Carcinoma;   Lymphoma;   Malignant Uterine Neoplasm;   Melanoma;   Ovarian Carcinoma;   Pancreatic Carcinoma;   Plasma Cell Myeloma;   Prostate Carcinoma;   Rectal Carcinoma;   Recurrent Bladder Carcinoma;   Recurrent Breast Carcinoma;   Recurrent Cervical Carcinoma;   Recurrent Colon Carcinoma;   Recurrent Colorectal Carcinoma;   Recurrent Esophageal Carcinoma;   Recurrent Gastric Carcinoma;   Recurrent Glioma;   Recurrent Head and Neck Carcinoma;   Recurrent Liver Carcinoma;   Recurrent Lung Carcinoma;   Recurrent Lymphoma;   Recurrent Malignant Solid Neoplasm;   Recurrent Melanoma;   Recurrent Ovarian Carcinoma;   Recurrent Pancreatic Carcinoma;   Recurrent Plasma Cell Myeloma;   Recurrent Prostate Carcinoma;   Recurrent Rectal Carcinoma;   Recurrent Skin Carcinoma;   Recurrent Thyroid Gland Carcinoma;   Recurrent Uterine Corpus Carcinoma;   Refractory Lymphoma;   Refractory Malignant Solid Neoplasm;   Refractory Plasma Cell Myeloma;   Skin Carcinoma;   Thyroid Gland Carcinoma;   Uterine Corpus Cancer
Interventions:   Drug: Afatinib;   Drug: Akt inhibitor AZD5363;   Drug: Binimetinib;   Drug: Crizotinib;   Other: Cytology Specimen Collection Procedure;   Drug: Dabrafenib;   Drug: Dasatinib;   Drug: Defactinib;   Drug: FGFR Inhibitor AZD4547;   Other: Laboratory Biomarker Analysis;   Biological: Nivolumab;   Drug: Osimertinib;   Drug: Palbociclib;   Biological: Pertuzumab;   Drug: PI3K-beta Inhibitor GSK2636771;   Drug: Sapanisertib;   Drug: Sunitinib Malate;   Drug: Taselisib;   Drug: Trametinib;   Biological: Trastuzumab Emtansine;   Drug: Trk Inhibitor LOXO-101;   Drug: Vismodegib;   Drug: WEE1 Inhibitor AZD1775
Sponsor:   National Cancer Institute (NCI)
Recruiting - verified July 2017

http://ift.tt/2u0CpXt

Prognostic score in patients with recurrent or metastatic carcinoma of the head and neck treated with cetuximab and chemotherapy

by Teresa Magnes, Thomas Melchardt, Lukas Weiss, Christof Mittermair, Daniel Neureiter, Eckhard Klieser, Simon Gampenrieder, Gerhard Moser, Alexander Gaggl, Richard Greil, Alexander Egle

Despite modern treatment approaches, survival of patients with recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) remains low and it is difficult to identify patients who derive optimal benefit from treatment. We therefore analyzed which commonly available laboratory and clinical parameters may help improve the prognostication in this patient group. This retrospective monocenter analysis includes 128 patients with recurrent or metastatic SCCHN treated with cetuximab alone or in combination with polychemotherapy as first line therapy. Factors with independent prognostic power in the multivariate analysis were used to build up a score separating patient groups with different survival. Patients had a median age of 61 years and 103 patients were treated with polychemotherapy plus cetuximab. An ECOG score above 1, high CRP and leukocyte levels, less intensive treatment and a time below 12 months from primary diagnosis to relapse remained as independent negative prognostic factors in multivariate analysis. Patients with 0 to 1 risk factors had a median OS of 13.6 months compared to a median OS of less than one month for patients 4 to 5 risk factors (p

http://ift.tt/2u0rT2o

Assessment of circulating copy number variant detection for cancer screening

by Bhuvan Molparia, Eshaan Nichani, Ali Torkamani

Current high-sensitivity cancer screening methods, largely utilizing correlative biomarkers, suffer from false positive rates that lead to unnecessary medical procedures and debatable public health benefit overall. Detection of circulating tumor DNA (ctDNA), a causal biomarker, has the potential to revolutionize cancer screening. Thus far, the majority of ctDNA studies have focused on detection of tumor-specific point mutations after cancer diagnosis for the purpose of post-treatment surveillance. However, ctDNA point mutation detection methods developed to date likely lack either the scope or analytical sensitivity necessary to be useful for cancer screening, due to the low (

http://ift.tt/2tVbNq7

Autoimmunity and allergy control in adults submitted to complete thymectomy early in infancy

by Susana L. Silva, Adriana Albuquerque, Andreia J. Amaral, Quan-Zhen Li, Catarina Mota, Rémi Cheynier, Rui M. M. Victorino, M. Conceição Pereira-Santos, Ana E. Sousa

The contribution of the decline in thymic activity for the emergence of autoimmunity is still debatable. Immune-competent adults submitted to complete thymectomy early in life provide a unique model to address this question. We applied here strict criteria to identify adults lacking thymic activity based on sjTREC levels, to exclude thymic rebound and/or ectopic thymuses. In agreement, they featured severe naïve CD4 T-cell depletion and contraction of T-cell receptor diversity. Notwithstanding this, there was neither increased incidence of autoimmune disease in comparison with age-matched controls nor significant changes in their IgG/IgA/IgM/IgE autoreactivity profiles, as assessed through extensive arrays. We reasoned that the observed relative preservation of the regulatory T-cell compartment, including maintenance of naïve regulatory CD4 T-cells, may contribute to limit the emergence of autoimmunity upon thymectomy. Our findings have implications in other clinical settings with impaired thymic activity, and are particularly relevant to studies of autoimmunity in ageing.

http://ift.tt/2u08UFd

Free-flap surgical correction of facial deformity after anteromedial maxillectomy

Publication date: Available online 6 July 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Shunji Sarukawa, Hideaki Kamochi, Tadahide Noguchi, Ataru Sunaga, Hirokazu Uda, Yoshiyuki Mori, Hiroshi Nishino, Kotaro Yoshimura
Anteromedial maxillectomy is typically performed in conjunction with low-dose radiotherapy and intraarterial chemotherapy. In doing so, the extent of surgical defects is reduced. However, nasal deviation and oral incompetence may ensue, due to cicatricial contracture of wounds, and may be distressing to these patients. Herein, we report a series of eight free perforator flap procedures (anterolateral thigh [ALT] flap, 6; thoracodorsal artery perforator [TAP] flap, 2) used to correct such deformities. The TAP flap was combined with scapular tip [ST] osseous flap in patients with added zygomatic prominence defects. Three adipocutaneous parts developed from each perforator flap were applied as follows: two to reconstruct nasal lining and oral vestibule, and one to augment cheek volume. All aesthetic results proved satisfactory, although orbital dystopia and contracture of mimic muscles were not resolved completely. These secondary interventions are suitable for sequelae of simple anteromedial maxillectomy. Immediate reconstruction should be considered if orbital floor and mimic muscles are involved.



http://ift.tt/2u0xyFP

The pterygoalar bar: A meta-analysis of its prevalence, morphology and morphometry

Publication date: Available online 6 July 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Przemysław A. Pękala, Brandon Michael Henry, Jakub R. Pękala, Paulina A. Frączek, Dominik Taterra, Konstantinos Natsis, Maria Piagkou, Janusz Skrzat, Iwona M. Tomaszewska
PurposeThe pterygoalar (PA) bar is a bony bridge resulting from the partial or complete ossification of a PA ligament. The aim of this meta-analysis was to systematically analyze and provide the most comprehensive data on the prevalence, morphology and topographical anatomy of the PA bar.Materials and MethodsA comprehensive search of the major electronic databases (PubMed, Embase, ScienceDirect, SciELO, BIOSIS, and Web of Science) was conducted in order to identify relevant studies. Studies reporting the prevalence, side of occurrence, gender dimorphism and morphometry of the PA bar were included in the current study.ResultsA total of 25 articles (n=16,168 subjects) were included in the meta-analysis. The overall pooled prevalence of the complete PA bar was 4.4% (95% CI: 3.0-6.0) and of the incomplete was 8.4% (95% CI: 4.6-13.3). The PA bar was most often observed unilaterally, on the left side. Analysis of geographical subgroups revealed considerable differences, with the lowest prevalence rates in Europe for both incomplete and complete PA bars.ConclusionsConsidering the prevalence and anatomical characteristics of the PA bar, caution is recommended while planning or performing transfacial needle approach to the foramen ovale and when considering a differential diagnosis for nerve compression or entrapment syndromes.



