Head and Neck Medicine by Alexandros G.Sfakianakis: 08/16/17

Τετάρτη 16 Αυγούστου 2017

Morbidity and mortality in children undergoing bronchoscopy for foreign body removal

Objectives/Hypothesis

Analyze morbidity and mortality among children undergoing bronchoscopy for foreign body removal.

Study Design

Multicenter retrospective review using the American College of Surgeons Pediatric National Surgical Quality Improvement Program from 2014 and 2015.

Methods

Patients were identified using Current Procedural Terminology code 31635. Demographics, time to surgery, operative times, hospitalization time, and complications were collected. Multivariate logistic regression was used to identify predictive factors for major adverse events.

Results

Three hundred thirty-four patients were included (mean age 3.7 years, 59.0% male). Preoperative sepsis syndrome was present in 5.7% of patients and 8.1% had asthma. Of the patients, 5.1% percent of patients had a tracheostomy. Bronchoscopy was performed by an otolaryngologist (65.4%) or a pediatric surgeon (33.1%). Mean operative time was 27.4 minutes, whereas mean total operating room time was 54.6 minutes. Airway foreign bodies were located in 269 patients (80.5%), with 62.5% being located in the mainstem bronchus. Operative time was longer when foreign bodies were in the mainstem bronchus or distal to it. Mean time to surgery from admission was 0 days, and mean duration of hospitalization was 1 day. One patient (0.3%) required reoperation for respiratory reasons, and three (0.9%) required readmission for related reasons. No patients remained hospitalized at 30 days. Two (0.6%) had a postoperative pneumonia, and two (0.6%) required reintubation. One patient death (0.3%) occurred within 2 weeks of bronchoscopy. No significant differences were identified in operative time, time to surgery, or hospitalization time based on age, gender, presence of a tracheostomy, or surgical specialty.

Conclusions

Bronchoscopy for identification and removal of airway foreign bodies had minimal morbidity in this group.

Level of Evidence

2b Laryngoscope, 2017

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Myxofibrosarcoma in Head and Neck: Case Report of Unusually Aggressive Presentation

Publication date: Available online 16 August 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Anastasiya Quimby, Abigail Estelle, Arun Gopinath, Rui Fernandes
Myxofibrosarcoma (MFS) is a malignant fibroblastic tumor that primarily affects lower and upper extremities. It is usually described as a slow growing tumor with high recurrence rates but low metastatic potential. Reported incidence of head and neck MFS is 2-4% rarely presenting with distant metastases[1, 2]. We present a case of maxillary MFS in a 72-year-old woman whose disease progression followed an atypical course with an extremely rapid rate of growth and early pulmonary and central nervous system lesions. Due to pulmonary symptoms as initial presentation, arriving at a final diagnosis was a challenge. Various diagnostic modalities and multidisciplinary collaboration were required. The disease course and management are outlined. To our knowledge, this is the first case of MFS originating in the maxillary alveolus with multiple metastases including brain and lungs in the early course of the disease.

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Health Policy Research May Ensure the Future of Oral and Maxillofacial Surgery

Publication date: Available online 16 August 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Nisarg A. Patel, Yisi D. Ji, Thomas B. Dodson, R. Bruce Donoff

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African-Americans in Oral and Maxillofacial Surgery: Factors Affecting Career Choice, Satisfaction and Practice Patterns

Publication date: Available online 12 August 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Thalia-Rae Criddle, Newton C. Gordon, George Blakey, R. Bryan Bell
IntroductionThere is little data available on experience of minority surgeons in the field of oral and maxillofacial surgery(OMS). Therefore, the purpose of this study is to: 1) explore factors that contribute to African-Americans choosing OMS as a career; 2) examine satisfaction among minority oral and maxillofacial surgeons with the residency application and training process; 3) report on practice patterns amongst minority oral and maxillofacial surgeons; and 4) to identify perceived bias for or against minority oral and maxillofacial surgeons in attempt to aid the efforts of OMS residency organizations to foster diversity.MethodsA 19-item survey was sent to 80 OMS practitioners using information from the National Society of Oral and Maxillofacial Surgeons, an AAOMS affiliated organization, mailing list. All surveys were sent by mail and were followed by a reminder mailing after eight weeks. Responses returned within 16 weeks were accepted for analysis.ResultsOf the 80 mailed surveys, 41 returned within the 16-week parameters representing a return rate of 51%. The majority of minority surgeon respondents were married males with a mean age of 60 who work as private practitioners. Most respondents practice on the eastern and western coasts of the United States. Exposure in dental school was the most important factor in selecting OMS as a specialty. Location and prestige were the most important factors in selecting a residency program. Most respondents reported that race did not affect the success of their application to residency and does not currently affect the success of their practice. However, 25-46% of participants experienced race-related harassment and 48-55% of participants feel there is a bias against African-Americans in OMS.ConclusionsOur data suggests that a significant number of minority oral and maxillofacial surgeons subjectively perceive race-based bias in their career, although it does not appear to affect professional success.

