Head and Neck Medicine by Alexandros G.Sfakianakis: 07/31/17

Δευτέρα 31 Ιουλίου 2017

Double whammy: a tale of two malignancies

Description

A 61-year-old woman was referred to the dermatology clinic with multiple skin lesions on her scalp and central back. They were relatively asymptomatic but had increased in size over the previous few months. Her medical history was significant as she had a cerebellar medulloblastoma when she was 19 years old that was treated with a 6-month course of radiotherapy on her scalp and along the spinal cord.

On examination, she had multiple erythematous scaly plaques on the right occipital scalp and lower back, consistent with superficial basal cell carcinomas (BCC) and a nodular BCC in the left occipital scalp. They were present within the areas previously treated with radiotherapy, arising from the skin that showed poikilodermatous (atrophic) changes (figures 1 and 2). Scarring alopecia from the previous radiotherapy was also prominent in the occipital scalp. A diagnosis of postradiotherapy BCCs was made. In...

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Acquired capillary haemangioma of the eyelid in a 10-year-old boy

A 10-year-old boy presented with painless, gradually increasing mass in right upper lid without preceding trauma for the past 2 months. On examination, the mass was bluish red, soft to firm in consistency which bleeds on touch. Contrast-enhanced CT showed a well-defined heterogeneously enhancing mass lesion without any continuity with the underlying bone or the orbital cavity. Complete excision of the mass was performed under general anaesthesia, subsequent histopathological examination showed findings consistent with an acquired variant of capillary haemangioma. At the end of 1 year, patient is cosmetically fine without any recurrence/morbidity.

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Large chordoma of the sacrum

Description

A 53-year-old man presented to our service with a 1-month history of subacute bowel obstruction. Clinical examination was unremarkable with normal power and sensation in the lower limbs. This patient had no medical or surgical history. MRI of the pelvis identified a well-defined presacral midline lesion of 9.9 cm diameter, which appeared to arise from the S2 nerve root and below (figure 1A,B). These nerve roots control anal sphincter tone and prohibit faecal incontinence. Whole spine MRI and CT-thorax abdomen pelvis CT-TAP) out ruled metastasis. A biopsy confirmed diagnosis of chordoma. This patient was discussed by a multidisciplinary team consisting of orthopaedics, colorectal, vascular and plastic surgeons. Anterior mobilisation of the lesion, with ileostomy due to expected loss of anal tone and supporting vessel ligation, was undertaken. A wide sacral en-masse resection at the level of S1 disc and inferior nerve roots, incorporating partial gluteus...

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Carotid dissection presenting as a prolonged cluster-like headache in a patient with episodic cluster headache

We present a patient with known episodic cluster headache, who presented with cluster-like headache in the course of internal carotid artery dissection (ICAD) and discuss possible pathophysiological links between the two diseases. It is well known that cluster-like headache could be the presenting symptom of ICAD. However, ICAD occurring in a patient with a known episodic cluster headache was only once previously described. In the end of the manuscript, we propose red flags to help clinicians differentiate between primary cluster headache and cluster-like attacks masking underlying ICAD. Finally, we raise the question whether at least some proportion of those patients with cluster headache and Horner syndrome previously classified as a primary headache disorder might have been secondary cases to ICAD.

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The non-resolving lung cavity: a case of pulmonary cystic echinococcosis

The authors report a case of a 20-year-old woman who was diagnosed with pulmonary cystic echinococcosis. She was admitted to hospital with a 1-week history of unresolving cough, coloured sputum with occasional haemoptysis and fever despite oral antibiotics. Radiology revealed a cavitating right lower lobe lung abscess. After 4 weeks of treatment, follow-up radiology showed incomplete resolution. Bronchoscopy revealed a white, avascular cystic lesion in the right lower lobe and serology testing for Echinococcus granulosus was positive. Repeat imaging eventually confirmed the cystic lesion with the 'air bubble'sign. A thorough travel history, a high index of clinical suspicion and close follow-up are essential in making a diagnosis of pulmonary cystic echinococcosis.

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Early intracardiac thrombus and pulmonary embolus after trauma

Here, we present the case of a patient with the findings of an early intracardiac thrombus and a pulmonary embolus after major trauma. A large clot was identified extending from the inferior vena cava into the right atrium and ventricle in the setting of preserved right ventricular function. Post-traumatic intracardiac thrombus is extremely rare and no comparable cases have previously been described in the absence of a congenital heart defect and obvious myocardial injury. Best practice afterpost-traumatic intracardiac thrombus is not well established but we found that early inferior vena cava filter placement and treatment with therapeutic coagulation resulted in clinical improvement, resolution of the thrombus and no further emboli. The successful use of rivaroxaban, a direct-acting oral anticoagulant, to treat a right heart thrombus has, to our knowledge, not previously been reported. Early acute traumatic coagulopathy has received much attention but the hypercoagulable state that often follows is less well appreciated.

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Incidental finding of persistent left superior vena cava after 'bubble study verification of central venous catheter

We report a case of a patient with septic shock who underwent central venous catheter placement in the left internal jugular vein, and a bedside ultrasound 'bubble study' revealed venous cannulation. A chest X-ray postprocedure revealed concern for arterial system catheterisation. However, the possibility of a persistent left superior vena cava was discussed and confirmed with a formal transthoracic echocardiogram and CT. This case demonstrates the importance of ultrasound-guided visualisation of anatomical structures in real time during central venous catheterisation. Other similar cases from the literature are briefly described.

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Turbulent tackle: a novel surgical approach to a rugby-related jejunal perforation

Viscus perforation in the context of blunt-force abdominal trauma is a rarity. Within a sporting context, it is especially rare. However, the increasing physicality observed in rugby union, both in the amateur and professional setting, has resulted in a higher rate of serious injury. We report a novel laparoscopic surgical approach to the management of a traumatic jejunal perforation sustained on the playing field in a previously fit and healthy 28-year-old.

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Valacyclovir-associated neurotoxicity treated with intensification of peritoneal dialysis

We report a 57-year-old woman with end-stage renal disease (ESRD) on maintenance peritoneal dialysis (PD), who presented to the emergency room (ER) by ambulance with complaints of confusion and altered sensorium for 48 hours. She had been reviewed in a walk-in clinic 72 hours earlier and had been prescribed the standard 1000 mg three times per day of valacyclovir for an acute attack of shingles instead of 500 mg once a day on ESRD. In the ER, she received further 500 mg of intravenous acyclovir as herpes encephalitis was clinically suspected. CT of the brain and lumbar puncture were non-contributory to the diagnosis. Valacyclovir and acyclovir were discontinued when the diagnosis of valacyclovir-associated neurotoxicity became clinically evident. As the patient's Glasgow Coma Scale declined, we intensified her PD regimen from one to six exchanges per day and 24 hours later there was a significant neurological improvement.

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Huge cardiac myxoma in pregnancy

A 28-year-old pregnant woman presented at 28 weeks of gestation. She was diagnosed to have a left atrial myxoma 2 years earlier, but was lost to follow-up. During this pregnancy, the transthoracic echocardiography showed a 9 cm mass in the left atrium obstructing mitral valve inflow, interfering with mitral valve closure, causing severe mitral regurgitation and severe pulmonary hypertension. However, there were no clinical signs of pulmonary and systemic congestion or obstruction. Based on the clinical symptoms of the patient, the echocardiographic findings and the term of her pregnancy, the patient decided to schedule for a vaginal delivery with surgical correction after delivery. She gave birth at 32 weeks of gestation. During labour, pulmonary oedema developed but was detected early and it responded to therapy. Two weeks after delivery, a right anterior thoracotomy was performed to facilitate the removal of the left atrial myxoma and repair of the mitral valve.

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Peripheral hepatojejunostomy: a last resort palliative solution in Greece during the economic crisis

The geographical distribution of Greece and the growing proportion of uninsured patients make imperative the need for effective and efficient palliative solutions regarding obstructive jaundice due to hepatic malignancy, while repeated endoscopic interventions and all associated materials are either not accessible to the whole population or not even available on a daily basis due to the economic crisis and the difficulties on the hospital supply. On this basis, palliative hepatojejunostomy, introduced more than 50 years ago, could be revisited in the Greek reality in very selected cases and under these special circumstances. We report on two patients with locally advanced hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma, respectively, who were treated with a combination of double hepaticojejunostomy with peripheral hepatojejunostomy or peripheral hepatoejunostomy alone, respectively. Both patients experienced an adequate decompression of the biliary tract over more than a year. Palliative hepatojejunostomy could be an ultimate solution for selected patients and circumstances in Greece during the economic crisis.

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Embryonal carcinoma presenting as a calcified solitary testicular mass on ultrasound

A 24-year-old man presented with a 2-week history of a painless right testicular mass; ultrasound demonstrated a dense, solitary calcified mass. The patient elected observation after further workup showed no evidence of metastasis.