http://ift.tt/2uz5ztL

Hydroxyapatite collagen scaffold with autologous bone marrow aspirate for mandibular condylar reconstruction

Publication date: Available online 6 July 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Debraj Howlader, U. Vignesh, Dichen P. Bhutia, Rahul Pandey, Sumit Kumar, Tulika Chandra, Divya Mehrotra
PurposeThis study was designed with the aim to assess the efficiency of hydroxyapatite/collagen (HA/Col) bio-scaffold with bone marrow aspirate (BMA) to reconstruct mandibular condyle in patients with temporomandibular joint (TMJ) ankylosis.Materials and MethodsSeven pediatric patients with TMJ ankylosis, who visited our outpatient clinic and whose parents opted for this procedure, were included in this study. After a history and clinical examination for TMJ movements, computed tomography (CT) scans were obtained. Interposition arthroplasty, with or without coronoidectomy, was performed to gain at least 35 mm of mouth opening. A 2-ml quantity of BMA was aspirated from the posterior iliac crest. A HA/Col block was carved to shape the condyle, and was fixed to the ramus using a plate and screws. A collagen sponge soaked in BMA was interposed in between the graft and ramal end, and the temporal fascia was rotated between the glenoid fossa and graft. Physiotherapy was started on postoperative day 10. All patients were followed up for 1 year. Success was graded on the basis of the mouth opening and TMJ score based on efficiency of chewing, speech, activity, recreation, mood, and anxiety on a five-point ordinal scale.ResultsThe mean age was 9.71 years (range 5-14 years), and the male-to-female ratio was 5:2. The mean preoperative mouth opening was 4.14 mm, which improved to 34.57 mm at 1-year follow-up. The mean protrusive movement improved from 0 to 2.86 mm. The mean success score was 4.43 out of 5. The mean TMJ score improved from 2.38 to 3.94.ConclusionA HA/Col bio-scaffold with bone marrow aspirate is a safe and cost-effective alternative for reconstruction of the mandibular condyle, particularly in growing individuals with high osteogenic potential.



http://ift.tt/2u0yPN2

Use of fused deposit modeling for additive manufacturing in hospital facilities: European certification directives

Publication date: Available online 6 July 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Joel J. Otero, An Vijverman, Maurice Y. Mommaerts
PurposeThe goal of this study was to identify current European Union regulations governing hospital-based use of fused deposit modeling (FDM), as implemented via desktop three-dimensional (3D) printers.Materials and MethodsLiterature and Internet sources were screened, searching for official documents, regulations/legislation, and views of specialized attorneys or consultants regarding European regulations for 3D printing or additive manufacturing (AM) in a healthcare facility. A detailed review of the latest amendment (2016) of the European Parliament and Council legislation for medical devices and its classification was performed. It has regularly updated published guidelines for medical devices, which are classified by type and duration of patient contact. As expected, regulations increase in accordance with the level (I-III) of classification.ResultsCustom-made medical devices are subject to different regulations than those controlling serially mass-produced items, as originally specified in 98/79/EC European Parliament and Council legislation (1993) and again recently amended (2016). Healthcare facilities undertaking in-house custom production are not obliged to fully follow the directives as stipulated, given an exception for this scenario (Article 4.4a, 98/79/EC).ConclusionPatient treatment and diagnosis with the aid of customized 3D printing in a healthcare facility can be performed without fully meeting the European Parliament and Council legislation if the materials used are ISO 10993 certified and article 4.4a applies.



http://ift.tt/2uzj3py

The validity and reliability of computed tomography orbital volume measurements

Publication date: Available online 6 July 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Silviu C. Diaconu, David Dreizin, Mehmet Uluer, Corey Mossop, Michael P. Grant, Arthur J. Nam
PurposeOrbital volume calculations allow surgeons to design patient-specific implants to correct volume deficits. It is estimated that changes as small as 1 ml in orbital volume can lead to enophthalmos. Awareness of the limitations of orbital volume computed tomography (CT) measurements is critical to differentiate between true volume differences and measurement error. The aim of this study is to analyze the validity and reliability of CT orbital volume measurements.Materials and MethodsA total of 12 cadaver orbits were scanned using a standard CT maxillofacial protocol. Each orbit was dissected to isolate the extraocular muscles, fatty tissue, and globe. The empty bony orbital cavity was then filled with sculpting clay. The volumes of the muscle, fat, globe, and clay (i.e., bony orbital cavity) were then individually measured via water displacement. The CT-derived volumes, measured by manual segmentation, were compared to the direct measurements to determine validity.Results and Conclusions: The difference between CT orbital volume measurements and physically measured volumes is not negligible. Globe volumes have the highest agreement with 95% of differences between −0.5 and 0.5 ml, bony volumes are more likely to be overestimated with 95% of differences between −1.8 and 2.6 ml, whereas extraocular muscle volumes have poor validity and should be interpreted with caution.



http://ift.tt/2u0spNS

PRAC Wants Lactose Out of Injectable Methylprednisolone

The committee advises against the use of injectable methylprednisolone containing lactose in patients with suspected or known allergy to cow's milk proteins.
News Alerts

http://ift.tt/2uyZFZB

Georgia Public Health Chief Brenda Fitzgerald, MD, to Head CDC

Widely respected in public health circles and politically connected, Dr Fitzgerald is perhaps best known for an initiative to encourage language development in babies.
News Alerts

http://ift.tt/2uz2l9s

Personalized Vaccines Hold Cancer at Bay in Two Early Trials

A novel class of personalized cancer vaccines, tailored to the tumors of individual patients, kept disease in check in two early-stage clinical trials, pointing to a new way to help the immune system fight back.
Reuters Health Information

http://ift.tt/2tWwOkQ

Continuing Nivolumab After Melanoma Progression Benefits Some Patients

Some clinically stable patients with advanced melanoma benefit from continued nivolumab treatment after disease progression, researchers say.
Reuters Health Information

http://ift.tt/2tuILLN

Autoimmunity and allergy control in adults submitted to complete thymectomy early in infancy

by Susana L. Silva, Adriana Albuquerque, Andreia J. Amaral, Quan-Zhen Li, Catarina Mota, Rémi Cheynier, Rui M. M. Victorino, M. Conceição Pereira-Santos, Ana E. Sousa

The contribution of the decline in thymic activity for the emergence of autoimmunity is still debatable. Immune-competent adults submitted to complete thymectomy early in life provide a unique model to address this question. We applied here strict criteria to identify adults lacking thymic activity based on sjTREC levels, to exclude thymic rebound and/or ectopic thymuses. In agreement, they featured severe naïve CD4 T-cell depletion and contraction of T-cell receptor diversity. Notwithstanding this, there was neither increased incidence of autoimmune disease in comparison with age-matched controls nor significant changes in their IgG/IgA/IgM/IgE autoreactivity profiles, as assessed through extensive arrays. We reasoned that the observed relative preservation of the regulatory T-cell compartment, including maintenance of naïve regulatory CD4 T-cells, may contribute to limit the emergence of autoimmunity upon thymectomy. Our findings have implications in other clinical settings with impaired thymic activity, and are particularly relevant to studies of autoimmunity in ageing.

http://ift.tt/2u08UFd

The microbiota and autoimmunity: Their role in thyroid autoimmune diseases

Publication date: Available online 6 July 2017
Source:Clinical Immunology
Author(s): Hedda L. Köhling, Sue F. Plummer, Julian R. Marchesi, Kelly S. Davidge, Marian Ludgate
Since the 1970s, the role of infectious diseases in the pathogenesis of Graves' disease (GD) has been an object of intensive research. The last decade has witnessed many studies on Yersinia enterocolitica, Helicobacter pylori and other bacterial organisms and their potential impact on GD. Retrospective, prospective and molecular binding studies have been performed with contrary outcomes. Until now it is not clear whether bacterial infections can trigger autoimmune thyroid disease. Common risk factors for GD (gender, smoking, stress, and pregnancy) reveal profound changes in the bacterial communities of the gut compared to that of healthy controls but a pathogenetic link between GD and dysbiosis has not yet been fully elucidated. Conventional bacterial culture, in vitro models, next generation and high-throughput DNA sequencing are applicable methods to assess the impact of bacteria in disease onset and development. Further studies on the involvement of bacteria in GD are needed and may contribute to the understanding of pathogenetic processes. This review will examine available evidence on the subject.



http://ift.tt/2sxEeXy

Infection and apoptosis associated with inflammation in periodontitis: an immunohistologic study

Abstract

Objective

Evidence of increased apoptosis is observed in periodontitis, and may be associated with destruction of the periodontal tissue caused by the increased cell death, with the release of danger signals and subsequent stimulation of the proinflammatory processes. However, the exact mechanisms associated with these processes remain unclear. This study aimed to investigate the presence of the periodontal pathogen Treponema denticola, apoptosis, High Mobility Group Box1 as a damage-associated molecular pattern and several inflammatory markers in periodontitis and gingivitis subjects.