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Giant pilomatrix carcinoma of the face

Publication date: Available online 12 August 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Sapna Lohiya, Yeshwant B. Rawal, Jasjit K. Dillon
This case report describes an unusually large facial pilomatrix carcinoma (PC) in a 60-year-old man. This PC had been growing slowly for 11 months and had recently ulcerated. It measured 9cm x 7cm x 5cm. An initial punch biopsy was inconclusive. The tumor was excised in total with 5mm margins in a supra-superficial musculoaponeurotic system (SMAS) plane. The defect was reconstructed with a cervicofacial bilobed rotational advancement flap. Histopathology confirmed the diagnosis of PC. There was no lymph node spread or distant metastasis. The patient recovered with a good esthetic result. This case represents one of the largest facial PCs reported in literature. Diagnostic challenges are discussed and literature is reviewed.

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Histochemical and immunohistochemical examination of odontoblasts (petroblasts) in petrodentine formation of lungfish

Publication date: November 2017
Source:Archives of Oral Biology, Volume 83
Author(s): Shunya Oka, Ichiro Sasagawa, Mikio Ishiyama
ObjectivePetrodentine, the core of the lungfish tooth plate, is a well-mineralized tissue similar to mammalian enamel and analogous to enameloid in fish teeth. Petrodentine is formed solely by petroblasts, which are specialized odontoblasts, whereas enameloid is a composite tissue produced by both odontoblasts and dental epithelial cells. To clarify the details of petrodentine formation, petroblasts were investigated using histochemical and immunohistochemical techniques.MethodsExtant lungfish (Lepidosiren paradoxa) were used in this study. Tooth plates during the stage of petrodentine formation were observed by means of histochemistry and immunohistochemistry. Commercial kits were used to detect enzyme activity. Correlative sections were immunostained using antibodies against selected peptides. Routine staining such as periodic acid-Schiff (PAS) reaction to identify glycogen and Elastica van Gieson staining for the detection of elastic fibers in histological sections were performed. In addition, conventional transmission electron microscopy was used for observing the fine structure.ResultsPetroblasts showed marked acid and alkaline phosphatase activities, and positive immunoreactivities against anti-nestin, anti-V-ATPase, and anti-Ca²⁺-ATPase, during the maturation stage, but in the matrix formation stage, reactions were much weaker than that of the maturation stage. During the maturation stage, petroblasts showed intense PAS reactivity, and glycogen particles were observed in petroblasts by transmission electron microscopy. Glucose transporter 1-immunoreactivity was observed in petroblasts in the matrix formation stage and the initial to mid part of the maturation stage.ConclusionsThe results in this study suggested that petroblasts have two functional stages, matrix formation and maturation, and glycogen plays an important role in the modulation of petroblasts.

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Diabetes increases interleukin-17 levels in periapical, hepatic, and renal tissues in rats

Publication date: November 2017
Source:Archives of Oral Biology, Volume 83
Author(s): Mariane Maffei Azuma, João Eduardo Gomes-Filho, Annelise Katrine Carrara Prieto, Renata Oliveira Samuel, Valéria Marçal Felix de Lima, Dóris Hissako Sumida, Edilson Ervolino, Luciano Tavares Angelo Cintra
ObjectivesThis study aimed to evaluate the association between endodontic infection and diabetes on interleukin-17 levels in periapical, hepatic, and renal tissues of rats.DesignForty male rats were divided into groups: normoglycemic rats (N), normoglycemic rats with apical periodontitis (N-AP), rats with experimental diabetes (ED), and rats with experimental diabetes and apical periodontitis (ED-AP). Diabetes was induced by intravenous streptozotocin injection, and blood sugar levels were monitored to confirm disease development. Apical periodontitis (AP) was induced by pulp exposure to the oral environment during 30days. After 30days, hepatic and renal tissues were obtained, and IL-17 levels were quantified by ELISA. The right hemi-jaw was used to quantify IL-17 levels by immunohistochemistry. The values obtained in parametric tests were tabulated and analyzed statistically by analysis of variance (ANOVA) and Tukey tests, and the values obtained for scores were statistically analyzed by using the Kruskal-Wallis and Dun tests. The level of significance was set at 5%.ResultsED and ED-AP groups expressed significantly higher IL-17 levels in both hepatic and renal tissues (p<0.05), compared to N and N-AP groups. Apical periodontitis (AP) in ED-AP group was significantly more severe than that in N-AP group (p<0.05). Furthermore, there was a significantly larger increase in the IL-17 levels in ED-AP group compared to N group (p<0.05).ConclusionOur results indicate that diabetes increases IL-17 levels in hepatic and renal tissues and also enhances IL-17 production in apical periodontitis area of rats.

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Histochemical and immunohistochemical examination of odontoblasts (petroblasts) in petrodentine formation of lungfish

Diabetes increases interleukin-17 levels in periapical, hepatic, and renal tissues in rats

A systematic review of molecular responses to cancer therapy in normal human mucosa