A repeat ultrasound 3 months later showed interval growth and the patient underwent right radical orchiectomy. Pathology was consistent with pure embryonal carcinoma of the testis. Calcified testicular masses are typically benign but do carry a differential of spermatic granuloma, large-cell calcifying Sertoli cell tumour, trauma, tuberculosis, filariasis, calcified Leydig cell tumour and burned-out testicular tumour.

To our knowledge, this is the first case report of pure embryonal carcinoma presenting as a solitary calcified testicular mass.

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Wernickea{euro}™s encephalopathy associated with liver abscess

Wernicke's encephalopathy is a rare neurological disorder caused by thiamine deficiency, characterised by ocular motor dysfunction, ataxia and impairment in consciousness. It predominantly affects brain regions with a high metabolic rate such as mammillary bodies, medial thalamic nuclei, the tectal region and the cerebellum. Although chronic alcoholism is the most common cause of Wernicke's encephalopathy, various other conditions not related to alcohol consumption such as bariatric surgery, acute pancreatitis, hyperemesis gravidarum, prolonged fasting and gastrointestinal surgery have been implicated in its aetiology. We report the case of a patient who underwent surgery for liver abscess and subsequently developed Wernicke's encephalopathy; he showed a positive response to thiamine supplementation. This is the first report describing liver abscess as the cause of Wernicke's encephalopathy.

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Pseudo retinitis pigmentosa in a case of missed intraocular foreign body

A 35-year-old man presented with history of painless, progressive loss of vision in the left eye for the past 7 years. There was history of trauma to the same eye with an iron object 7 years prior. Fundus examination revealed pigmentary retinopathy (unilateral advanced retinitis pigmentosa (RP)-like picture). X-ray orbits were suspicious of retained intraocular foreign body (IOFB). CT orbits confirmed the presence of IOFB. Electroretinogram revealed depressed responses. Right eye examination was within normal limits. A diagnosis of siderosis bulbi with unilateral pseudo RP-like fundus was made. No surgical intervention was planned for IOFB in view of poor visual prognosis.

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Triggering of the abductor pollicis longus in association with deQuervain's tenosynovitis

DeQuervain's tenosynovitis is a common cause of radial-sided wrist pain. Symptoms result from a narrow first dorsal compartment and associated tendinosis of the enclosed extensor pollicis brevis and/or abductor pollicis longus (APL). Surgical intervention, offered when conservative measures fail to adequately relieve symptoms, requires a detailed understanding of potentially aberrant anatomy in order to avoid persistence or recurrence of symptoms. We describe a case whereby the patient presented with complaints of thumb triggering in extension and associated disabling first dorsal compartment tendinosis. Intraoperatively, after supernumerary tendons were identified and addressed, the APL was at risk for subluxation over a prominent fibroosseous ridge. Routine first dorsal compartment release alone may have failed to address all of this patient's pathology.

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Tuberculosis presenting as broncho-oesophageal fistula in a young healthy man

A 21-year-old Saudi man presented with a history of dysphagia and choking. CT scan of the chest showed clear evidence of chronic recurrent aspiration pneumonia in the left lung. It also showed a fistula connecting the left main bronchus to the oesophagus. Endoscopy showed clear opening on the oesophageal side. Bronchoscopy also confirmed the presence of a broncho-oesophageal fistula on the left bronchial side with the presence of secretions on swallowing. Bronchoalveolar lavage (BAL) was done and sent for mycobacterial tuberculosis culture. The fistula was closed with clips under endoscopic guidance, which alleviated his symptoms of dysphagia and choking. The BAL culture grew mycobacterial tubercle bacilli. The patient showed marked improvement after starting antitubercular therapy and was discharged to be followed up in the clinic.

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Re: Comparison of different hypotensive anaesthesia techniques in orthognathic surgery with regard to intraoperative blood loss, quality of the surgical field, and postoperative nausea and vomiting

In regard to our low incidence of postoperative nausea and vomiting (PONV) after bimaxillary osteotomies, minimizing the use of inhalational agents and narcotic pain medication are the two main focuses in our clinical practice, as inhalational agents and narcotics are associated with an increased incidence of PONV.

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Characterizing the skull base in craniofacial microsomia using principal component analysis

The aim of this study was to compare the anatomical differences in the skull base between the affected and non-affected side in patients with craniofacial microsomia (CFM), and to compare the affected and non-affected sides with measurements from a normal population. Three-dimensional computed tomography scans of 13 patients with unilateral CFM and 19 normal patients (age range 7–12 years) were marked manually with reliable homologous landmarks. Principal component analysis (PCA), as part of a point distribution model (PDM), was used to analyse the variability within the normal and preoperative CFM patient groups.

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Hypotensive anaesthesia techniques in orthognathic surgery

We read with interest the article by Lin et al., "Comparison of different hypotensive anaesthesia techniques in orthognathic surgery with regard to intraoperative blood loss, quality of the surgical field, and postoperative nausea and vomiting".1 It provoked a lot of discussion and an audit of our practice. The low incidence of postoperative nausea and vomiting (PONV) was particularly notable. In a group of similar cases of similar age and sex ratio, the incidence of PONV requiring intervention in the post anaesthesia care unit (PACU) was 35%, comparable to the sevoflurane group in the study.

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Efficacy and tolerability of a double-conjugated retinoid cream vs 1.0% retinol cream or 0.025% tretinoin cream in subjects with mild to severe photoaging

Summary

Background

Topical retinoids are used to treat the visible signs of photoaging. While efficacious, they are irritating.

Objective

Evaluate the effectiveness and tolerability of a double-conjugate retinoid cream (AlphaRet Overnight Cream; AHA-Ret) in improving visible signs of photoaging vs 1.0% retinol or 0.025% tretinoin.

Methods

A 12-week, split-face, randomized trial was conducted in 48 female subjects, aged 30-65 years with mild to severe photodamage. AHA-Ret was applied to one side of the face and either retinol (n=24) or tretinoin (n=24) to the other side (PM). Expert blinded evaluation of images and Nova measurements occurred at 4, 8, and 12 weeks. Tolerability was assessed throughout the study.

Results

Forty-seven subjects completed the study. AHA-Ret demonstrated significant reductions in average severity from baseline: Fine Lines/Wrinkles (P<.001; all time points); Erythema (P=.004, P<.0001; 8 and 12 weeks, respectively); Dyschromia (P<.0001; all time points); Skin Tone (P<.0001; all time points), and Pore Size (P=.035, P<.0001; 8 and 12 weeks, respectively). AHA-Ret induced less Erythema vs retinol at 8 (P=.008) and 12 (P<.02) weeks. AHA-Ret was noninferior to prescription tretinoin in all categories at 4 and 8 weeks, and for Fine Lines/Wrinkles, Erythema, Dyschromia, and Skin Tone at 12 weeks. Improvements in Hydration occurred at every time point with AHA-Ret only (P<.04, P<.03, P<.01). Less irritation was reported with AHA-Ret vs retinol or tretinoin.

Conclusions

Treatment with a double-conjugate retinoid cream demonstrated early reductions in photodamage and improvements in Hydration. AHA-Ret induced less Erythema vs retinol and was more tolerable vs retinol and tretinoin.

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Conceptualisation, development and validation of T-QoL© (Teenagers’ Quality of Life): a patient-focused measure to assess quality of life of adolescents with skin diseases

Abstract

Aim

To develop and validate a dermatology-specific quality of life (QoL) instrument for adolescents with skin diseases.

Methods

Qualitative semi-structured interviews were conducted with adolescents with skin disease to gain in-depth understanding of how skin diseases affect their QoL. A prototype instrument based on the themes identified from content analysis of interviews was tested in several stages, using Classical Test Theory (CTT) and Item Response Theory (IRT) models to develop this new tool and conduct its psychometric evaluation.

Results

Thirty-three QoL issues were identified from semi-structured interviews with 50 adolescents. A questionnaire based on items derived from content analysis of interviews was subjected to Rasch analysis: factor analysis identified three domains, therefore not supporting the validity of T-QoL as a unidimensional measure. Psychometric evaluation of the final 18-item questionnaire was carried out in a cohort of 203 adolescents. Convergent validity was demonstrated by significant correlation with Skindex-Teen and CDLQI or DLQI. The T-QoL showed excellent internal consistency reliability: Cronbach's α=0.89 for total scale score and 0.85, 0.60, and 0.74 respectively for domains 1, 2 and 3. Test-retest reliability was high in stable subjects. T-QoL showed sensitivity to change in two sub-groups of patients who indicated change in their self-assessed disease severity.

Conclusion

Built on rich qualitative data from patients, the T-QoL is a simple and valid tool to quantify the impact of skin disease on adolescents' QoL; it could be used as an outcome measure in both clinical practice and clinical research.

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Association Between Handgrip Muscle Strength and Cardiometabolic z-Score in Children 6 to 19 Years of Age: Results from the Canadian Health Measures Survey

Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.