Materials and methods

Soft tissue specimens from gingival tissues of periodontitis and gingivitis patients were used for immunohistochemical and immunofluorescence staining of Treponema denticola chymotrypsin-like proteinase (CTLP), apoptosis markers, High Mobility Group Box1, Toll-like receptor 4, inflammatory cell markers and proinflammatory cytokines.

Results

Treponema denticola was detected in all periodontitis-affected tissues. This was associated with a significant increase in the number of apoptotic cells, including macrophages, alterations in the expression of High Mobility Group Box1 and its receptor, and increased levels of proinflammatory cytokines compared with gingivitis.

Conclusions

In summary, the presence of Treponema denticola (especially its CTLP), apoptosis, High Mobility Group Box1, and inflammatory markers suggest their potential involvement in the pathogenesis of periodontitis.

This article is protected by copyright. All rights reserved.

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Persistent Vulval Symptoms in a 16-Year-Old Girl

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Patient Perspectives: What is Tinea?

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Asymptomatic Upper Lip Swelling in an 8-Year-Old Boy

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Issue Information

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Multiple Milia as an Isolated Skin Manifestation of Dominant Dystrophic Epidermolysis Bullosa: Evidence of Phenotypic Variability

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Recurrent Erythematous Papules and Nodules on the Trunk and Extremities of a 3-Year-Old Girl

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Deviated septum: Causes, symptoms, and treatment

It is quite common for people to not have a straight septum. What is a deviated septum, what causes it, and how is a deviated septum diagnosed?

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A comparative study on basophil activation test, histamine release assay and passive sensitization histamine release assay in the diagnosis of peanut allergy

Abstract

Background

Allergy can be diagnosed using basophil tests. Several methods measuring basophil activation are available. This study aimed at comparing basophil activation test (BAT), histamine release assay (HR) and passive sensitization histamine release assay (passive HR) in the diagnosis of peanut allergy.

Methods

BAT, HR, and passive HR were performed on eleven peanut allergic and fourteen non-allergic subjects. Blood was incubated with peanut extract or anti-IgE and tests performed as follows: BAT - CD63-upregulation assessed by flow cytometry; HR - released histamine quantified by a glass fiber-based fluorometric method; Passive HR - IgE-stripped donor basophils were incubated with participants' serum and histamine release quantified as HR.

Results

CDsens, a measure of basophil allergen sensitivity, was significantly higher for BAT (80.1 ± 17.4) compared to HR (23.4 ± 10.31) and passive HR (11.1 ± 2.0). BAT, HR, and passive HR had a clinical sensitivity of 100%, 100%, and 82%, and specificity of 100%, 100%, and 100%, respectively when excluding inconclusive results. BAT identified 11 of 11 allergic patients, HR 10 and passive HR 9. Likewise, BAT recognized 12 of 14 non-allergic subjects, HR 10 and passive HR 13. However, the tests' diagnostic performances were not statistically different. Interestingly, non-releasers in HR but not in BAT had lower basophil count compared to releasers (249 vs. 630 counts/min).

Conclusion

BAT displayed a significant higher CDsens compared to HR and passive HR. The basophil tests' diagnostic performances were not significantly different. Still, BAT could diagnose subjects with low basophil number in contrast to HR.

This article is protected by copyright. All rights reserved.

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Erratum to: clinical comparison of the effectiveness of 7- and 14-day intracanal medications in root canal disinfection and inflammatory cytokines

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Unusual acute lupus hemophagocytic syndrome – a test of diagnostic criteria: a case report

Hemophagocytic lymphohistiocytosis is an aggressive life-threatening syndrome of excessive immune activation. Hemophagocytic lymphohistiocytosis due to systemic lupus erythematosus is described as acute lupus ...

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Mesenteric cysts and mesenteric venous thrombosis leading to intestinal necrosis in pregnancy managed with laparotomy: a case report and review of the literature

Mesenteric cyst is a rare clinical entity especially in pregnancy; therefore, few cases have been reported in the literature. The standard method of their treatment is surgical excision either with laparotomy ...

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BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

Abstract

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10–15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

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Cover Image

The cover image, by J. Just et al., is based on the Original Article Clinical phenotypes in asthma during childhood, DOI 10.1111/cea.12939

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Issue Information

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Rhinitis guidelines

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Forthcoming Meetings

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Effects of low to moderate levels of deoxynivalenol on feed and water intake, weight gain, and slaughtering traits of broiler chickens

Abstract

The aim of the study was to evaluate the effects of low to moderate oral exposure to the Fusarium toxin deoxynivalenol (DON; derived from culture material) on performance, water intake, and carcass parameters of broilers during early and late developmental phases. A total of 160 Ross 308 broilers were randomly allocated to four different feeding groups (n = 40/group) including 0 (control), 2.5, 5, and 10 mg DON/kg wheat-soybean meal-based feed. Three consecutive replicates of the experiment were performed. Half of the broilers were slaughtered in week 3 of the trial whereas the other half were slaughtered in week 5. Dry matter intake (DMI) and water intake (WI) were recorded on a daily basis and the body weight (BW) and BW gain (BWG) were determined weekly. The following carcass traits were recorded and calculated in absolute and relative data: dressed carcass weight, breast muscle weight, leg weight, and liver weight. Data showed that BW (P < 0.001), BWG (P = 0.005), and DMI (P < 0.001) were reduced by DON-feeding during the entire feeding period. The ratio of DMI to body weight gain (DMI/BWG) was not affected by the treatment. However, the ratio of water to DMI (WI/DMI) increased in DON-treated birds (P = 0.021). Contrast analysis showed that DON tendentially reduced slaughter weight (P = 0.082) and decreased leg yield (P = 0.037) in DON-fed chickens in week 5 of the experiment. Liver organ weight decreased in the 3-week-old DON-fed broilers compared to that in the control-fed birds (P = 0.037). In conclusion, the study suggests that DMI and BW were negatively affected under the experimental conditions at DON levels lower than the current guidance value in the European Union of 5 mg/kg feed. The study also indicates that broilers fed on low to moderate level DON-contaminated diets showed increased WI/DMI ratio which might have negative influence on wet litter syndrome.

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Risk of cutaneous T-cell lymphoma in patients with chronic lymphocytic leukemia and other subtypes of non-Hodgkin lymphoma

Abstract

Background

Second hematologic cancers in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) are well documented and include Hodgkin lymphoma, therapy-related acute myeloid leukemia/myelodysplastic syndromes, and transformation to diffuse large B-cell lymphoma. Although cutaneous T-cell lymphoma (CTCL) has been reported in patients with CLL, the incidence and comparison to expected rates are unknown. We evaluated the incidence of CTCL among patients with CLL or other non-Hodgkin lymphoma (NHL) subtypes using data from the Surveillance, Epidemiology, and End Results (SEER) Program.

Methods

We searched the SEER 13 registries for patients with a diagnosis of CLL and NHL between 1992 and 2008. Among patients identified, we evaluated the incidence of CTCL.

Results

Among 31,286 patients with CLL, the incidence of CTCL was not significantly higher in men than women: 104.2 (95% CI, 50.0–191.8) and 28.1 (95% CI, 3.4–101.3) per 1,000,000 person-years, respectively (P = 0.06). Among 97,691 patients with NHL, the incidence of CTCL was similar in men and women (97.9 [95% CI, 62.0–146.9] and 92.0 [95% CI, 56.2–142.1] per 1,000,000 person-years, respectively; P = 0.84). The incidence of CTCL among males with CLL (standardized incidence ratio [SIR], 3.0 [95% CI, 1.4–5.5]), males with NHL (SIR, 3.7 [95% CI, 2.3–5.5]), and females with NHL (SIR, 5.9 [95% CI, 3.6–9.1]) was significantly higher than expected in the general population (all P < 0.001).

Conclusion

The risk of CTCL is greater in men with CLL than in the general population. In patients with NHL, both men and women are at greater risk for CTCL than in the general population.