Publication date: Available online 15 August 2017
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Mette Marcussen, Conni Skrubbeltrang, Julie Støve Bødker, Ilse Christiansen, Martin Bøgsted, Karen Dybkær, Olav Jonas Bergmann, Hans Erik Johnsen
ObjectiveCancer therapy-induced inflammation of oral and gastrointestinal mucosa affects patients non-uniformly. Preventive strategies are limited; no biomarker exists for pretreatment identification of patients likely to be severely affected. Animal models are preferred for studying molecular responses in mucosa during chemotherapy, but translation into clinical practice is difficult. We performed a systematic review to retrieve papers that described molecular changes in human mucosa during cancer therapy.Study DesignWe searched MEDLINE and Ovid Embase searches for English-language literature from January 1990 to November 2016 and studies referenced in selected papers, that analyzed human mucosa from patients at risk of developing mucositis during cancer therapy. Two authors extracted data according to predefined data fields, including study quality indicators.ResultsWe identified 17 human studies on chemotherapy (n=9) and radiotherapy (n=8), but no targeted therapy studies. Studies were heterogeneous regarding patient cohort, analysis methods, cancer treatment, biopsy timing, and correlations to clinical mucositis. Consequently, meta-analysis was not feasible.ConclusionsFew human studies described the molecular responses of normal mucosa to cancer therapy. Studies were heterogeneous with sparse correlations to clinical mucositis. We proposed a model for acquiring data on treatment- and disease-specific phenotypes and transcriptomes for predictive or preventive initiatives.

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Atypical presentation of anti-N-methyl-D-aspartate receptor encephalitis: two case reports

Anti-N-methyl-D-aspartate receptor encephalitis is a rare autoimmune disease characterized by severe neurological and psychiatric symptoms and a difficult diagnosis.

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Wilms tumor screening in diffuse capillary malformation with overgrowth and macrocephaly–capillary malformation: A retrospective study

CLOVES (congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal anomalies) syndrome is associated with regional bony and/or soft tissue overgrowth, capillary malformation, and an increased risk for Wilms tumor.

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Facilitation and Debriefing in Simulation Education

Successful simulation requires effective facilitation and debriefing to achieve educational goals. Simulation educational methods are diverse, ranging from partial task training to complicated, interdisciplinary team training. Various debriefing models have emerged based on method of instruction, learner experience, time and equipment capability, and physical facilities. The general structure of most debriefing sessions focuses on participant reactions, followed by analysis, and ending with a discussion of lessons learned. Two leading debriefing models, the Structured and Supported Debriefing Model and the Debriefing with Good Judgment Model, are described in further detail.

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Otologic Skills Training

This article presents a summary of the current simulation training for otologic skills. There is a wide variety of educational approaches, assessment tools, and simulators in use, including simple low-cost task trainers to complex computer-based virtual reality systems. A systematic approach to otologic skills training using adult learning theory concepts, such as repeated and distributed practice, self-directed learning, and mastery learning, is necessary for these educational interventions to be effective. Future directions include development of measures of performance to assess efficacy of simulation training interventions and, for complex procedures, improvement in fidelity based on educational goals.

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Improving Rhinology Skills with Simulation

The convergence of technology and medicine has led to many advances in surgical training. Novel surgical simulators have led to significantly improved skills of graduating surgeons, leading to decreased time to proficiency, improved efficiency, decreased errors, and improvement in patient safety. Endoscopic sinus surgery poses a steep learning curve given the complex 3-dimensional anatomy of the nasal and paranasal cavities, and the necessary visual-spatial motor skills and bimanual dexterity. This article focuses on surgical simulation in rhinological training and how innovative high-fidelity and low-fidelity simulators can maximize resident training and improve procedural skills before operating in the live environment.

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Dentoskeletal parameters related to visual perception of facial asymmetry in patients with skeletal class III malocclusion after orthognathic surgery

The purpose of the study is to explore the critical parameters determining the visual perception of postoperative facial symmetry. This study retrospectively included 24 patients with skeletal class III malocclusion and double-jaw orthognathic surgery (OgS). The patients were classified according to the outcome of subjective visual perception scores (SVPS) based on the postoperative frontal images by 10 orthodontists: symmetrical surgical outcome (S group, n=12) and facial asymmetry after surgery (A group, n=12).

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Precise osteotomies for mandibular distraction in infants with Robin sequence using virtual surgical planning

Mandibular distraction osteogenesis (MDO) has become the first-line operation in many centers for the management of obstructive sleep apnea (OSA) in infants with (Pierre) Robin sequence (RS) not relieved by non-surgical approaches. Preoperative virtual surgical planning (VSP) may improve precision and decrease complications for this operation. This article reports a retrospective study of RS infants who underwent MDO for OSA using preoperative VSP and three-dimensionally printed cutting guides performed by one surgeon.

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The value of cone beam computed tomography in the detection of salivary stones prior to sialendoscopy

This study aimed to assess the value of cone beam computed tomography (CBCT) in the detection of salivary stones in patients with signs and symptoms of salivary gland obstruction. A total of 142 major salivary glands were analysed in a cohort of 127 patients with signs and symptoms of salivary gland obstruction. CBCT scans were performed in order to determine the presence of one or more salivary stones. All glands were also investigated by sialendoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for the submandibular gland, the parotid gland, and the whole group, based on the observers' abilities to diagnose the presence or absence of calculi in the CBCT scan using the sialendoscopy data as the gold standard.

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Signs of disease occur in the majority of third molars in an adult population

The purpose of this study was to assess clinical and radiographic signs of disease in third molars within a population that is representative of the Finnish adult population aged 30 years and older. A two-stage stratified cluster sampling method was used to collect the 6005 subjects, who were examined clinically and also by panoramic radiography. The state of impaction, presence of dentinal caries and/or restorations, presence of root canal fillings, periodontal pocket depth, and additional pathological findings such as over-eruption and widened follicle were assessed.