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Expression of C-X-C motif chemokine receptors 4 and 7 in salivary gland neoplasms

Publication date: November 2017
Source:Archives of Oral Biology, Volume 83
Author(s): Ekarat Phattarataratip, Kittipong Dhanuthai
ObjectivesChemokine receptors have been shown to overexpress in several cancer types. Binding of chemokines to their cognate chemokine receptors on tumor cells can promote tumor growth, angiogenesis and metastasis. The purposes of this study was to examine the expression of chemokine receptors, CXCR4 and CXCR7, in salivary gland neoplasms and its association with pathologic characteristics.DesignSixty-two cases of salivary gland neoplasms, including 25 mucoepidermoid carcinomas (MEC), 18 adenoid cystic carcinomas (ACC), 14 pleomorphic adenomas (PA) and 5 polymorphous low-grade adenocarcinoma (PLGA) were investigated for CXCR4 and CXCR7 expression immunohistochemically. The immunoreactivity was categorized as low expression or high expression group, based on whether the positive staining was below or higher than 50% of the neoplastic cells, respectively.ResultsThe majority of MECs, ACCs and PLGAs showed high CXCR4 and CXCR7 expression, whereas most PAs showed high CXCR4 but low CXCR7 expression. The levels of CXCR4 and CXCR7 expression were significantly correlated. In MECs, the expression of both chemokine receptors was localized to squamous cells, intermediate cells and glandular epithelial cells, whereas mucous cells and clear cells were negative. In ACCs and PAs, their immunoreactivity was more intense in ductal cells than myoepithelial cells. Most neoplastic myoepithelial cells in PAs did not express CXCR7, while those in ACCs showed strong CXCR7 expression. The increased CXCR4 expression was significantly associated with advanced pathologic grade of MECs (P=0.03).ConclusionOverexpression of CXCR4 and CXCR7 is common in the 4 salivary gland neoplasms investigated. CXCR4 may play a role in the progression of MECs.

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Expression of C-X-C motif chemokine receptors 4 and 7 in salivary gland neoplasms

Selective removal of carious lesion with Er:YAG laser followed by dentin biomodification with chitosan

Abstract

The aim of this study was to evaluate the effect of Er:YAG laser for selective removal of carious lesion, followed by biomodification with chitosan gel where the subsurface microhardness, chemical composition, and morphological changes of the residual caries-affected dentin were examined. Artificial dentinal lesions were created by pH-cycling method (14 days) in 104 bovine specimens (5 × 5 mm). Specimens were randomly divided according to the carious removal method: bur (low-speed handpiece) or Er:YAG laser (250 mJ/4 Hz). Specimens were treated with 35% phosphoric acid and were subdivided into two groups according to dentin biomodification: without chitosan (control) and 2.5% chitosan. Forty specimens were restored with an adhesive system and composite resin. Subsurface microhardness tests were performed in sound dentin, caries-affected dentin, residual caries-affected dentin, and after the restoration. The other 64 specimens were subjected to SEM-EDS atomic analysis. Data were statistically analyzed (p < 0.05). After the Er:YAG laser excavation, the microhardness value of residual caries-affected dentin was higher (p < 0.05) than bur-treated dentin. A significant decrease in the amount of Ca, P, and Ca/P ratio was found after the removal of carious lesions with Er:YAG laser (p < 0.05). The biomodification with chitosan did not influence the microhardness and atomic percentage of Ca, P, and Ca/P ratio of residual caries-affected dentin (p > 0.05). SEM analysis showed morphological changes on residual caries-affected dentin (p > 0.05). The selective removal of carious dentin with Er:YAG laser increased microhardness of residual caries-affected dentin, changing its surface morphology and chemical composition. The biomodification with chitosan did not influence the structural and chemical composition of residual caries-affected dentin.

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MAIT cells in infectious diseases

Marion Salou | Katarzyna Franciszkiewicz | Olivier Lantz

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Vaccines targeting helper T cells for cancer immunotherapy

Marit Melssen | Craig L Slingluff

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Towards an evidence based approach for the development of adjuvanted vaccines

Derek T O'Hagan | Leonard R Friedland | Emmanuel Hanon | Arnaud M Didierlaurent

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Tuberculosis vaccines — perspectives from the NIH/NIAID Mycobacteria vaccine testing program

Angelo A Izzo

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TNF-receptor superfamily agonists as molecular adjuvants for cancer vaccines

Timothy NJ Bullock

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Four pathways of CD1 antigen presentation to T cells

D Branch Moody | Rachel N Cotton

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Dural metastasis of nasopharyngeal carcinoma: A case report

Publication date: Available online 16 June 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Mohd Irman Shah Ibrahim, Aishah Harizah Abdullah Alwi, Amran Mohamad, Norhafiza Mat Lazim
Nasopharyngeal carcinoma (NPC) with dural metastasis is extremely rare, mostly asymptomatic, leaving it to be highly at risk of being overlooked. We report a case of a woman with dural metastasis of NPC almost 1year post concurrent chemoradiotherapy (CCRT) that was detected following a trivial trauma to her head. Owing to its rare occurence, it presents a great challenge for clinicians to make a prompt diagnosis because delayed in the treatment may lead to a fatal outcome.

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Effect of glycerol test on audiovestibular tests in patients with Meniere’s disease

Publication date: Available online 9 May 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Enass S. Mohamed, Eman A. Said, Nashwa A. Mahmoud
This stud to explore the effect of glycerol on audiovestibular tests in patients with Meniere's disease (MD) and to reflect different pathologic states of endolymphatic hydrops (EH) in the inner ear and compare the results of glycerol on these results.SubjectsThirty patients and 15 normal volunteers.MethodsEach subject of this study underwent pure tone audiometry testing, evoked vestibular evoked myogenic potential (VEMP) and Vidionystagmography (VNG) before G1 and 2h after glycerol G2 administration (1.3g/kg).ResultsAffected ears were 32 and unaffected ears were 28. The affected ears had higher hearing and SRT thresholds when compared to the unaffected ears and control group. VEMPs of the affected ears were normal in six ears (18.75%), absent in four ears (12.5%) and augmented amplitude in 22 (68.75%), their VNG results showed peripheral vestibular disorder. After oral administration of glycerol, the previous test battery was repeated and it's result on PTA showed that 53.13% (17/32) of affected ears had positive glycerol test mainly in stage II and III. Ten of the 32 affected ears (31.26%) showed improvement of VEMPs after glycerol administration. Also, two (7.8%) of the unaffected ears showed positive glycerol. Latency of the VEMP had no significant changes after glycerol administration and there was no statistical correlation between the results of G-PTA and G-VEMP. There was statistical significant improvement of the slow peak velocity of caloric test in patient's affected ears and insignificant improvement in control group and in unaffected ears after glycerol administration.

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Editorial Board

Publication date: March 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences, Volume 18, Issue 1

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Comparative study between selective nerve blocks and the intravenous opioids in mastoid surgery

Publication date: Available online 17 June 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Santosh Kumar Swain, Chandrasekhar Pradhan, Sidharth Mohanty, Mahesh Chandra Sahu
ObjectiveThis double-blind randomized trial was conducted to compare the efficacy of selective nerve blocks over intravenous use of morphine during mastoid surgery.Materials and methodsA total of 50 patients between the ages 25 to 45years were divided into two groups as per the anaesthetic techniques used; nerve block group (N) and intravenous morphine group (M). After induction of general anaesthesia and before surgical incision: Group N patients (nerve block group) were given Great Auricular Nerve (GAN) and Auriculo-Temporal Nerve (ATN) block with 0.25% bupivacaine. Group M patients (morphine group) received 0.1mg/kg morphine. In the post anaesthesia care unit (PACU), Visual Analogue Scale (VAS) was used to assess post operative pain, Ramsay Sedation Scale (RSS) for sedation and post operative nausea and vomiting (PONV) impact scale score.ResultsVAS scores and requirement of rescue analgesics in the PACU was significantly less in the N Group for first 3h. The group N patients had a less frequent incidence of vomiting requiring intervention and were ready to be discharged from hospital after 3h of surgery.ConclusionCombination of GAN and ATN block with general anaesthesia is an uncomplicated, effective and well tolerated method for the safe conduct of mastoid surgery.

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Effect of mechanical loading on the metabolic activity of cells in the temporomandibular joint: a systematic review

Abstract

Objectives

The purpose of this systematic review was to elucidate how different modalities and intensities of mechanical loading affect the metabolic activity of cells within the fibro-cartilage of the temporomandibular joint (TMJ).

Materials and methods

A systematic review was conducted according to PRISMA guidelines using PubMed, Embase, and Web of Science databases. The articles were selected following a priori formulated inclusion criteria (viz., in vivo and in vitro studies, mechanical loading experiments on TMJ, and the response of the TMJ).

A total of 254 records were identified. After removal of duplicates, 234 records were screened by assessing eligibility criteria for inclusion. Forty-nine articles were selected for full-text assessment. Of those, 23 were excluded because they presented high risk of bias or were reviews. Twenty-six experimental studies were included in this systematic review: 15 in vivo studies and 11 in vitro ones.