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Adrenal incidentaloma in a patient with HIV/AIDS

Abstract

Human immunodeficiency virus (HIV) is well known to be associated with various neoplasms and opportunistic infections. Kaposi sarcoma (KS), associated with human herpes virus 8 (HHV8) infection, is the most common tumour in HIV positive patients and is also an acquired immune deficiency syndrome (AIDS) defining illness. Cutaneous manifestations are the most common presenting symptom; however, visceral involvement is also recognized. We present the case of a 55-year-old male who was diagnosed with AIDS-related KS, who was referred to our surgical unit with an indeterminate left adrenal lesion. He subsequently started antiretroviral therapy and given the indeterminate nature of his adrenal lesion, we performed a laparoscopic left adrenalectomy, with KS of the adrenal gland confirmed on histology

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Eccrine angiokeratomatous hamartoma: case report of a 1.5-year girl

Abstract

Eccrine angiokeratomatous hamartoma is a rare newly defined vascular lesion of the skin, the first case of which was reported in 2006 (Kanitakis J, Ly A, Claudy A. Eccrine angiokeratomatous hamartoma: a new variant of eccrine hamartoma with angiokeratoma. J Am Acad Dermatol 2006; 55: S104–6). On web Literature Search, Only three previously documented cases of the lesions were found. A 1.5-year-old female child presented with a painless lesion on her right leg since birth which has been gradually increasing in size and recently developed central ulceration. Histological examination of the excised lesion confirmed the diagnosis. This is the first of the cases to be reported in paediatric age-group (<2 years)

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Myomectomies for massive hemoperitoneum from spontaneous bleeding of a uterine myoma

Abstract

Massive hemoperitoneum from spontaneous bleeding of uterine myoma is an extremely rare condition, that needs urgent surgical exploration. We report a 40-year-old woman, admitted for acute onset of abdominal pain. Physical examination revealed hypovolemic shock. The hemoglobin level was of 5 g/dL. Ultrasonography revealed hemoperitoneum. Emergency surgical exploration was planned. There was hemoperitoneum of 3 L, uterine myomas with multiple subserous myomas, bleeding from superficial ruptured varice overlying the most largest subserous myoma, which measured 15 cm. Glove adapted as a tourniquet, was applied at the base of the uterus, and myomectomies were performed with removal of around twenty myomas. The postoperative course was uneventful. Myomectomies can be safely and effectively performed by using a tourniquet, for massive hemoperitoneum with precarious hemodynamic status due to subserous myoma bleeding, despite the number and the size of myomas.

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Treatment, short-term outcomes, and costs associated with larynx cancer care in commercially insured patients

Objectives/Hypothesis

To examine associations between treatment, complications, and costs in patients with laryngeal cancer.

Study Design

Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data.

Methods

We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression.

Results

Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio [RRR] = 5.9 [4.4–7.8]), pretreatment gastrostomy (RRR = 4.0 [2.7–6.1]), and alcohol abuse (RRR = 0.5 [0.3–0.9]). Treatment-related complications occurred in 23% of patients, with medical complications in 22% and surgical complications in 7%. Chemoradiation (odds ratio [OR] = 3.7 [2.6–5.2]), major surgical procedures (OR = 4.9 [3.5–6.8]), reconstruction (OR = 7.7 (4.1–14.7)], and advanced comorbidity (OR = 9.7 [5.7–16.5] were associated with acute complications. Recurrent/persistent disease occurred in 23% of patients and was associated with high-volume care (OR = 1.4 [1.1–1.8]). Salvage surgery was performed in 46% of patients with recurrent/persistent disease and was less likely for supraglottic disease (OR = 0.5 [0.4–0.8]) and after chemoradiation (OR = 0.4 [0.2–0.6]). Initial treatment and 1-year overall costs for chemoradiation were higher than all other treatment categories, after controlling for all other variables including complications and salvage. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment.

Conclusions

In commercially insured patients <65 years old with laryngeal cancer, chemoradiation was associated with increased costs, an increased likelihood of treatment-related medical complications, and a reduced likelihood of surgical salvage. Higher-volume surgical care was associated with lower initial treatment and 1-year costs of care. These data have implications for discussions of value and quality in an era of healthcare reform.

Level of Evidence

2c Laryngoscope, 2017

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Ventilation with high versus low peep levels during general anaesthesia for open abdominal surgery does not affect postoperative spirometry: A randomised clinical trial

BACKGROUND: Invasive mechanical ventilation during general anaesthesia for surgery typically causes atelectasis and impairs postoperative lung function. OBJECTIVE: We investigated the effect of intraoperative ventilation with high positive end-expiratory pressure (PEEP) and recruitment manoeuvres (RMs) on postoperative spirometry. DESIGN: This was a preplanned, single-centre substudy of an international multicentre randomised controlled trial, the PROVHILO trial. SETTING: University hospital from November 2011 to January 2013. PATIENTS: Nonobese patients scheduled for major abdominal surgery at a high risk of postoperative pulmonary complications (PPCs). INTERVENTION: Intraoperative low tidal volume ventilation with PEEP levels of 12 cmH2O and RM (the high PEEP group) or with PEEP levels of 2 cmH2O or less without RM (the low PEEP group). MAIN OUTCOME MEASURES: Time-weighted averages (TWAs) of the forced expiratory volume in 1 s (FEV1) and the forced vital capacity (FVC) up to postoperative day five. RESULTS: Thirty-one patients were allocated to the high PEEP group and 32 to the low PEEP group. No postoperative spirometry test results were available for 6 patients. In both groups, TWA of FEV1 and FVC until postoperative day five were lower than preoperative values. Postoperative spirometry test results were not different between the high and low PEEP group; Data are median [interquartile range], TWA FVC 1.8 [1.6 to 2.4] versus 1.7 [1.2 to 2.4] l (P = NS) and TWA FEV1 1.2 [1.1 to 2.5] versus 1.2 [0.9 to 1.9] l (P = NS). Patients who developed PPCs had lower FEV1 and FVC on postoperative day five; 1.1 [0.9 to 1.6] versus 1.6 [1.4 to 1.9] l (P = 0.001) and 1.6 [1.2 to 2.6] versus 2.3 [1.7 to 2.6] l (P = 0.036), respectively. CONCLUSION: Postoperative spirometry is not affected by PEEP and RM during intraoperative ventilation for open abdominal surgery in nonobese patients at a high risk of PPCs, but rather is associated with the development of PPCs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01441791.

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A case series of life-threatening succinylcholine-induced anaphylaxis

No abstract available

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Postoperative pulmonary complications - Still room for improvement

No abstract available

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Muscle relaxation for tracheal intubation during paediatric anaesthesia: A meta-analysis and trial sequential analysis

BACKGROUND: Muscle relaxation for tracheal intubation during paediatric anaesthesia remains a subject of debate. OBJECTIVE: The aim of the current meta-analysis was to investigate the effect of muscle relaxants (MR) compared with opioids on intubation conditions in children. DESIGN: Meta-analysis of randomised controlled studies. DATA SOURCES: Exhaustive literature analysis. ELIGIBILITY CRITERIA: Clinical trials, with no high-risk bias, that examined the effect of MR in comparison with opioids on intubation conditions (excellent: primary outcome, acceptable: secondary outcome) in children were included. RESULTS: Excellent intubation conditions were not significantly different in their occurrence between children receiving MR or opioids, risk ratio [95% Confidence Interval]  = 1.17 [0.96, 1.43], I2 = 36%, number of studies = 5, number of patients = 226. However, trial sequential analysis indicated the lack of power of this result and the need for more trials to provide certainty for this outcome (81 patients needed in future trials). Acceptable intubation conditions were more frequent when administering MR, risk ratio = 1.25 [1.06, 1.47], I2 = 70%, number of studies = 6, number of patients = 362. This effect was confirmed using the trial sequential analysis. Grading of Recommendations Assessment, Development and Evaluation analysis found a low and moderate quality of evidences for excellent and acceptable intubation conditions, respectively. CONCLUSION: The current meta-analysis shows that the use of MR during tracheal intubation might improve the quality of intubation conditions. Further studies, including at least 81 children, are required to confirm this and determine the impact of MR on complications related to intubation.

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Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - an observational study in 29 countries

BACKGROUND: Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES: To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN: This was a prospective international 1-week observational study using the 'Assess Respiratory Risk in Surgical Patients in Catalonia risk score' (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING: Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES: The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS: A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg−1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P 

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Anaesthesia and orphan disease series: What is the yield?