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Cirugía radioguiada en el hiperparatiroidismo primario: resultados y correlación con el diagnóstico anatomopatológico intraoperatorio

Publication date: Available online 12 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Juan P. Suárez, María L. Domínguez, Francisco J. de Santos, José M. González, Nuria Fernández, Fidel J. Enciso
Introducción y objetivosLa cirugía radioguiada es una técnica de tratamiento quirúrgico mínimamente invasivo del hiperparatiroidismo primario. Los objetivos de este estudio fueron estudiar el porcentaje de éxito de esta técnica y realizar una comparación de la misma con el estudio histológico intraoperatorio.MétodosEstudiamos retrospectivamente a 84 pacientes con hiperparatirodismo primario con gammagrafía paratiroidea positiva. Se administró una dosis de Tc-99m sestamibi previa a la cirugía y se utilizó una sonda gammadetectora intraoperatoria para detectar el tejido paratiroideo anómalo, siguiendo la «regla del 20%». En todos los casos se realizó estudio anatomopatológico intraoperatorio y seguimiento clínico y analítico durante al menos 6 meses. Asimismo, se comparó el valor predictivo positivo de la ecografía cervical respecto a la gammagrafía paratiroidea.ResultadosEl porcentaje de éxito de la cirugía radioguiada fue 99%. La sonda gammadetectora intraoperatoria tuvo una sensibilidad, especificidad, valores predictivos positivo y negativo respecto al estudio histológico intraoperatorio de 99, 73, 97 y 89%, respectivamente. La calcemia se normalizó en 83 de 84 pacientes (99%) y la paratohormona se normalizó en 77 de los 84 pacientes (92%). La ecografía mostró un bajo valor predictivo positivo (41%) comparada con la gammagrafía.ConclusionesLa cirugía radioguiada es una técnica con excelentes resultados en el tratamiento quirúrgico mínimamente invasivo del hiperparatiroidismo primario y podría sustituir tanto al estudio anatomopatológico intraoperatorio como a la determinación intraoperatoria de paratohormona. Esta última posibilidad debe ser demostrada en futuros estudios.Introduction and objectivesRadioguided surgery is a minimally invasive surgical technique for the treatment of primary hyperparathyroidism. The goals of our study were to evaluate the rate of success and compare the results with intraoperative histological analysis.MethodsWe retrospectively studied 84 patients with primary parathyroidism who had undergone radioguided surgery. All the patients had a positive parathyroid scintigraphy prior to surgery. An intravenous injection of Tc-99m sestamibi was administered before surgery, and radioguided location of the pathologic parathyroid tissue was performed using an intraoperative gamma probe, applying the "20% rule". All resected specimens underwent intraoperative histologic analysis. All patients were followed up for at least 6 months. Positive predictive values of both parathyroid scintigraphy and cervical ultrasonography were also compared.ResultsRadioguided surgery success rate was 99%. Sensitivity, specificity, positive and negative predictive values for gamma probe were 99, 73, 97 and 89%, respectively. After surgery, 83 of 84 patients were eucalcaemic (99%) and parathyroid hormone normalised in 77 of 84 patients (92%). Ultrasonography showed low positive predictive value (41%) when compared with scintigraphy.ConclusionsRadioguided surgery is a minimally invasive surgical technique with excellent results for the treatment of primary hyperparathyroidism and could replace both intraoperative histological analysis and intraoperative parathyroid hormone assay. Further studies are needed to confirm these findings.

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Coverage of IVIG for Autoimmune Blistering Diseases by US Insurers

In this study, the authors examine coverage for IVIG to treat autoimmune blistering diseases by public and private insurers in the United States.

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Coalescing Subcutaneous Nodules

A man in his 40s presented with enlarging, nonpainful upper extremity nodules developing over the preceding 9 months; he was renovating a commercial cannabis grow house in California at time of onset and described the construction site as being filled with intoxicating mold. What is your diagnosis?

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Pathophysiology and Treatment Considerations for Erosive Pustular Dermatosis

In this issue of JAMA Dermatology, Mervak et al describe the rare condition of erosive pustular dermatosis (EPD) that presented in a series of patients after undergoing fully ablative carbon dioxide laser resurfacing or deep chemical peel. Several weeks to months after the procedure, the patients exhibited facial nonhealing erythematous plaques with overlying pustules, erosions, and yellow crust. Results of histologic and microbial work-up were nondiagnostic, which was consistent with EPD. Each patient experienced an arduous and lengthy healing regimen, as is expected with this difficult diagnosis. The authors conclude that tincture of time and reassurance in addition to antibiotics, anti-inflammatories, and immunomodulators are warranted in the treatment of EPD. In the wake of increasing demand for elective surgical treatments, this case series highlights an important and fortunately rare adverse effect of ablative procedures. This phenomenon begs the questions, Are these cases underreported? What is the pathophysiology of EPD? What other options exist for treatment?

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Pubic Hair Grooming Injuries and Identification of High-Risk Individuals

This cross-sectional study of US adults identifies demographic and behavioral risk factors associated with pubic hair grooming–related injuries to characterize individuals at high risk for injury and develop recommendations for safe grooming practices.