Conclusion

The studies showed that dynamic mechanical loading is an important stimulus for mandibular growth and for the homeostasis of TMJ cartilage. When this loading is applied at a low intensity, it prevents breakdown of inflamed cartilage. Yet, frequent overloading at excessive levels induces accelerated cell death and an increased cartilage degradation.

Clinical Significance

Knowledge about the way temporomandibular joint (TMJ) fibrocartilage responds to different types and intensities of mechanical loading is important to improve existing treatment protocols of degenerative joint disease of the TMJ, and also to better understand the regenerative pathway of this particular type of cartilage.

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Synovial sarcoma showing loss of a green signal in SS18 fluorescence in situ hybridization: a clinicopathological and molecular study of 12 cases

Abstract

The phenomenon of losing a green signal in synovial sarcoma (SS) using the SS18 break-apart probe by fluorescence in situ hybridization (FISH) has been poorly described. In this study, 12 SS with missing a green signal were identified. This series included 7 males and 5 females, aged 17 to 69 years (median, 38.5 years). The tumors involved the extremities (50%), mediastinum (16.7%), hypopharynx (8.3%), neck (8.3%), thyroid (8.3%), and retroperitoneum (8.3%). The tumors were classified as monophasic SS (58.3%) and poorly differentiated SS (41.7%). An anaplastic SS showing features of pleomorphic sarcoma was observed. Immunostaining for TLE1, BCL2, CD99, epithelial membrane antigen, cytokeratin (AE1/AE3), cytokeratin 7, S-100 protein, and CD34 was consistent with typical SS. In FISH, all the tumors showed the pattern of 1 to 3 fused signal(s) with 1 to 3 red signal(s), without corresponding a green signal. The fusion transcripts included SS18-SSX1 (8/10, 80%) and SS18-SSX2 (2/10, 20%) fusions. Median and 5-year overall survival were 19.1 months and 43.6%, respectively. In conclusion, we reported a series of SS losing a green signal in the SS18 FISH assay. We propose that this variant FISH pattern should be interpreted as a peculiar unbalanced rearrangement of the SS18 gene and subsequent SS18-SSX fusion test should be recommended. The cases in this study seem to show some unusual clinicopathological features, including unusual locations, higher proportions of poorly differentiated SS, and aggressive clinical course. However, whether this variant FISH pattern is associated with peculiar clinicopathologic features awaits larger series.

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Giant mucinous adenocarcinoma of the appendix: a case report

Appendiceal mucinous adenocarcinoma is an extremely rare disease in clinical practice. Here, we report a case of unprecedented size that occupied the entire abdomen of a man.

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“Jihad Against the Enemies of Allah”: The Berlin Christmas Market Attack from a Threat Assessment Perspective

Violence and Gender , Vol. 0, No. 0.

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B Cell Tetramer Development for Veterinary Vaccinology

Viral Immunology , Vol. 0, No. 0.

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Sevoflurane attenuates systemic inflammation compared with propofol, but does not modulate neuro-inflammation: A laboratory rat study.

BACKGROUND: Septic encephalopathy is believed to be a result of neuro-inflammation possibly triggered by endotoxins, such as lipopolysaccharides (LPS). Modulation of the immune system is a property of volatile anaesthetics. OBJECTIVE: We aimed to investigate the systemic and cerebral inflammatory response in a LPS-induced sepsis model in rats. We compared two different sedation strategies, intravenous propofol and the volatile anaesthetic sevoflurane, with the hypothesis that the latter may attenuate neuro-inflammatory processes. DESIGN: Laboratory rat study. SETTING: Basic research laboratories at the University Hospital Zurich and University Zurich Irchel between August 2014 and June 2016. PATIENTS: A total of 32 adult male Wistar rats. INTERVENTIONS: After tracheotomy and mechanical ventilation, the anaesthetised rats were monitored before sepsis was induced by using intravenous LPS or phosphate-buffered saline as control. Rats were sedated with propofol (10 mg kg-1 h-1) or sevoflurane (2 vol%) continuously for 12 h. MAIN OUTCOME MEASURES: Systemic inflammatory markers such as cytokine-induced neutrophil chemo-attractant protein 1, monocyte chemo-tactic protein-1 and IL-6 were determined. The same cytokines were measured in brain tissue. Cellular response in the brain was assessed by defining neutrophil accumulation with myeloperoxidase and also activation of microglia with ionised calcium-binding adaptor molecule-1 and astrocytes with glial fibrillary acidic protein. Finally, brain injury was determined. RESULTS: Animals were haemodynamically stable in both sedation groups treated with LPS. Blood cytokine peak values were lower in the sevoflurane-LPS compared with propofol-LPS animals. In brain tissue of LPS animals, chemoattractant protein-1 was the only significantly increased cytokine (P = 0.003), however with no significance between propofol and sevoflurane. After LPS challenge, cerebral accumulation of neutrophils was observed. Microglia activation was pronounced in the hippocampus of animals treated with LPS (P = 0.006). LPS induced prominent astrogliosis (P

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Pharyngolaryngeal symptoms associated with thyroid disease.

Purpose of review: The current review summarizes previous reports on laryngopharyngeal symptoms associated with thyroid disease. This review also includes pharyngolaryngeal symptoms caused by thyroidectomy. However, we focus on pharyngolaryngeal symptoms following uncomplicated thyroidectomy, as this is an important issue in the fields of otolaryngology. Recent findings: An enlarged thyroid gland, as in thyroiditis, multinodular goiter, or large nodules, can cause compressive symptoms. Malignant nodules invading the recurrent laryngeal nerve and benign nodules compressing the nerve can cause vocal cord paralysis and hoarseness. Pharyngolaryngeal symptoms are known to develop after a thyroidectomy, generally as a result of injury to the superior or recurrent laryngeal nerve. However, recent studies have shown that various pharyngolaryngeal symptoms, such as globus symptoms and voice changes, occur after thyroidectomy in the absence of laryngeal nerve injury. These symptoms are known collectively as postthyroidectomy syndrome. Several possible explanations have been proposed and evaluated for postthyroidectomy syndrome. Summary: Several thyroid disorders can cause compressive symptoms and hoarseness. Superior and/or recurrent laryngeal nerve injury during thyroidectomy is the main cause of various pharyngolaryngeal symptoms. However, other pharyngolaryngeal symptoms that arise following thyroidectomy in the absence of nerve injury, a condition known as postthyroidectomy syndrome, are becoming more common. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: A Randomized Controlled Trial.

Background and Objectives: Truncal blocks have a place within multimodal analgesia techniques in abdominal surgery. The quadratus lumborum block is a new abdominal truncal block used for somatic analgesia of both the upper and lower abdomen. In this prospective, double-blind, randomized study, we aimed to compare quadratus lumborum block and transversus abdominis plane block in pediatric patients undergoing lower abdominal surgery. Methods: Fifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery were randomized into 2 groups: transversus abdominis plane block and quadratus lumborum block. All blocks were performed under general anesthesia before surgery. Pain levels were assessed using an FLACC (Face, Legs, Activity, Cry, Consolability) scale. Results: The study included 50 patients, after excluding 3 patients who were not eligible. The number of patients who required analgesia in the first 24 hours postoperatively was significantly lower in the quadratus lumborum block group (P

http://ift.tt/2wf0F5k

Ultrasound-Guided Regional Anesthesia Simulation Training: A Systematic Review.

Background and Objectives: Ultrasound-guided regional anesthesia (UGRA) has become the criterion standard of regional anesthesia practice. Ultrasound-guided regional anesthesia teaching programs often use simulation, and guidelines have been published to help guide URGA education. This systematic review aimed to examine the effectiveness of simulation-based education for the acquisition and maintenance of competence in UGRA. Methods: Studies identified in MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC were included if they assessed simulation-based UGRA teaching with outcomes measured at Kirkpatrick level 2 (knowledge and skills), 3 (transfer of learning to the workplace), or 4 (patient outcomes). Two authors independently reviewed all identified references for eligibility, abstracted data, and appraised quality. Results: After screening 176 citations and 45 full-text articles, 12 studies were included. Simulation-enhanced training improved knowledge acquisition (Kirkpatrick level 2) when compared with nonsimulation training. Seven studies measuring skill acquisition (Kirkpatrick level 2) found that simulation-enhanced UGRA training was significantly more effective than alternative teaching methods or no intervention. One study measuring transfer of learning into the clinical setting (Kirkpatrick level 3) found no difference between simulation-enhanced UGRA training and non-simulation-based training. However, this study was discontinued early because of technical challenges. Two studies examined patient outcomes (Kirkpatrick level 4), and one of these found that simulation-based UGRA training improved patient outcomes compared with didactic teaching. Conclusions: Ultrasound-guided regional anesthesia knowledge and skills significantly improved with simulation training. The acquired UGRA skills may be transferred to the clinical setting; however, further studies are required to confirm these changes translate to improved patient outcomes. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Impact of Different Ventilation Strategies on Driving Pressure, Mechanical Power, and Biological Markers During Open Abdominal Surgery in Rats.