No abstract available

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Magnesium sulphate improves pulmonary function after video-assisted thoracoscopic surgery: A randomised double-blind placebo-controlled study

BACKGROUND: Reduced lung volumes are unavoidable after lung resection surgery. Magnesium sulphate (MgSO4) administration has been reported to reduce the requirement for neuromuscular blocking drugs and postoperative analgesics in surgical patients. OBJECTIVE: To investigate the effect of MgSO4 on pulmonary function after video-assisted thoracoscopic surgery (VATS). DESIGN: A randomised, double-blind, placebo-controlled trial. SETTING: A university tertiary care centre. PATIENTS: Sixty-six patients scheduled for pulmonary lobectomy or segmentectomy via VATS. INTERVENTION: Patients were allocated to one of two groups: the Mg (MgSO4 50 mg kg−1 intravenously for 10 min, followed by a continuous infusion of 15 mg kg−1 h−1 during surgery) or the control (same volume of 0.9% saline). MAIN OUTCOME MEASURES: Pulmonary function tests [forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate] were measured before surgery and at three time points after surgery (2, 24 and 48 h postoperatively) using a portable spirometer. Twelve months after surgery, pulmonary function test values were repeated at a regular outpatient follow-up visit. RESULTS: FEV1 at 24 (1.7 ± 0.6 vs. 1.3 ± 0.5 l, P = 0.033) and 48 h (1.7 ± 0.6 vs. 1.4 ± 0.5 l, P = 0.021) and FVC at 24 (2.0 ± 0.8 vs. 1.6 ± 0.6 l, P = 0.038) and 48 h (2.2 ± 0.8 vs. 1.7 ± 0.7 l, P = 0.008) after surgery were significantly greater in the Mg group. Patients in the Mg group required less rocuronium than those in the control group (64.2 ± 19.9 vs. 74.9 ± 20.3 mg, respectively; P = 0.041). Consumption of postoperative patient-controlled analgesia was also significantly less at 24 and 48 h after surgery in the Mg group (P = 0.022 and 0.015, respectively), although pain scores and rescue analgesics were comparable. Five patients in the control group were diagnosed with postoperative pneumonia using clinical and radiological criteria before discharge. FEV1 and FVC at 12 months after surgery were not different between the two groups. CONCLUSION: Intraoperative administration of MgSO4 improved pulmonary function and reduced the need for rocuronium and postoperative analgesics in patients who underwent VATS. TRIAL REGISTRATION: cris.nih.go.kr identifier: KCT0001410

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Frequency and risk factors for malnutrition in children undergoing general anaesthesia in a French university hospital: A cross-sectional observational study

BACKGROUND: Malnutrition is often underdiagnosed in hospitalised children, although it is associated with postoperative complications, longer hospital lengths of stay and increased healthcare-related costs. OBJECTIVE: We aimed to estimate the frequency of, and identify factors associated with, malnutrition in children undergoing anaesthesia. DESIGN: Cross-sectional observational study. SETTING: Paediatric anaesthesia department at the University Children's Hospital, Bordeaux, France. PARTICIPANTS: A total of 985 patients aged less than 18 years. MAIN OUTCOME MEASURES: Anthropometric measurements, American Society of Anesthesiologists physical status classification score and the Pediatric Nutritional Risk Score (PNRS) recorded at the pre-anaesthesia evaluation. RESULTS: When assessed as a Waterlow index less than 80%, malnutrition was present in 7.6% children. This increased to 8.1% of children assessed by clinical signs and to 11% of children when defined by a BMI less than the third percentile. In a univariate analysis, children with a BMI less than the third percentile were more often born prematurely (22.4 vs 10.4%; P = 0.0008), were small for gestational age at birth (18.4 vs 4.5%; P 

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Effects of different fresh gas flows with or without a heat and moisture exchanger on inhaled gas humidity in adults undergoing general anaesthesia: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND: The minimum inhaled gas absolute humidity level is 20 mgH2O l−1 for short-duration use in general anaesthesia and 30 mgH2O l−1 for long-duration use in intensive care to avoid respiratory tract dehydration. OBJECTIVE: The aim is to compare the effects of different fresh gas flows (FGFs) through a circle rebreathing system with or without a heat and moisture exchanger (HME) on inhaled gas absolute humidity in adults undergoing general anaesthesia. DESIGN: Systematic review and meta-analyses of randomised controlled trials. We defined FGF (l min−1) as minimal (0.25 to 0.5), low (0.6 to 1.0) or high (≥2). We extracted the inhaled gas absolute humidity data at 60 and 120 min after connection of the patient to the breathing circuit. The effect size is expressed as the mean differences and corresponding 95% confidence intervals (CI). DATA SOURCES: PubMed, EMBASE, SciELO, LILACS and CENTRAL until January 2017. RESULTS: We included 10 studies. The inhaled gas absolute humidity was higher with minimal flow compared with low flow at 120 min [mean differences 2.51 (95%CI: 0.32 to 4.70); P = 0.02] but not at 60 min [mean differences 2.95 (95%CI: −0.95 to 6.84); P = 0.14], and higher with low flow compared with high flow at 120 min [mean differences 7.19 (95%CI: 4.53 to 9.86); P 

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Anaesthesia and orphan disease: Management of a case of Strumpell–Lorrain disease and review of the literature

No abstract available

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

BACKGROUND: Surgical stress affects the autonomic nervous system by increasing sympathetic outflow. One method of monitoring sympathetic activity is pulse photoplethysmographic analysis. From this two indices can be derived – autonomic nervous system state (ANSS) and ANSS index (ANSSi). It has recently been claimed that these indices can be used to measure sympathetic activity in anaesthetised patients, but their validity has not yet been demonstrated. OBJECTIVE: To measure changes in pulse photoplethysmographic indices and determine any agreement with autonomic nervous system modulation of the cardiovascular system in healthy study participants during surgery under general anaesthesia. DESIGN: Prospective observational study. SETTING: Single-centre study based at a tertiary care centre in Milan, Italy. PATIENTS: Healthy patients undergoing general anaesthesia for elective laparoscopic cholecystectomy. INTERVENTIONS: ANSS, ANSSi, and heart rate variability (HRV) were analysed at three main times: baseline, after induction of general anaesthesia, and after pneumoperitoneum insufflation. MAIN OUTCOME MEASURES: The magnitude of changes in photoplethysmographic and HRV indices was measured. The agreement between pulse photoplethysmographic and HRV-derived indices was assessed by Bland–Altman plots. RESULTS: In total, 52 patients were enrolled and their data analysed. Both pulse photoplethysmographic and HRV indices changed during the study phases. An agreement was found between ANSSi and low frequency spectral components of HRV [bias 10.2nu, 95% confidence interval (CI) −13 to 33.4], high frequency spectral components of HRV (bias 6.1 nu, 95% CI −16.3 to 28.6), and low frequency/high frequency ratio (bias 16.1nu, 95% CI −1.4 to 33.5). The agreement was weaker between ANSSI and HRV indices. CONCLUSION: The study endorses the use of pulse photoplethysmographic indices ANSS and ANSSi as surrogates to estimate changes of autonomic modulation of the cardiovascular system in healthy adults during surgery under general anaesthesia. Orcid ID: http://ift.tt/2tTz9MS.

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Mobile phone text messaging reminder decreases the rate of nonattendance at a preoperative anaesthesia clinic

No abstract available

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Anesthesia for minimally invasive neurosurgery.

Purpose of review: With an ultimate aim of improving patients overall outcome and satisfaction, minimally invasive surgical approach is becoming more of a norm. The related anesthetic evidence has not expanded at the same rate as surgical and technological advancement. This article reviews the recent evidence on anesthesia and perioperative concerns for patients undergoing minimally invasive neurosurgery. Recent findings: Minimally invasive cranial and spinal surgeries have been made possible only by vast technological development. Points of surgical interest can be precisely located with the help of stereotaxy and neuronavigation and special endoscopes which decrease the tissue trauma. The principles of neuroanethesia remain the same, but few concerns are specific for each technique. Dexmedetomidine has a favorable profile for procedures carried out under sedation technique. As the new surgical techniques are coming up, lesser known anesthetic concerns may also come into light. Summary: Over the last year, little new information has been added to existing literature regarding anesthesia for minimally invasive neurosurgeries. Neuroanesthesia goals remain the same and less invasive surgical techniques do not translate into safe anesthesia. Specific concerns for each procedure should be taken into consideration. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Criteria for Intensive Care admission and monitoring after elective craniotomy.