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Facial Erosive Pustular Dermatosis After Cosmetic Resurfacing

This case series describes 3 women who sustained nonhealing erosive pustular dermatosis on the face after undergoing ablative cosmetic procedures.

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Periodontal ligament-like Tissue Regeneration with Drilled Porous Decalcified Dentin Matrix Sheet Composite

Abstract

Objective

In this study, we constructed a composite by combining the human dental follicle cell sheet and a manual drilled porous decalcified dentin matrix that was used to construct ectopic tissue-engineered periodontal ligament-like tissues in renal capsules of nude mice.

Materials and Methods

Human dental follicle cells were harvested from human lower third molars and then embedded into a temperature-sensitive culture dish. These cells were then placed into frozen porous decalcified dentin matrix sheets and induced by 50 g/ml ascorbic acid. This established a "sandwich structure" in vitro implant that was placed in nude mice under the renal capsule. The mice were sacrificed at 4 weeks and 8 weeks after implantation, and the implants were assessed after haematoxylin-eosin staining, Masson staining and immunohistochemical staining.

Results

The experimental group showed a fibre structure between the dentin and HA-TCP after 4 weeks. After 8 weeks, the collagen fibres increased, and the direction was perpendicular to the dentin. Immunohistochemistry showed positive staining in the osteopontin and periostin.

Conclusion

The composite can induce ectopic bone and fibre formation, and the fibre had a certain directionality. Besides, the composite can maintain the stability of the periodontal ligament width.

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Proposed: Trial of Vitamin Derivative to Prevent Melanoma

The vitamin B3 derivative nicotinamide was previously shown to reduce nonmelanoma skin cancers in a phase 3 trial.
Medscape Medical News

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Cosentyx Highly Effective in Scalp Psoriasis

Reuters Health Information

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Continuing chronic beta-blockade in the acute phase of severe sepsis and septic shock is associated with decreased mortality rates up to 90 days

Abstract

Background. There is growing evidence that beta-blockade may reduce mortality in selected patients with sepsis. However, it is unclear if a pre-existing, chronic oral beta-blocker therapy should be continued or discontinued during the acute phase of severe sepsis and septic shock.Methods. The present secondary analysis of a prospective observational single centre trial compared patient and treatment characteristics, length of stay and mortality rates between adult patients with severe sepsis or septic shock, in whom chronic beta-blocker therapy was continued or discontinued, respectively. The acute phase was defined as the period ranging from two days before to three days after disease onset. Multivariable Cox regression analysis was performed to compare survival outcomes in patients with pre-existing chronic beta-blockade.Results. A total of 296 patients with severe sepsis or septic shock and pre-existing, chronic oral beta-blocker therapy were included. Chronic beta-blocker medication was discontinued during the acute phase of sepsis in 129 patients and continued in 167 patients. Continuation of beta-blocker therapy was significantly associated with decreased hospital (P=0.03), 28-day (P=0.04) and 90-day mortality rates (40.7% vs 52.7%; P=0.046) in contrast to beta-blocker cessation. The differences in survival functions were validated by a Log-rank test (P=0.01). Multivariable analysis identified the continuation of chronic beta-blocker therapy as an independent predictor of improved survival rates (HR = 0.67, 95%-CI (0.48, 0.95), P=0.03).Conclusions. Continuing pre-existing chronic beta-blockade might be associated with decreased mortality rates up to 90 days in septic patients.

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Epidemiology of sepsis and septic shock in critical care units: comparison between sepsis-2 and sepsis-3 populations using a national critical care database

Abstract

Background: New sepsis and septic shock definitions could change the epidemiology of sepsis because of differences in criteria. We therefore compared the sepsis populations identified by the old and new definitions.Methods: We used a high-quality, national, intensive care unit (ICU) database of 654 918 consecutive admissions to 189 adult ICUs in England, from January 2011 to December 2015. Primary outcome was acute hospital mortality. We compared old (Sepsis-2) and new (Sepsis-3) incidence, outcomes, trends in outcomes, and predictive validity of sepsis and septic shock populations.Results: From among 197 724 Sepsis-2 severe sepsis and 197 142 Sepsis-3 sepsis cases, we identified 153 257 Sepsis-2 septic shock and 39 262 Sepsis-3 septic shock cases. The extrapolated population incidence of Sepsis-3 sepsis and Sepsis-3 septic shock was 101.8 and 19.3 per 100 000 person-years, respectively, in 2015. Sepsis-2 severe sepsis and Sepsis-3 sepsis had similar incidence, similar mortality and showed significant risk-adjusted improvements in mortality over time. Sepsis-3 septic shock had a much higher Acute Physiology And Chronic Health Evaluation II (APACHE II) score, greater mortality and no risk-adjusted trends in mortality improvement compared with Sepsis-2 septic shock. ICU admissions identified either as Sepsis-3 sepsis or septic shock and as Sepsis-2 severe sepsis or septic shock had significantly greater risk-adjusted odds of death compared with non-sepsis admissions (P<0.001). The predictive validity was greatest for Sepsis-3 septic shock.Conclusions: In an ICU database, compared with Sepsis-2, Sepsis-3 identifies a similar sepsis population with 92% overlap and much smaller septic shock population with improved predictive validity.