BACKGROUND: Intraoperative mechanical ventilation may yield lung injury. To date, there is no consensus regarding the best ventilator strategy for abdominal surgery. We aimed to investigate the impact of the mechanical ventilation strategies used in 2 recent trials (Intraoperative Protective Ventilation [IMPROVE] trial and Protective Ventilation using High versus Low PEEP [PROVHILO] trial) on driving pressure ([DELTA]PRS), mechanical power, and lung damage in a model of open abdominal surgery. METHODS: Thirty-five Wistar rats were used, of which 28 were anesthetized, and a laparotomy was performed with standardized bowel manipulation. Postoperatively, animals (n = 7/group) were randomly assigned to 4 hours of ventilation with: (1) tidal volume (VT) = 7 mL/kg and positive end-expiratory pressure (PEEP) = 1 cm H2O without recruitment maneuvers (RMs) (low VT/low PEEP/RM-), mimicking the low-VT/low-PEEP strategy of PROVHILO; (2) VT = 7 mL/kg and PEEP = 3 cm H2O with RMs before laparotomy and hourly thereafter (low VT/moderate PEEP/4 RM+), mimicking the protective ventilation strategy of IMPROVE; (3) VT = 7 mL/kg and PEEP = 6 cm H2O with RMs only before laparotomy (low VT/high PEEP/1 RM+), mimicking the strategy used after intubation and before extubation in PROVHILO; or (4) VT = 14 mL/kg and PEEP = 1 cm H2O without RMs (high VT/low PEEP/RM-), mimicking conventional ventilation used in IMPROVE. Seven rats were not tracheotomized, operated, or mechanically ventilated, and constituted the healthy nonoperated and nonventilated controls. RESULTS: Low VT/moderate PEEP/4 RM+ and low VT/high PEEP/1 RM+, compared to low VT/low PEEP/RM- and high VT/low PEEP/RM-, resulted in lower [DELTA]PRS (7.1 +/- 0.8 and 10.2 +/- 2.1 cm H2O vs 13.9 +/- 0.9 and 16.9 +/- 0.8 cm H2O, respectively; P

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Targeting Hypoxia Signaling for Perioperative Organ Injury.

Perioperative organ injury has a significant impact on surgical outcomes and presents a leading cause of death in the United States. Recent research has pointed out an important role of hypoxia signaling in the protection from organ injury, including for example myocardial infarction, acute respiratory distress syndrome, acute kidney, or gut injury. Hypoxia induces the stabilization of hypoxia-inducible factors (HIFs), thereby leading to the induction of HIF target genes, which facilitates adaptive responses to low oxygen. In this review, we focus on current therapeutic strategies targeting hypoxia signaling in various organ injury models and emphasize potential clinical approaches to integrate these findings into the care of surgical patients. Conceptually, there are 2 options to target the HIF pathway for organ protection. First, drugs became recently available that promote the stabilization of HIFs, most prominently via inhibition of prolyl hydroxylase. These compounds are currently trialed in patients, for example, for anemia treatment or prevention of ischemia and reperfusion injury. Second, HIF target genes (such as adenosine receptors) could be activated directly. We hope that some of these approaches may lead to novel pharmacologic strategies to prevent or treat organ injury in surgical patients. (C) 2017 International Anesthesia Research Society

http://ift.tt/2f258Vu

Avoiding Complications From Patient Positioning for Intraocular Surgery.

Collaboration of the surgical and anesthesia teams for patient positioning is essential to assure patient comfort and safety, preventing systemic and ophthalmic complications. The goals and rationales of positioning for intraocular surgery are discussed including placing the head above the heart, elevating the chin, using a head rest that is sufficiently firm, maximizing anesthesia care team access and minimizing fire risk, and taping the patient's head to the operating table to reduce unexpected movement with intraocular injury. (C) 2017 International Anesthesia Research Society

http://ift.tt/2hhwRT5

Aortocaval Compression Syndrome: Time to Revisit Certain Dogmas.

More than 70 years ago, the phenomenon of "postural shock" in the supine position was described in healthy women in late pregnancy. Since then, avoidance of the supine position has become a key component of clinical practice. Indeed, performing pelvic tilt in mothers at term to avoid aortocaval compression is a universally adopted measure, particularly during cesarean delivery. The studies on which this practice is based are largely nonrandomized, utilized a mix of anesthetic techniques, and were conducted decades ago in the setting of avoidance of vasopressors. Recent evidence is beginning to refine our understanding of the physiologic consequences of aortocaval compression in the context of contemporary clinical practice. For example, magnetic resonance imaging of women at term in the supine and tilted positions has challenged the dogma that 15[degrees] of left tilt is sufficient to relieve inferior vena cava compression. A clinical investigation of healthy term women undergoing elective cesarean delivery with spinal anesthesia found no difference in neonatal acid-base status between women randomized to be either tilted to the left by 15[degrees] or to be in the supine position, if maternal systolic blood pressure is maintained at baseline with a crystalloid coload and prophylactic phenylephrine infusion. This review presents a fresh look at the decades of evidence surrounding this topic and proposes a reevaluation and appraisal of current guidelines regarding entrenched practices. (C) 2017 International Anesthesia Research Society

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Current Approach to Heart Failure.

No abstract available

http://ift.tt/2hhC8df

Whiplash Injury: Perspectives on the Development of Chronic Pain.

No abstract available

http://ift.tt/2f24Rlq

The Expected Role of the Anesthesiologist in Delivering Bad News.

No abstract available

http://ift.tt/2f2yvXF

Limits of Agreement With Confidence Intervals Are Necessary to Assess Comparability of Measurement Devices.

No abstract available

http://ift.tt/2f2unHs

The Evaluation of a Noninvasive Respiratory Volume Monitor in Pediatric Patients Undergoing General Anesthesia.

BACKGROUND: Pediatric patients following surgery are at risk for respiratory compromise such as hypoventilation and hypoxemia depending on their age, comorbidities, and type of surgery. Quantitative measurement of ventilation in nonintubated infants/children is a difficult and inexact undertaking. Current respiratory assessment in nonintubated patients relies on oximetry data, respiratory rate (RR) monitors, and subjective clinical assessment, but there is no objective measure of respiratory parameters that could be utilized to predict early respiratory compromise. New advances in technology and digital signal processing have led to the development of an impedance-based respiratory volume monitor (RVM, ExSpiron, Respiratory Motion, Inc, Waltham, MA). The RVM has been shown to provide accurate real-time, continuous, noninvasive measurements of tidal volume (TV), minute ventilation (MV), and RR in adult patients. In this prospective observational study, our primary aim was to determine whether the RVM accurately measures TV, RR, and MV in pediatric patients. METHODS: A total of 72 pediatric patients (27 females, 45 males), ASA I to III, undergoing general anesthesia with endotracheal intubation were enrolled. After endotracheal intubation, continuous data of MV, TV, and RR were recorded from the RVM and an in-line monitoring spirometer (NM3 monitor, Phillips Healthcare). RVM and NM3 measurements of MV, TV, and RR were compared during a 10-minute period prior to the incision ("Presurgery") and a 10-minute period after the end of surgery ("Postsurgery"). Relative errors were calculated over 1-minute segment within each 10-minute period. Bias, precision, and accuracy were calculated using Bland-Altman analyses and paired-difference equivalence tests were performed. RESULTS: Combined across the Presurgery and Postsurgery periods, the RVM's mean measurement bias (RVM - NM3 measurement) for MV was -3.8% (95% limits of agreement) (+/-1.96 SD): (-19.9% to 12.2%), for TV it was -4.9 (-21.0% to 11.3%), and for RR it was 1.1% (-4.1% to 6.2%). The mean measurement accuracies for MV, TV, and RR were 11.9%, 12.0%, and 4.2% (0.6 breaths/min), respectively. Note that lower accuracy numbers correspond to more accurate RVM measurements. The equivalence tests rejected the null hypothesis that the RVM and NM3 have different mean values and conclude with 90% power that the measurements of MV, TV, and RR from the RVM and NM3 are equivalent within +/-10%. CONCLUSIONS: Our data indicate acceptable agreement between RVM and NM3 measurements in pediatric mechanically-ventilated patients. Future studies assessing the capability of the RVM to detect respiratory compromise in other clinical settings are needed. (C) 2017 International Anesthesia Research Society

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Chronic Hiccups: An Underestimated Problem.