Purpose of review: The current article revises the recent evidence on ICU admission criteria and postoperative neuromonitoring for patients undergoing elective craniotomy. Recent findings: Only a small proportion of elective postoperative neurosurgical patients require specific medical interventions and invasive monitoring. Among these, patients undergoing elective craniotomy are frequently admitted to neuro-ICU, specialist postanaesthesia care units or intermediate-level care unit in the postoperative period. Craniotomy patients have a high risk of neurological complications in the immediate postoperative period and might require advanced neuromonitoring, especially if sedation is continued in the ICU. Furthermore, the concept of enhanced recovery after surgery with the goal of improving functional capacity after surgery and decreasing morbidity has expanded to encompass neurosurgery. Postoperative clinical examination and neurological scores, bispectral index and simplified electroencephalography, and morning discharge huddles are the most used strategies in this context. Summary: After elective craniotomy, ICU admission should be warranted to patients who show new neurological deficits, especially when these include reduced consciousness or deficits of the lower cranial nerves, or have surgical indication for delayed extubation. Currently, evidence does not allow defining standardized protocol to guide ICU admission and postoperative neuromonitoring. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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A rare graft-versus-host disease-like thymoma-associated paraneoplastic autoimmune multiorgan syndrome

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Evaluation and management of nonsyndromic congenital hearing loss.

Purpose of review: Nonsyndromic congenital hearing loss represents the largest proportion of paediatric sensorineural hearing loss. The optimal evaluation and management of affected patients remains clinically challenging. Current controversies in the diagnostic work-up of nonsyndromic congenital hearing loss are presented in this review. Recent findings: The improved diagnostic yield of comprehensive genetic testing due to new sequencing technologies is changing the diagnostic for congenital hearing loss. Concerns for both ionizing radiation and general anaesthetic exposure are also driving shifts in imaging modality preferences for infants and toddlers. Summary: A thoughtful systematic, targeted approach taking into consideration the audiologic phenotype of the patient is recommended for the work-up of nonsyndromic congenital hearing loss. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2sTJx2F

Current assessment of newborn hearing screening protocols.

Purpose of review: The objective of this article is to assess current newborn hearing screening protocols. We will focus on technologies or modalities used, protocol steps, training of screeners, timing of first screen, and loss to follow-up. A summary of program reports focusing on protocols from Greece, China, South Africa, France, Spain, South Korea, Denmark, Italy, Turkey, Taiwan, South Korea, Poland and Iran as they are recently reported will also be presented. Recent findings: Community-based hearing screening programs in South Africa and efforts in the Asian region are being reported. The use of automated auditory brainstem response and staged procedures are gaining popularity because of low refer rates. However, follow-up issues remain a problem. The importance of having trained nonprofessional screeners and an efficient database is becoming more evident as the number of newborns screened for hearing loss increase each year. Summary: There are many reported protocols using different technologies, involving several stages, implemented in different settings which should not confuse but rather guide stakeholders so that programs may attain certain benchmarks and ultimately help the hard-at-hearing child in achieving his or her full potential. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2tnUU6I

Increasing access to hearing rehabilitation for older adults.

Purpose of review: To provide an update on the recent research and policy developments affecting the current and future care of the 23 million older Americans with untreated hearing loss. Recent findings: Increasing evidence supports the association of age-related hearing loss with significant negative outcomes that affect the ability of older adults to age well. Despite an evolving understanding of the role hearing loss plays in the well being and vitality of older adults, the vast majority of older adults go untreated and hearing health care disparities exist. Recent work to understand the multitude of factors involved in hearing health care decisions, coupled with innovative approaches and technology to deliver hearing care, aim to provide more older adults with equal access to the tools needed to age well. Most importantly, significant national efforts and policy proposals substantiate these efforts and will be reviewed. Summary: Age-related hearing loss is a critical public health issue that affects almost all older adults. Through the application of novel approaches and perspectives, the delivery of hearing health care for older adults is evolving to provide more affordable and accessible care. Accompanying policy efforts provide the necessary support needed to increase access to care significantly. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2sTvZEz

Invariant natural killer cells change after an oral allergy desensitization protocol for cow's milk

Abstract

Background

Cow milk (CM) allergy (CMA) affects up to 3% of the pediatric population and recent data suggest that only about 50% will outgrow by age 8. Oral immunotherapy (OIT) is a type of immune-modulating treatment that is able to induce desensitization to food allergens, to increase tolerance threshold, to reduce the risk of anaphylaxis, and to improve the patient's quality of life. The examination of the immunological changes observed during the establishment of food allergy (FA) desensitization in FA patients is a window into the pathogenesis of food allergy and food tolerance development. In this pathway, we have previously found that invariant natural killer T cells (iNKTs) are involved in CM allergy sensitization and now examine their role in OIT.

Methods

In this study, 10 of the 11 children with CM induced anaphylaxis enrolled in a CMA OIT clinical trial and completed the protocol. Peripheral blood iNKTs were quantitatively and qualitatively via flow cytometry characterized ex-vivo and after culture with milk lipids before and after completing the OIT protocol.

Results

After completing OIT for CM, children were able to reintroduce CM in their diet. For the first time, we demonstrated that OIT induced a significant increase in the peripheral blood iNKT, as well as their switch from a T helper (Th-2; i.e. IL-4, IL-13) to Th-1 (i.e. IFN-γ) cytokine profile.

Conclusions and clinical relevance

This study confirms the efficacy and safety of CM-OIT as well as the role of iNKT cells in CM allergy.

This article is protected by copyright. All rights reserved.

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Erosive pustular dermatosis of the scalp following topical ingenol mebutate for actinic keratoses

http://ift.tt/2sTnoBB

Evaluation and management of nonsyndromic congenital hearing loss.

Purpose of review: Nonsyndromic congenital hearing loss represents the largest proportion of paediatric sensorineural hearing loss. The optimal evaluation and management of affected patients remains clinically challenging. Current controversies in the diagnostic work-up of nonsyndromic congenital hearing loss are presented in this review. Recent findings: The improved diagnostic yield of comprehensive genetic testing due to new sequencing technologies is changing the diagnostic for congenital hearing loss. Concerns for both ionizing radiation and general anaesthetic exposure are also driving shifts in imaging modality preferences for infants and toddlers. Summary: A thoughtful systematic, targeted approach taking into consideration the audiologic phenotype of the patient is recommended for the work-up of nonsyndromic congenital hearing loss. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2sTJx2F

Current assessment of newborn hearing screening protocols.

Purpose of review: The objective of this article is to assess current newborn hearing screening protocols. We will focus on technologies or modalities used, protocol steps, training of screeners, timing of first screen, and loss to follow-up. A summary of program reports focusing on protocols from Greece, China, South Africa, France, Spain, South Korea, Denmark, Italy, Turkey, Taiwan, South Korea, Poland and Iran as they are recently reported will also be presented. Recent findings: Community-based hearing screening programs in South Africa and efforts in the Asian region are being reported. The use of automated auditory brainstem response and staged procedures are gaining popularity because of low refer rates. However, follow-up issues remain a problem. The importance of having trained nonprofessional screeners and an efficient database is becoming more evident as the number of newborns screened for hearing loss increase each year. Summary: There are many reported protocols using different technologies, involving several stages, implemented in different settings which should not confuse but rather guide stakeholders so that programs may attain certain benchmarks and ultimately help the hard-at-hearing child in achieving his or her full potential. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2tnUU6I

Increasing access to hearing rehabilitation for older adults.

Purpose of review: To provide an update on the recent research and policy developments affecting the current and future care of the 23 million older Americans with untreated hearing loss. Recent findings: Increasing evidence supports the association of age-related hearing loss with significant negative outcomes that affect the ability of older adults to age well. Despite an evolving understanding of the role hearing loss plays in the well being and vitality of older adults, the vast majority of older adults go untreated and hearing health care disparities exist. Recent work to understand the multitude of factors involved in hearing health care decisions, coupled with innovative approaches and technology to deliver hearing care, aim to provide more older adults with equal access to the tools needed to age well. Most importantly, significant national efforts and policy proposals substantiate these efforts and will be reviewed. Summary: Age-related hearing loss is a critical public health issue that affects almost all older adults. Through the application of novel approaches and perspectives, the delivery of hearing health care for older adults is evolving to provide more affordable and accessible care. Accompanying policy efforts provide the necessary support needed to increase access to care significantly. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2sTvZEz

An Analysis of Substandard Propofol Detected in Use in Zambian Anesthesia.