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Frontal alpha-delta EEG does not preclude volitional response during anaesthesia: prospective cohort study of the isolated forearm technique

Abstract

Background: The isolated forearm test (IFT) is the gold standard test of connected consciousness (awareness of the environment) during anaesthesia. The frontal alpha-delta EEG pattern (seen in slow wave sleep) is widely held to indicate anaesthetic-induced unconsciousness. A priori we proposed that one responder with the frontal alpha-delta EEG pattern would falsify this concept.Methods: Frontal EEG was recorded in a subset of patients from three centres participating in an international multicentre study of IFT responsiveness following tracheal intubation. Raw EEG waveforms were analysed for power–frequency spectra, depth-of-anaesthesia indices, permutation entropy, slow wave activity saturation and alpha-delta amplitude-phase coupling.Results: Volitional responses to verbal command occurred in six out of 90 patients. Three responses occurred immediately following intubation in patients (from Sites 1 and 2) exhibiting an alpha-delta dominant (delta power >20 dB, alpha power >10 dB) EEG pattern. The power–frequency spectra obtained during these responses were similar to those of non-responders (P>0.05) at those sites. A further three responses occurred in (Site 3) patients not exhibiting the classic alpha-delta EEG pattern; these responses occurred later relative to intubation, and in patients had been co-administered ketamine and less volatile anaesthetic compared with Site 1 and 2 patients. None of the derived depth-of-anaesthesia indices could robustly discrimate IFT responders and non-responders.Conclusions: Connected consciousness can occur in the presence of the frontal alpha-delta EEG pattern during anaesthesia. Frontal EEG parameters do not readily discriminate volitional responsiveness (a marker of connected consciousness) and unresponsiveness during anaesthesia.Clinical trial registration: NCT02248623

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Prehabilitation

1I052A073J03

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Emerging Gene Therapies for Genetic Hearing Loss

Abstract

Gene therapy, or the treatment of human disease using genetic material, for inner ear dysfunction is coming of age. Recent progress in developing gene therapy treatments for genetic hearing loss has demonstrated tantalizing proof-of-principle in animal models. While successful translation of this progress into treatments for humans awaits, there is growing interest from patients, scientists, clinicians, and industry. Nonetheless, it is clear that a number of hurdles remain, and expectations for total restoration of auditory function should remain tempered until these challenges have been overcome. Here, we review progress, prospects, and challenges for gene therapy in the inner ear. We focus on technical aspects, including routes of gene delivery to the inner ear, choice of vectors, promoters, inner ear targets, therapeutic strategies, preliminary success stories, and points to consider for translating of these successes to the clinic.

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Emerging Gene Therapies for Genetic Hearing Loss

Abstract

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Aggressive haematological malignancies

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Assessing the ideal microwave duration for disinfection of sinus irrigation bottles- a quantitative study

Abstract

Objectives

Saline irrigation of the nasal cavity and paranasal sinuses by one-way valved sinus containers has a recognised role in the management of chronic rhinosinusitis. However, bacterial recontamination of irrigation bottles through backflow from the sinonasal cavity is a concern in recurrent sinus cavity infections. While patients are encouraged to clean the irrigation bottles regularly, there remains significant concern that the use of contaminated bottles may perpetuate chronic rhinosinusitis. This study assesses the optimal microwave duration to achieve decontamination for each irrigation bottle component part (reservoir, tube, and nozzle) using a standard, commercially available microwave. In addition, the irrigation fluid was also tested for contamination after each microwave cycle.

Study Design

Laboratory-based experimental study.

Participants

No patients were involved in this study.

Main outcome measures

The percentage in vitro decontamination of the bottles' components was determined following 30, 60, 90, 120, 150 seconds of microwave cycles.

Results

Complete decontamination of the bottles was not achieved at any of the tested microwave cycles. Levels of decontamination differed for the different bottle components and the greatest degree of decontamination for all bottle components occurred at 90 seconds. Although higher levels of decontamination were observed at microwave durations exceeding 90 seconds, this was at the expense of thermal degradation and deformation of the reservoir plastic component of the irrigation bottle. Similarly, lowest contamination of irrigation fluid was observed at 120 seconds.

Conclusions

This study highlights the importance of establishing precise decontamination procedures and recommends a microwave cycle of 90 seconds for optimal decontamination.

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Anaphylactoid Purpura Associated with Streptococcal Cellulitis: A Case Report and Literature Review

A 54-year-old Japanese man noticed painful swelling and redness of his left leg. He was admitted for treatment of cellulitis, which was accompanied with increased anti-streptolysin O and anti-streptokinase titers in his clinical course. After Piperacillin/Tazobactam administration, the skin lesion resolved. However, the patient then developed arthritis, palpable purpura, and intermittent abdominal pain, later found to be secondary to a severe duodenal ulcer. He was diagnosed with cellulitis-associated anaphylactoid purpura and was given prednisolone, which dramatically improved his symptoms. The anaphylactoid purpura was likely caused by Streptococcus-induced cellulitis, which was successfully treated with prednisolone. Association between these diseases is rare.