Persistent singultus, hiccupping that lasts for longer than 48 hours, can have a tremendous impact on a patient's quality of life. Although involved neurologic structures have been identified, the function of hiccups remains unclear-they have been controversially interpreted as a primitive reflex preventing extent swallowing of amniotic fluid in utero, an archaic gill ventilation pattern, or a fetus' preparation for independent breathing. Persistent singultus often presents as a symptom for various diseases, most commonly illnesses of the central nervous system or gastrointestinal tract; they can also be evoked by a variety of pharmacological agents. It is often impossible to define a singular cause. A wide range of treatment attempts, pharmacological and nonpharmacological, have been concerted to this date; however, chlorpromazine remains the only Food and Drug Administration-approved drug in this context. Large-scale studies on efficacy and tolerance of other therapeutic strategies are lacking. Gabapentin, baclofen, and metoclopramide have been reported to accomplish promising results in reports on the therapy of persistent singultus; they may also be effective when given in combination with other drugs, eg, proton pump inhibitors, or as conjoined therapy. As another approach of note, acupuncture treatment was able to abolish hiccups in a number of studies. When managing hiccup patients within the clinical routine, it is of importance to conduct a comprehensive and effective diagnostic workup; a well-functioning interdisciplinary team is needed to address possible causes for the symptom. Persistent singultus is a medical problem not to be underestimated; more research on options for effective treatment would be greatly needed. (C) 2017 International Anesthesia Research Society

http://ift.tt/2f28Zlv

Degenerative Severe Aortic Stenosis in Tetralogy of Fallot: Multimodality Echocardiographic Hemodynamic Assessment.

No abstract available

http://ift.tt/2hhEPv6

Trauma Anesthesiology as Part of the Core Anesthesiology Residency Program Training: Expert Opinion of the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP).

No abstract available

http://ift.tt/2hhGbpF

Addition of Nasal Cannula Can Either Impair or Enhance Preoxygenation With a Bag Valve Mask: A Randomized Crossover Design Study Comparing Oxygen Flow Rates.

BACKGROUND: A critical safety component of emergency anesthesia is the avoidance of hypoxemia during the apneic phase of a rapid sequence intubation. Preoxygenation with a bag valve mask (BVM) or anesthetic circuit may be improved with supplemental oxygen by nasal cannula (NC) if there is a mask leak. In addition, NC is recommended for apneic oxygenation after induction and may be placed before preoxygenation. However, the optimum NC flow rate for preoxygenation or whether the presence of NC alone creates a mask leak remains unclear. METHODS: We performed a randomized crossover study on healthy volunteers comparing BVM alone and BVM with NC flow rates of 0 (NC-0), 5 (NC-5), 10 (NC-10), and 15 (NC-15) liters per minute (lpm). Our primary outcome was end-tidal oxygen (ETO2) after 3-minute preoxygenation. RESULTS: There was no difference in ETO2 between NC-15, NC-10, or BVM-only at 3 minutes. NC-0 and NC-5 recorded significantly lower ETO2 at all times compared with NC-15, NC-10, or BVM-only (least difference NC-5, -7% [95% confidence interval {CI}, -4% to -10%), NC-0, 16% [95% CI, 13%-19%]). There was a difference in ETO2 between NC-15 and BVM-only at 1 minute (7%; 95% CI, 5%-9%), but not at 2 or 3 minutes. There was no difference in ETO2 between NC-10 and NC-15. CONCLUSIONS: Our study found that NC at 0 and 5 lpm with a BVM is deleterious to preoxygenation and should be avoided. In addition, a lack of difference between NC-10 and BVM-only demonstrates that NC at flows of at least 10 lpm should not impair the preoxygenation process. While NC-15 may offer a benefit by reaching maximal ETO2 at 1 minute, this would need to be balanced against patient comfort. (C) 2017 International Anesthesia Research Society

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Questionable Design to Validate the ProAQT/Pulsioflex Device.

No abstract available

http://ift.tt/2hgR1fN

Managing Obstetric Emergencies and Trauma, Revised 3rd ed.

No abstract available

http://ift.tt/2f2tTRE

Alarm Limits for Intraoperative Drug Infusions: A Report From the Multicenter Perioperative Outcomes Group.

BACKGROUND: Continuous medication infusions are commonly used during surgical procedures. Alarm settings for infusion pumps are considered important for patient safety, but limits are not created in a standardized manner from actual usage data. We estimated 90th and 95th percentile infusion rates from a national database for potential use as upper limit alarm settings. METHODS: We extracted infusion rate data from 17 major hospitals using intraoperative records provided by Multicenter Perioperative Outcomes Group for adult surgery between 2008 and 2014. Seven infusions were selected for study: propofol, remifentanil, dexmedetomidine, norepinephrine, phenylephrine, nitroglycerin, and esmolol. Each dosage entry for an infusion during a procedure was included. We estimated the 50th, 90th, and 95th percentile levels for each infusion across institutions, and performed quantile regression to examine factors that might affect the percentiles rates, such as use in general anesthesia versus sedation. RESULTS: The median 90th and 95th percentile infusion rates (with interquartile range) for propofol were 150 (140-150) and 170 (150-200) [mu]g/kg/min. Quantile regression demonstrated higher 90th and 95th percentile rates during sedation for gastrointestinal endoscopy than for all surgical procedures performed under general anesthesia. For selected vasoactive medications, the corresponding median 90th and 95th percentile rates (with interquartile range) were norepinephrine 14.0 (9.8-18.1) and 18.3 (12.6-23.9) [mu]g/min, and phenylephrine 60 (55-80) and 80 (75-100) [mu]g/min. CONCLUSIONS: Alarm settings based on infusion rate percentile limits would be triggered at predictable rates; ie, the 95th percentile would be exceeded and an alarm sounded during 1 in 20 infusion rate entries. As a result, institutions could establish pump alarm settings consistent with desired alarm frequency using their own or externally validated usage data. Further study will be needed to determine the optimal percentile for infusion alarm settings. (C) 2017 International Anesthesia Research Society

http://ift.tt/2hgTYwO

Pharyngolaryngeal symptoms associated with thyroid disease.

Neuropathic symptoms of the ocular surface: dryness, pain, and itch.

Purpose of review: This review aims to describe the recent findings on epidemiology, pathophysiology, and management of neuropathic symptoms of the ocular surface, with a focus on potential similarities between sensations of dry eye, pain and itch. Recent findings: A narrative review of the literature was undertaken. Key references from research in dry eye, neuropathic symptoms of the ocular surface, ocular pain and itch, as well as general references on itch and pain neurobiology were included. Recent findings suggest aspects of dry eye, chronic ocular pain and itch symptomatology are driven by neuropathic pain mechanisms involving peripheral and central sensitization processes. Summary: Ocular dryness, pain, and itch are prevalent complaints with several of shared features. Multiple lines of evidence suggest that peripheral and central neuronal sensitization processes are involved in generating and maintaining ocular sensory symptoms. Research is warranted on the epidemiology of ocular sensations, molecular mechanisms involved in nociception and pruriception in the eye, electrophysiological alterations in animal models of eye conditions, and therapeutic modalities that can alleviate unpleasant ocular sensations. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2vYYB1K

When nutrition and allergy collide: the rise of anaphylaxis to plant foods.

Purpose of review: Interest in nutrition is increasing, but in the world of internet health gurus, whilst the nutritional benefits of fruits and vegetables are extolled, wheat is often vilified. This review will assess the positive nutritional effects of plant foods in relation to allergy prevention, the effectiveness of gluten-avoidance and the likelihood of anaphylaxis to fruits and vegetables. Recent findings: Although the numbers of people who report gluten sensitivity is rising, hard evidence of mass sensitivity to gluten is scant. Also, the avoidance of wheat containing foods could lead to nutritional imbalance and effects on the gut microbiome. The evidence that fruits and vegetables have a protective effect on the development of allergy is inconsistent, although fruit juices may promote beneficial changes to gut microflora. Fruits and vegetables can cause severe allergic reactions, especially due to the presence of lipid transfer proteins, but this is not just a Mediterranean phenomenon, and not limited to peaches. Summary: These findings emphasise the importance of a keeping an open mind about reported reactions to plant foods, to ensure the correct diagnosis is made and nutrition is optimised to prevent any adverse effects of avoidance on the gut microbiome. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2uNWYFC

Neuropathic symptoms of the ocular surface: dryness, pain, and itch.

When nutrition and allergy collide: the rise of anaphylaxis to plant foods.

Atopic Dermatitis in Adults Tough Nut to Crack

Only half as many adults as children are affected by atopic dermatitis, but diagnosis is more complicated, and the condition may be underreported in this population.
Medscape Medical News

http://ift.tt/2uLmZpd

Dermatology Goes to the Dogs and Human Patients Benefit

Animal treatments should inspire new therapies for people with the same conditions, according to presenters at the American Academy of Dermatology 2017 Summer Meeting.
Medscape Medical News

http://ift.tt/2tR3fla

A long-term survival case after surgical resection of skeletal muscle metastasis following esophagectomy for squamous cell carcinoma of the esophagus

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Abstract

Cases of skeletal muscle metastasis of esophageal carcinoma are very rare, with few reports of long-term survival. We report a case of long-term survival after surgical resection of skeletal muscle metastasis. A 56-year-old man with advanced esophageal cancer and early gastric cancer underwent thoracoscopic esophagectomy, 2-field lymph node dissection, partial gastrectomy and gastric tube reconstruction. Six months later, cervical lymph node metastasis and mediastinal lymph node recurrence were found. Therefore, the patient underwent cervical lymph node dissection and adjuvant chemoradiotherapy. Two years and 3 months after the esophagectomy, a muscle metastasis was found in the left shoulder, and he underwent tumor dissection, followed by adjuvant chemotherapy for a year. There has been no sign of recurrence since, even 13 years after the esophagectomy. We believe our aggressive surgical treatment might have led to long-term survival.

http://ift.tt/2vYLE8u

Multifocal rib osteomyelitis in children: a case report and literature review

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Abstract

Rib osteomyelitis is a rare disease, occurring in ~1% or less of all cases of haematogenous osteomyelitis. During the last century, 58 cases of rib osteomyelitis were reported in the literature, of which, multiple ribs were involved in only five patients. Because of its rarity and non-specific clinical signs, diagnostic of rib osteomyelitis may be delayed. We report a case of multifocal rib osteomyelitis revealed by a dorsal mass in a healthy 13-year-old female child.

http://ift.tt/2vYeQMA

Neurofibromatosis type 1 and male breast cancer: emerging risk factor?