BACKGROUND: In early 2015, clinicians throughout Zambia noted a range of unpredictable adverse events after the administration of propofol, including urticaria, bronchospasm, profound hypotension, and most predictably an inadequate depth of anesthesia. Suspecting that the propofol itself may have been substandard, samples were procured and sent for testing. METHODS: Three vials from 2 different batches were analyzed using gas chromatography-mass spectrometry methods at the John L. Holmes Mass Spectrometry Facility. RESULTS: Laboratory gas chromatography-mass spectrometry analysis determined that, although all vials contained propofol, its concentration differed between samples and in all cases was well below the stated quantity. Two vials from 1 batch contained only 44% +/- 11% and 54% +/- 12% of the stated quantity, whereas the third vial from a second batch contained only 57% +/- 9%. The analysis found that there were no hexane-soluble impurities in the samples. CONCLUSIONS: None of the analyzed vials contained the stated amount of propofol; however, our analysis did not detect additional contaminants that would explain the adverse events reported by clinicians. Our results confirm the presence of substandard propofol in Zambia; however, anecdotal accounts of substandard anesthetic medicines in other countries abound and warrant further investigation to provide estimates of the prevalence and scope of this global problem. (C) 2017 International Anesthesia Research Society

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Baseline Morphine Consumption May Explain Between-Study Heterogeneity in Meta-analyses of Adjuvant Analgesics and Improve Precision and Accuracy of Effect Estimates.

BACKGROUND: Statistical heterogeneity can increase the uncertainty of results and reduce the quality of evidence derived from systematic reviews. At present, it is uncertain what the major factors are that account for heterogeneity in meta-analyses of analgesic adjuncts. Therefore, the aim of this review was to identify whether various covariates could explain statistical heterogeneity and use this to improve accuracy when reporting the efficacy of analgesics. METHODS: We searched for reviews using MEDLINE, EMBASE, CINAHL, AMED, and the Cochrane Database of Systematic Reviews. First, we identified the existence of considerable statistical heterogeneity (I2 > 75%). Second, we conducted meta-regression analysis for the outcome of 24-hour morphine consumption using baseline risk (control group morphine consumption) and other clinical and methodological covariates. Finally, we constructed a league table of adjuvant analgesics using a novel method of reporting effect estimates assuming a fixed consumption of 50 mg postoperative morphine. RESULTS: We included 344 randomized controlled trials with 28,130 participants. Ninety-one percent of analyses showed considerable statistical heterogeneity. Baseline risk was a significant cause of between-study heterogeneity for acetaminophen, nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, tramadol, ketamine, [alpha]2-agonists, gabapentin, pregabalin, lidocaine, magnesium, and dexamethasone (R2 = 21%-100%; P 10 mg). We could not exclude a moderate clinically significant effect with ketamine. Dexamethasone demonstrated a small clinical benefit (>5 mg). CONCLUSIONS: We empirically identified baseline morphine consumption as the major source of heterogeneity in meta-analyses of adjuvant analgesics across all surgical interventions. Controlling for baseline morphine consumption, clinicians can use audit data to estimate the morphine-reducing effect of adding any adjuvant for their local population, regardless which surgery they undergo. Moreover, we have utilized these findings to present a novel method of reporting and an amended method of graphically displaying effect estimates, which both reduces confounding from variable baseline risk in included trials and is able to adjust for other clinical and methodological confounding variables. We recommend use of these methods in clinical practice and future reviews of analgesics for postoperative pain. (C) 2017 International Anesthesia Research Society

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Preoperatively Screened Obstructive Sleep Apnea Is Associated With Worse Postoperative Outcomes Than Previously Diagnosed Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) affects up to 26% of US adults, is often undiagnosed, and increases perioperative morbidity. We hypothesized that patients screened on the day of surgery as moderate/high risk for OSA (S-OSA) present similar perioperative respiratory complications, hospital use, and mortality than patients with previously diagnosed OSA (D-OSA). Second, we hypothesized that both OSA groups have more respiratory complications than No-OSA patients. METHODS: The electronic medical database from 1 academic and 2 community hospitals was retrospectively queried to identify adults undergoing nonemergent inpatient surgery (January 1, 2012, to December 31, 2014). Based on the day-of-surgery preoperative assessment and STOP-BANG (Snoring, Tiredness, Observed apnea during sleep, high blood Pressure, Body mass index >35, Age >50 years, thick Neck, Gender male) score, they were classified as D-OSA, S-OSA, or No-OSA. Perioperative respiratory events and interventions, hospital use, and mortality were measured. The primary outcome composite (adverse respiratory events [AREs]) included perioperative hypoxemic events and difficult airway management. Hypoxemic event was defined as peripheral saturation of oxygen (SpO2) =3 minutes, or if validated and/or manually entered into the medical chart. Hypoxemia was classified as mild (lowest SpO2 86%-89%) or moderate/severe (lowest SpO2 =1 moderate/severe hypoxemic event after discharge from the postanesthesia care unit (PACU; 39.9% in S-OSA; 39.5% in D-OSA; and 27.1% in No-OSA patients). S-OSA patients compared to D-OSA patients presented lower rates of moderate/severe hypoxemia in the PACU but similar intraoperatively and postoperatively, higher difficult mask ventilation rates, and similar difficult intubation reports. After adjusting for demographic, health, and surgical differences and hospital type, the likelihood of >=1 ARE was not different in S-OSA and D-OSA patients (adjusted odds ratio 0.90 [99% confidence interval, 0.75-1.09]; P = .15). S-OSA patients compared to D-OSA patients had significantly increased postoperative reintubation, mechanical ventilation, direct intensive care unit admission after surgery, hospital length of stay, and 30-day all-cause mortality. CONCLUSIONS: Patients classified as S-OSA have similar rates of AREs to D-OSA patients, but increased postoperative respiratory interventions, hospital use, and 30-day all-cause mortality. These worse postoperative outcomes in S-OSA patients than D-OSA patients could reflect the lack of awareness and appropriate management of this bedside S-OSA diagnosis after PACU discharge. Multidisciplinary interventions are needed for these high-risk patients. (C) 2017 International Anesthesia Research Society

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House of Suicide in Les Morticoles by Daudet: A Prime Literary Allusion to Suicide Assisted by Anesthesia.

No abstract available

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Role of Sigma-1 Receptor/p38 MAPK Inhibition in Acupoint Catgut Embedding-Mediated Analgesic Effects in Complete Freund's Adjuvant-Induced Inflammatory Pain.

BACKGROUND: The endoplasmic reticulum chaperone protein Sigma-1 receptor (Sig-1 R) and mitogen-activated protein kinases (MAPKs) are involved in the mechanism of pain. Acupoint stimulation exerts an exact antihyperalgesic effect in inflammatory pain. However, whether Sig-1 R and MAPKs are associated with the acupoint stimulation-induced analgesic effects is not clear. This study investigated the analgesic effect of acupoint catgut embedding (ACE) and the inhibition of Sig-1 R and MAPKs in ACE analgesia. METHODS: Rats were prepared with intrathecal catheter implantation. ACE was applied to bilateral "Kunlun" (BL60), "Zusanli" (ST36), and "Sanyinjiao" (SP6) acupoints in the rat model of inflammatory pain (complete Freund's adjuvant [CFA] intraplantar injection). Then, Sig-1R agonist PRE084 or saline was intrathecally given daily. The paw withdrawal thresholds and paw edema were measured before CFA injection and at 1, 3, and 5 day after CFA injection. Western bolt was used to evaluate the protein expression of spinal Sig-1R, p38MAPK, and extracellular signal-regulated kinase (ERK), and immunohistochemistry of Sig-1R was detected at 1, 3, and 5 days after CFA injection. RESULTS: ACE exhibited specific analgesic effects. ACE increased paw withdrawal thresholds and markedly decreased CFA-induced paw edema at 1, 3, and 5 days. ACE downregulated the protein expression of Sig-1R, which was increased significantly at 1, 3, and 5 days after CFA injection. ACE decreased the expression of p38 MAPK and ERK at 1 and 3 days but not at 5 days. However, an injection of Sig-1R agonist PRE084 markedly reversed these alterations, except ERK expression. CONCLUSIONS: The present study demonstrated that ACE exhibited antihyperalgesic effects via the inhibition of the Sig-1R that modulated p38 MAPK, but not ERK, expression in the CFA-induced inflammatory pain model in rats. (C) 2017 International Anesthesia Research Society

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Acute Intracardiac Thrombosis and Pulmonary Thromboembolism After Cardiopulmonary Bypass: A Systematic Review of Reported Cases.