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External jugular veno-accompanying artery adipofascial flap: A novel and convenient flap for head and neck reconstruction

Abstract

Background

The veno-accompanying artery adipofascial (VAF) flap is nourished by accompanying vessels near large superficial veins. We examined whether the VAF flap can be applied to the external jugular vein.

Methods

Based on anatomic and angiographic studies, we performed reconstructive surgeries using external jugular veno-accompanying artery adipofascial (EJ-VAF) flaps. A retrospective chart review was performed for all patients who underwent this surgery.

Results

The presence of arteries accompanying the external jugular vein was confirmed. The presence of source arteries was also confirmed. These included the occipital, facial, and superior thyroid arteries. All patients had satisfactory outcomes, except for 1 patient who had partial necrosis, which was managed using conservative treatment.

Conclusion

Our anatomic and angiographic studies in this clinical series indicate that the EJ-VAF flap is a reliable and convenient flap. Thus, it is useful in reconstruction of small to medium head and neck defects.

http://ift.tt/2vDEJU2

Radiation and chemotherapy with no excessive toxicity in a patient with human papillomavirus-related tonsillar cancer and porphyria cutanea tarda: Case report and literature review

Abstract

Background

Porphyria is a condition of cutaneous photosensitivity. It is unclear if radiotherapy (RT) is safe in patients with porphyria.

Methods

We report a patient case with uncontrolled porphyria cutanea tarda treated with chemoradiation for p16-positive oropharyngeal cancer. Given the scarcity of data on this subject, we also conducted a literature review on the topic of radiation in patients with porphyria.

Results

The patient in our study did not experience any unusual acute or late toxicity, despite receiving a high dose of cutaneous radiation. We also found the majority of the literature supports the safe use of therapeutic radiation in patients with porphyria.

Conclusion

In this patient, and in the majority of the literature, radiation seems safe in patients with porphyria; however, there are few reports on the subject in the literature, therefore, caution is warranted.

http://ift.tt/2wPSttl

Patient education materials assessment tool for laryngectomy health information

Abstract

Background

The decision to undergo laryngectomy carries medical, social, and emotional consequences. This study evaluates the understandability and actionability of current laryngectomy information.

Methods

Laryngectomy-related educational materials from an online search were evaluated using the validated Patient Education Materials Assessment Tool (PEMAT). Reading difficulty was calculated using the Flesch-Kincaid Level, Flesch Reading Ease, Gunning-Fog Index (GFI), Coleman-Liau Index, Automated Readability Index, and Simple Measure of Gobbledygook (SMOG) score. Interrater agreement was assessed using Cohen's kappa. Pearson's correlation coefficient was used to determine the relationship among readability, understandability, and actionability.

Results

Forty-four articles were included. Interrater agreement was substantial (κ = 0.71). Mean understandability was 68.3% ± 17% and mean actionability was 66.3% ± 24%. Average reading difficulty exceeded the ability of an average American adult. There was a negative correlation between readability and understandability (R = −0.49; P < .05).

Conclusion

Most laryngectomy information is too difficult for the average person to read, understand, or act upon. Revisions may be warranted to benefit a larger readership.

http://ift.tt/2vDEHeS

Association between radioiodine treatment for thyroid cancer and risk of stroke

Abstract

Background

The purpose of this study was to evaluate the association between radioiodine (I-131) therapy for thyroid cancer and the risk of stroke in Taiwan.

Methods

A total of 10 104 of the patients aged 20 years or older, who were newly diagnosed with thyroid cancer during 2000-2010, were recruited and classified into 2 cohorts according to whether they received I-131 therapy through 1:1 propensity score matching. The cumulative Kaplan-Meier curves for the incidence of stroke in the 2 cohorts were compared using the log-rank test.

Results

After adjustment for age, sex, and comorbidities, the I-131 therapy group showed no significantly higher risk of ischemic stroke (adjusted HR [aHR] = 1.05; 95% confidence interval [CI] = 0.82-1.34) or hemorrhagic stroke (aHR = 1.06; 95% CI = 0.58-1.93) than did the non-I-131 therapy group.

Conclusion

The I-131 treatment for thyroid cancer did not increase the risk of stroke during 10-year follow-up.