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Abstract

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterized by the appearance of cafe au lait spots, neurofibromas and Lisch nodules. There is an established link between NF1 and the development of breast cancer in women; however, due to the rarity of both NF1 and male breast cancer, the same link has yet to be elucidated in men. The concurrent presentation of NF1 and male breast cancer is a very rare phenomenon with only a handful of case descriptions in the literature. To the best of our knowledge, there have only been four other reported cases of NF1 and male breast cancer before ours. We present one such case of a 56-year-old male with a four generation history of NF1 and a personal history of NF1 who presented with invasive ductal carcinoma of the right breast.

http://ift.tt/2vYn5s6

Ureterovaginal fistula following spontaneous vaginal delivery, repaired by vaginal ureteroneocystostomy in a low resource setting

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Abstract

Ureterovaginal fistula commonly follows ureteric injury during pelvic surgery, and presents with continuous urinary incontinence in spite of normal micturition. Continuous urinary incontinence has significant impact on quality of life, thus requiring effective surgical intervention in order to restore health. We found no reported case of ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labour. Relevant history and simple diagnostic procedures were used for diagnosis and the patient had successful vaginal ureteroneocystostomy. This could be the first reported ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labour. Vaginal ureteroneocystostomy though scarcely reported, is feasible in selected cases.

http://ift.tt/2vXQMcX

A Study Evaluating the Safety, Pharmacokinetics, and Anti-tumor Activity of ABBV-321 in Subjects With Advanced Solid Tumors Associated With Overexpression of the Epidermal Growth Factor Receptor (EGFR) or Its Ligands

Condition: Advanced Solid Tumors With Overexpression of Epidermal Growth Factor Receptor (EGFR) or EGFR Ligands
Intervention: Drug: ABBV-321
Sponsor: AbbVie
Not yet recruiting - verified July 2017

http://ift.tt/2vlzKbo

Dose Escalated Proton Beam Therapy or Photon Therapy for Esophageal Cancer

Condition: Esophageal Cancer
Interventions: Radiation: Proton Beam Therapy; Radiation: Photon Radiation Therapy; Drug: Chemotherapy
Sponsor: University of Florida
Not yet recruiting - verified July 2017

http://ift.tt/2wdKhSx

Determination of Efficacy, Safety and Tolerability of AG013 in Oral Mucositis Compared to Placebo When Administered Three Times Per Day

Condition: Oral Mucositis
Interventions: Biological: AG013; Other: Placebo
Sponsor: Oragenics, Inc.
Recruiting - verified July 2017

http://ift.tt/2vlIP41

Büschelartige Hämangiome („tufted angiomas“) im Kopf-Hals-Bereich

Zusammenfassung

Hintergrund

„Tufted angiomas" (TA, büschelartige Hämangiome) sind seltene, gutartige, vaskuläre Tumoren, die meist in der Kutis und Subkutis lokalisiert sind, während der Kindheit auftreten und langsam größenprogredient sind. TA stellen eine Unterform des lobulären, kapillären Hämangioms dar. Dies ist die erste Studie, die einen Überblick über aktuelle Literatur und einen klinischen Erfahrungsbericht zu dieser seltenen Entität im Kopf-Hals-Bereich mit nichtdermatologischer Manifestation darbietet.

Methodik

Es erfolgte eine selektive Literaturrecherche über MEDLINE und Google Scholar. Zusätzlich führten die Autoren eine ICD-10-basierte Datenbankrecherche (SAP) zu Hämangiomen (D18.0) an einer der größten Universitätskliniken Europas durch.

Ergebnisse

Es wurden 13 Publikationen mit 16 Fällen eines TA im Kopf-Hals-Bereich identifiziert. Männer waren mit 70,6 % am häufigsten von TA betroffen. Das mittlere Patientenalter zum Zeitpunkt der operativen Entfernung des Tumors lag bei 31,5 Jahren; die mittlere Größe der Raumforderungen lag bei 16,3 mm. Die Autoren berichten zusätzlich über ein intraorbitales TA eines männlichen Patienten, der sich mit Schwellung und Rötung des linken Oberlids vorstellte. Die Computertomographie zeigte einen linksseitigen suprabulbären Tumor mit einem Durchmesser von 13 mm. Der Tumor wurde in Vollnarkose via Blepharoplastik-Zugang transkutan exzidiert. Die Heilung verlief ohne Komplikationen.

Diskussion

Bisher wurde lediglich ein Fallbericht über die operative Entfernung eines intraorbitalen TA publiziert. Die vorliegende Arbeit gibt einen Überblick über Epidemiologie, therapeutische Möglichkeiten und Differenzialdiagnosen.

http://ift.tt/2uQprsQ

A Clinicopathologic Study of Head and Neck Malignant Peripheral Nerve Sheath Tumors

Abstract

Head and neck high grade malignant peripheral nerve sheath tumors (HN-MPNSTs) are rare highly aggressive soft tissue sarcomas that show overlapping morphologic and immunophenotypic features with melanoma and other high grade sarcomas, resulting in diagnostic challenges, particularly in sporadic settings. Recent discoveries have implicated loss of function mutations in the polycomb repressive complex 2 (PRC2) components, including EED or SUZ12 genes, as one of the leading pathogenetic mechanisms in high grade MPNST. MPNSTs with PRC2 loss are associated with complete loss of trimethylation at lysine 27 of histone H3 (H3K27me3), which emerged as a reliable immunohistochemical marker in the diagnosis of sporadic and radiation induced MPNST. As the diagnosis of MPNST in the HN is particularly challenging to distinguish from melanoma and other sarcoma types, we carried out a clinicopathologic analysis on HN-MPNST patients managed at our institution over a 20-year period (1997–2016), using the latest diagnostic criteria including H3K27me3 staining and other molecular investigations. The overall survival of HN-MPNST was compared with other HN soft tissue sarcomas. The diagnosis of HN-MPNST was confirmed in 13 patients (seven males and six females), with a mean age of 31 years; with 3 (23%) patients being of pediatric age. The most common site was the neck soft tissue (77%). Two-thirds of patients (n = 9) had stigmata of NF1, three had prior radiotherapy and only one developed a de novo MPNST. All except one tumor (86%) tested showed loss of H3K27me3 expression, including all non-NF1 patients. The 2 and 5-year DSS rates were 50 and 30%. The 2-year DFS rate was 21%. Adverse predictors on DSS included adult age (p = 0.011), prior-history of RT (p = 0.003) and recurrence (p = 0.003). Compared to other molecularly confirmed subsets of HN sarcomas (Ewing and Ewing-like sarcoma, rhabdomyosarcoma and synovial sarcoma), HN-MPNST had the worst overall survival (p < 0.0001). We conclude that HN-MPNSTs are highly aggressive sarcomas associated with an unfavorable outcome and the utility of H3K27me3 IHC stains in the evaluation of MPNST is a reliable ancillary diagnostic adjunct.

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A Clinicopathologic Study of Head and Neck Malignant Peripheral Nerve Sheath Tumors

Abstract

http://ift.tt/2tQFJAN

A Clinicopathologic Study of Head and Neck Malignant Peripheral Nerve Sheath Tumors

Abstract

http://ift.tt/2tQFJAN

Paraneoplastic pemphigus seen in 4 patients with hematologic malignancies formerly treated with rituximab

Abstract

Paraneoplastic pemphigus (PNP) is a peculiar variant of pemphigus with pathognomonic clinical, histological, and immunological features. It is typically associated with hematologic malignancies (84%), such as non-Hodgkin lymphomas (NHL) (most common), chronic lymphocytic leukemia (CLL), Castleman disease, thymoma, Waldenström's macroglobulinemia, Hodgkin lymphoma, and monoclonal gammopathy, as well as non-hematological neoplasms, such as epithelial carcinomas, mesenchymal sarcomas, and malignant melanoma.

http://ift.tt/2veBgeB

Hospitalization and outcomes attributed to epidermal necrolysis in United States: Predictors of Mortality

Abstract

Acute life-threatening mucocutaneous reactions characterized by extensive necrosis and detachment of the epidermis(epidermal necrolysis,EN) includes the spectrum of Stevens-Johnson syndrome (SJS, <10% body surface area), Toxic epidermal necrolysis (TEN, >20% BSA) and the SJS-TEN overlap(10-20%BSA). Prior older studies have revealed that the incidence of these rare conditions was estimated to be 1 to 6 cases per million person-years for SJS and 0.4 to 1.2 cases per million person-years for TEN. Current, large population based hospitalization outcomes attributed to EN in United States are lacking.