Intracardiac thrombosis (ICT) and pulmonary thromboembolism (PE) after cardiopulmonary bypass (CPB) are life-threatening events, but pathological mechanisms are not yet well defined. The aim of this review is to provide an update of case literature of a postbypass hypercoagulable state. Case commonalities among 48 ICT/PE events included congestive heart failure (50%), platelet transfusion (37.5%), CPB duration greater than 3 hours (37.5%), and aortic injury (27.1%). Preexisting thrombophilia was rarely reported, and 16.7% had low activated clotting time,

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Ringer's Lactate Versus Normal Saline in Urgent Cesarean Delivery in a Resource-Limited Setting: A Pragmatic Clinical Trial.

BACKGROUND: Crystalloids are used routinely for perioperative fluid management in cesarean delivery. Few studies have determined the crystalloid of choice in obstetric anesthesia. We compared the effects of Ringer's lactate (RL) versus 0.9% normal saline (NS) on maternal and neonatal blood pH and 24-hour postoperative morbidity in urgent cesarean delivery in a low-resource setting. Our hypothesis was that RL would result in 30% less acidosis than NS. METHODS: This was a pragmatic prospective double-blind randomized controlled trial in the Mulago National Referral Hospital Labor Ward Theater from September 2011 to May 2012. Five hundred parturients were studied; 252 were randomly assigned to NS and 248 to RL groups. Preoperative and postoperative maternal venous blood gases and placental umbilical arterial cord blood gases were analyzed. The primary outcome was incidence of maternal acidosis, as defined by a postoperative drop in venous pH below 7.32 or reduction in base excess below -3 in a previously normal parturient. Maternal 24-hour postoperative morbidity, neonatal pH, and neonatal base excess were the main secondary outcomes. The study was registered in ClinicalTrials.gov as NCT01585740. RESULTS: The overall incidence of maternal acidosis was 38% in NS and 29% in RL (relative risk, 1.29; 95% confidence interval, 1.01-1.66; P = .04). Thirty-two percent of parturients in NS experienced a drop in venous pH below 7.32 postoperatively, compared with 19% in RL (relative risk, 1.65; 95% confidence interval, 1.18-2.31; P = .003). The comparative drop in base excess postoperatively below -3 between the 2 groups was not statistically significant. There were no significant differences in the incidence of maternal 24-hour postoperative morbidity events and neonatal outcomes between the 2 groups. CONCLUSIONS: NS may be a safe choice for intraoperative fluid therapy in urgent cesarean delivery as RL, albeit with an increased incidence of metabolic acidosis. (C) 2017 International Anesthesia Research Society

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Diphenyleneiodonium Mitigates Bupivacaine-Induced Sciatic Nerve Damage in a Diabetic Neuropathy Rat Model by Attenuating Oxidative Stress.

BACKGROUND: Increased oxidative stress has been linked to local anesthetic-induced nerve injury in a diabetic neuropathy (DN) rat model. The current study explores the effects of diphenyleneiodonium (DPI) chloride, an NADPH oxidase (NOX) inhibitor, on bupivacaine-induced sciatic nerve injury in DN rats. METHODS: A rat DN model was established through high-fat diet feeding and streptozotocin injection. The model was confirmed via testing (i) blood glucose, (ii) hindpaw allodynia responses to von Frey (VF) monofilaments, (iii) paw withdrawal thermal latency (PWTL), and (iv) nerve conduction velocity (NCV). Bupivacaine (Bup, 0.2 mL, 5 mg/mL) was used to block the right sciatic nerve. DPI (1 mg/kg) was injected subcutaneously 24 hours and 30 minutes before the sciatic block. At 24 hours after the block, NCV, various reactive oxygen species, and Caspase-3 were evaluated to determine the extent of sciatic nerve injury. RESULTS: The DN rat model was successfully established. Compared with the DN control group, the postblock values of VF responses (DN-Con, 16.5 +/- 1.3 g; DN + Bup, 19.1 +/- 1.5 g, P

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The New World Health Organization Recommendations on Perioperative Administration of Oxygen to Prevent Surgical Site Infections: A Dangerous Reductionist Approach?.

In October 2016, the World Health Organization (WHO) published recommendations for preventing surgical site infections (SSIs). Among those measures is a recommendation to administer oxygen at an inspired fraction of 80% intra- and postoperatively for up to 6 hours. SSIs have been identified as a global health problem, and the WHO should be commended for their efforts. However, this recommendation focuses only on the patient's "wound," ignores other organ systems potentially affected by hyperoxia, and may ultimately worsen patient outcomes. The WHO advances a "strong recommendation" for the use of a high inspired oxygen fraction even though the quality of evidence is only moderate. However, achieving this goal by disregarding other potentially lethal complications seems inappropriate, particularly in light of the weak evidence underpinning the use of high fractions of oxygen to prevent SSI. Use of such a strategy thus should be intensely discussed by anesthesiologists and perioperative physicians. Normovolemia, normotension, normoglycemia, normothermia, and normoventilation can clearly be safely applied to most patients in most clinical scenarios. But the liberal application of hyperoxemia intraoperatively and up to 6 hours postoperatively, as suggested by the WHO, is questionable from the viewpoint of anesthesia and perioperative medicine, and its effects will be discussed in this article. (C) 2017 International Anesthesia Research Society

http://ift.tt/2swbO07

Defining the Primary Outcomes and Justifying Secondary Outcomes of a Study: Usually, the Fewer, the Better.

One of the first steps in designing and conducting a research study is identifying the primary and any secondary study outcomes. In an experimental, quasi-experimental, or analytic observational research study, the primary study outcomes arise from and align directly with the primary study aim or objective. Likewise, any secondary study outcomes arise from and directly align with any secondary study aim or objective. One designated primary study outcome then forms the basis for and is incorporated literally into the stated hypothesis. In a Methods section, authors clearly state and define each primary and any secondary study outcome variable. In the same Methods section, authors clearly describe how all primary and any secondary study outcome variables were measured. Enough detail is provided so that a clinician, statistician, or informatician can know exactly what is being measured and that other investigators could duplicate the measurements in their research venue. The authors provide published substantiation (preferably) or other documented evidence of the validity and reliability of any applied measurement instrument, tool, or scale. A common pitfall-and often fatal study design flaw-is the application of a newly created ("home-grown") or ad hoc modification of an existing measurement instrument, tool, or scale-without any supporting evidence of its validity and reliability. An optimal primary outcome is the one for which there is the most existing or plausible evidence of being associated with the exposure of interest or intervention. Including too many primary outcomes can (a) lead to an unfocused research question and study and (b) present problems with interpretation if the treatment effect differed across the outcomes. Inclusion of secondary variables in the study design and the resulting manuscript needs to be justified. Secondary outcomes are particularly helpful if they lend supporting evidence for the primary endpoint. A composite endpoint is an endpoint consisting of several outcome variables that are typically correlated with each. In designing a study, researchers limit components of a composite endpoint to variables on which the intervention of interest would most plausibly have an effect, and optimally with preliminary evidence of an effect. Ideally, components of a strong composite endpoint have similar treatment effect, frequency, and severity-with the most important being similar severity. (C) 2017 International Anesthesia Research Society

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Skeletal Muscle Metabolic Dysfunction in Patients With Malignant Hyperthermia Susceptibility.

BACKGROUND: Malignant hyperthermia (MH), a pharmacogenetic disorder of skeletal muscle, presents with a potentially lethal hypermetabolic reaction to certain anesthetics. However, some MH-susceptible patients experience muscle weakness, fatigue, and exercise intolerance in the absence of anesthetic triggers. The objective of this exploratory study was to elucidate the pathophysiology of exercise intolerance in patients tested positive for MH with the caffeine-halothane contracture test. To this end, we used phosphorus magnetic resonance spectroscopy, blood oxygen level-dependent functional magnetic resonance imaging (MRI), and traditional exercise testing to compare skeletal muscle metabolism in MH-positive patients and healthy controls. METHODS: Skeletal muscle metabolism was assessed using phosphorus magnetic resonance spectroscopy and blood oxygen level-dependent functional MRI in 29 MH-positive patients and 20 healthy controls. Traditional measures of physical capacity were employed to measure aerobic capacity, anaerobic capacity, and muscle strength. RESULTS: During 30- and 60-second exercise, MH-positive patients had significantly lower ATP production via the oxidative pathway compared to healthy controls. MH-positive patients also had a longer recovery time with blood oxygen level-dependent functional MRI compared to healthy controls. Exercise testing revealed lower aerobic and anaerobic capacity in MH-positive patients compared to healthy controls. CONCLUSIONS: Results of this exploratory study suggest that MH-positive patients have impaired aerobic metabolism compared to healthy individuals. This could explain the exercise intolerance exhibited in MH-susceptible patient population. (C) 2017 International Anesthesia Research Society

http://ift.tt/2tP6g4u