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Erforschung des Hautmikrobioms

http://ift.tt/2wdhhu0

Fütter‑, Ess- und Schluckstörungen bei Säuglingen und Kindern

Zusammenfassung

Essen und Schlucken sind dynamische Prozesse, an denen mehr als 30 Muskeln in Koordination der orofazialen Muskulatur sowie der Muskulatur des Rachens, des Kehlkopfs und der Speiseröhre beteiligt sind. Saug‑, Such- und Würgreflex des Neugeborenen und des Säuglings verändern/differenzieren sich mit zunehmendem Alter, sodass der Ess‑, Kau- und Schluckvorgang beim Kleinkind differenziert und willentlich möglich sind. Ess‑, Fütter- und Schluckstörungen sind im Säuglings- und Kleinkindalter häufig schwierig zu unterscheiden. Essstörungen umfassen Nahrungsverweigerung, inadäquate Essgewohnheiten, Verhaltensauffälligkeiten bei der Nahrungsaufnahme, selektive und/oder einseitige Nahrungspräferenzen. Schluckstörungen beschreiben eine Beeinträchtigung der oralen, pharyngealen sowie ösophagealen Phase; alle oder einzelne Phasen können betroffen sein. Ursachen sind Verhaltens- oder Entwicklungsstörungen, Syndrome, neurologische Erkrankungen, Erkrankungen der Atemwege und/oder Ösophagitiden (mit oder ohne gastroösophagealen Reflux, eosinophile Ösophagitis) oder anatomische Fehlbildungen der oberen Speisewege. Ess‑/Schluckbeschwerden werden bei bis zu 25 % aller Kinder beschrieben; circa 40 % der frühgeborenen Kinder, bis zu 64–78 % der entwicklungsauffälligen Kinder und bis zu 99 % der Kinder mit schweren Zerebralparesen zeigen Schluckstörungen.

Die Diagnostik der Ess‑/Schluckstörung beinhaltet einen multifaktoriellen Ansatz. Die Anamnese erfasst das soziale Umfeld, die Eltern-Kind-Interaktion und die elterlichen Sorgen, die körperliche Untersuchung den aktuellen Gesundheitszustand mit Bestimmung von Gewicht, Körpergröße und Kopfumfang sowie eine ausführliche HNO-ärztliche-Diagnostik. Klinische Füttersituationen können Teil der Kindesbeobachtung sein oder Videoaufnahmen von dem Kind beim Füttern/Essen die Diagnostik ergänzen. Zur Beurteilung schluckdynamischer Prozesse sind die Videofluoroskopie und die fiberoptische Diagnostik des Schluckens (FEES) möglich. Bei sehr jungen Kindern ist die standardisierte FEES selten aussagekräftig, stattdessen sollte eine fiberoptische-endoskopische Schluckuntersuchung (FESU) mit „Leeraufnahme" und Videoaufnahme nach dem Schluckversuch erfolgen.

Die Therapie beginnt mit der Empfehlung einer angenehmen Fütterumgebung, von Hilfsmitteln (spezielle Löffel etc.) beim Essen, Kostform/Konsistenz, Körperhaltung beim Essen, alternativen/additiven Ernährungsmethoden (Gastrostomien, Nasogastralsonden) sowie orofazialen Stimulationsverfahren und Kompensationsverfahren bei kooperativen älteren Kindern.

Ein interdisziplinäres Team ist die Basis für eine umfassende Diagnostik und Therapieplanung.

http://ift.tt/2uPI3cH

Vulvar lymphangioma circumscriptum: comparison of primary and acquired forms in a cohort of 57 patients

Abstract

Lymphedema, a rare debilitating disorder usually involving limbs. For lymphedema involving the genitalia, its terminology remains imprecise and not consensual. So, lymphangiectasia simply means dilatation of lymphatic vessels.

http://ift.tt/2vamOoB

Noodle pattern: A new dermoscopic pattern for crusted scabies (Norwegian scabies)

Abstract

A 36-year-old female patient with HIV infection and poor treatment adherence was seen due to a skin rash that was affecting mainly her trunk and extremities. Lesions consisted of non-pruriginous papules, hyperkeratotic plaques, and desquamation (Fig 1). Upon dermoscopic examination (10x, DermLite DL3N, San Juan Capistrano, CA, USA), the lesions exhibited a hyperkeratotic appearance, and the centre was composed of several burrows on top of each other in a noodle-like pattern.

http://ift.tt/2uPRbxS

Risk of aortic aneurysm in patients with psoriasis: a retrospective cohort study

Abstract

Psoriasis has been associated with cardiovascular disease and major adverse cardiovascular events. Studies suggests that the overexpression of inflammatory mediators contribute to the shared pathogenesis of psoriasis and atherosclerotic changes. Moreover, the aberrant inflammation in psoriasis may cause aortic injury, ultimately predisposing patients to develop an aortic aneurysm (AA).

http://ift.tt/2vaoI8t

Atopic dermatitis is associated with autoimmune but not with cardiovascular comorbidities in a random sample of the general population in Leipzig, Germany

Abstract

Atopic dermatitis (AD) was recently reported to be associated with multiple non-atopic comorbidities [1-4], especially of autoimmune or cardiovascular type. This co-occurrence was related to several immune mechanism of AD being shared with other immune-mediated diseases [2], as well as to chronic inflammation and life style factors [5].

http://ift.tt/2uPtUfw

Thermal injury caused by the explosion of a lithium-ion mobile phone battery

Abstract

Mobile phones are part of everyday life. They are generally considered safe for our health, but they may sometimes elicit contact dermatitis, especially due to metals. Furthermore they are under investigation for being involved in the development of defective testicular function and gliomas.

http://ift.tt/2vadTTK

Anti-epileptic drugs induce cutaneous lymphocyte-associated antigen down-regulation leading to potential human Herpes Virus-7 reactivation in clinically asymptomatic patients

Abstract

Anti-epileptic drugs (AED) are known to cause cutaneous adverse drug-induced reactions. The pathogenesis of these drug-induced reactions remains poorly understood. In our previous multicenter prospective study, we evidenced reactivation of Epstein-Barr Virus (EBV), Human Herpes Virus 6 (HHV-6) and/or Human Herpes Virus 7 (HHV-7) in 76% of Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) patients. As a consequence of this increased viral antigen exposure, EBV-specific CD8+ T lymphocytes that expressed high levels of Cutaneous Lymphocyte-associated Antigen (CLA) homing markers of skin were found both in blood and in involved organs including skin.

http://ift.tt/2uPEjrz

Comparison of two picosecond lasers to a nanosecond laser for treating tattoos: a prospective randomized study on 49 patients

Abstract

Background

Q-switched nanosecond lasers demonstrated their efficacy in treating most types of tattoos but complete disappearance is not always achieved even after performing numerous laser sessions. Picosecond lasers are supposed to be more efficient in clearing tattoos than nanosecond lasers but prospective comparative data remain limited.

Objective

To compare on different types of tattoos the efficacy of a nanosecond laser with two types of picosecond lasers.

Methods

We conducted a prospective randomized study performed from December 2014 to June 2016 on adult patients with all types of tattoos. The tattoos were divided into two halves of equal size. After randomization, half of the tattoo was treated with a picosecond laser and the other half with a nanosecond laser. The evaluation was performed on standardized pictures performed before treatment and 2 months after the last session, by two physicians, not involved in the treatment, blinded on the type of treatments received. The main end point was a clearance above 75% of the tattoos.

Results

A total of 49 patients were included. Professional tattoos represented 85.7%, Permanent makeup 8.2% and non-professional tattoo 6.1%. The majority were black or blue and 10.2% were polychromatic. No patient was lost during follow-up. A reduction of 75% or more of the color intensity was obtained for 33% of the tattoos treated with the picosecond lasers compared to 14% with the nanosecond laser (p=0.008). An improvement superior to 75% was obtained in 34% monochromic black or blue tattoos with the picosecond lasers compared to 9% for the nanosecond laser. Only 1 of the 5 polychromic tattoos achieved more than 75% of improvement with the two types of laser.

Conclusion

Our results show a statistically significant superiority of the picosecond lasers compared to the nanosecond laser for tattoo clearance. However, they don't show better efficacy for polychromic tattoos and the difference in terms of side effects were also minimal with a tendency of picosecond lasers to be less painful.

http://ift.tt/2vaEwIx

Αρχειοθήκη ιστολογίου

Δευτέρα 31 Ιουλίου 2017

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