http://ift.tt/2wQaE2b

Aggressive primär kutane B-Zell-Lymphome und neue EBV-positive Entitäten

Zusammenfassung

Zu den kutanen B‑Zell-Lymphomen mit intermediärer/schlechter Prognose werden das primär kutane diffus-großzellige B‑Zell-Lymphom (PCBLT), das Epstein-Barr-Virus (EBV)-positive diffus-großzellige B‑Zell-Lymphom, nicht weiter spezifiziert (EBV+ DLBCL, NOS) sowie das primär kutane intravaskuläre großzellige B‑Zell-Lymphom (PCIVLBL) gezählt. Eine Abgrenzung zu indolenten kutanen B‑Zell-Lymphomen ist sowohl klinisch als auch histologisch nicht immer einfach, aber vital für den Patienten. In den letzten Jahren wurden erhebliche Prognoseverbesserungen erzielt, insbesondere beim diffus-großzelligen B‑Zell-Lymphom durch den Einsatz von kombinierter Immuntherapie/Polychemotherapie wie R (Rituximab)-CHOP (Cyclophosphamid, Adriamycin, Oncovin, Prednison). Die Entscheidung für das therapeutische Vorgehen muss individuell getroffen werden, möglichst im Rahmen einer interdisziplinären Tumorkonferenz. Immunseneszenz spielt bei älteren Individuen mit EBV+ DLBCL, NOS eine Rolle in der Pathogenese. Die Prognose ist ungünstiger als die des EBV-negativen PCBLT, wobei dies insbesondere bei älteren Patienten zu beobachten ist. Bei einem Drittel der Patienten mit PCIVLBL kommt es im Verlauf zu einer systemischen Manifestation. Ein nodaler Befall ist eher selten. Die Symptome können je nach betroffenem Organsystem vielfältig sein. Aufgrund der Seltenheit der Erkrankung existieren keine evidenzbasierten Therapieempfehlungen. Das EBV-positive mukokutane Ulkus ist eine neue provisorische Kategorie in der aktuellen WHO-Klassifikation für lymphatische Neoplasien. Es wurde vom EBV+ DLBCL, NOS abgegrenzt aufgrund seines selbstlimitierenden Verlaufs und guten Ansprechens auf konservative Maßnahmen.

http://ift.tt/2i4klqa

Apatinib and Irinotecan Combination Treatment in Unresectable or Metastatic Esophageal Squamous Cell Carcinoma

Condition: Esophageal Squamous Cell Carcinoma
Interventions: Drug: Irinotecan; Drug: Apatinib
Sponsors: Peking University; Beijing Cancer Hospital
Recruiting - verified August 2017

http://ift.tt/2i5khq6

Appendicitis Caused by Primary Varicella Zoster Virus Infection in a Child with DiGeorge Syndrome

Introduction. Chickenpox is caused by varicella zoster virus (VZV). Although predominantly a mild disease, it can cause considerable morbidity and in rare occasions even mortality in healthy children as well as increased morbidity and mortality in immunocompromised patients. The aetiology of appendicitis is largely unknown but is thought to be multifactorial. Appendicitis is a suspected, but not well documented, complication from varicella zoster virus infection. Case Presentation. A five-year-old girl diagnosed with DiGeorge syndrome and a prolonged primary VZV infection was admitted due to abdominal pain, increasing diarrhoea, vomiting, and poor general condition. She developed perforated appendicitis and an intraperitoneal abscess. VZV DNA was detected by PCR in two samples from the appendix and pus from the abdomen, respectively. The child was treated with acyclovir and antibiotics and the abscess was drained twice. She was discharged two weeks after referral with no sequela. Conclusion. Abdominal pain in children with viral infections can be a challenge, and appendicitis has to be considered as a complication to acute viral diseases, especially if the child is immunocompromised.

http://ift.tt/2w1csrv

The value of frontal sinusotomy for chronic rhinosinusitis with nasal polyps—A cost utility analysis

Objectives/Hypothesis

The number of surgical procedures performed for frontal sinusitis and the associated costs have increased dramatically over the past decade. The purpose of this study was to evaluate the cost-effectiveness of endoscopic frontal sinusotomy (EFS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).

Study Design

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

Methods

Matched cohorts of CRSwNP patients who underwent endoscopic sinus surgery (ESS) with (n = 139) and without (n = 49) EFS were compared to each other and to patients (n = 139) from the Medical Expenditures Survey Panel database who underwent medical management for chronic rhinosinusitis. Multi-year health utility values were calculated from responses to the EuroQol 5-Dimension instrument. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

Results

Decision analysis showed that ESS without EFS proved more cost-effective than ESS with EFS or medical management. ESS without EFS compared to medical management yielded an ICER of $9,004/quality-adjusted life year (QALY). ESS with EFS compared to ESS without EFS yielded an ICER of $62,310/QALY. At a willingness-to-pay (WTP) threshold of $50,000/QALY, ESS without EFS was more cost-effective than ESS with EFS with 52.1% certainty. These results were robust to one-way analysis and probabilistic sensitivity analysis.

Conclusions

ESS remains a cost-effective intervention compared to medical therapy alone for patients with CRSwNP. In this study, the addition of frontal sinusotomy during ESS for patients with CRSwNP was not found to be cost-effective at a WTP threshold of $50,000/QALY, but may be cost effective at a higher threshold of $100,000/QALY.

Level of Evidence

2C. Laryngoscope, 2017

http://ift.tt/2uHZ9wc

Partial inferior turbinectomy in rhinoseptoplasty has no effect in quality-of-life outcomes: A randomized clinical trial

Objective

Evaluate the impact of endoscopic partial inferior turbinectomy (EPIT) associated with primary rhinoseptoplasty on quality-of-life outcomes (QOL), complications, and surgical duration.

Study Design

Randomized clinical trial.

Methods

Individuals with nasal obstruction aged ≥ 16 years who were candidates for functional and aesthetics primary rhinoseptoplasty were evaluated from March 2014 through May 2015. Eligible participants were randomly allocated to rhinoseptoplasty with or without EPIT (excision of one-third of the inferior turbinates).

Results

Fifty patients were studied. Most were Caucasian and had moderate/severe allergic rhinitis symptoms. Mean age was 36 ( ± 14.5) years. Rhinoseptoplasty was associated with improvement in all QOL scores irrespective of turbinate intervention (P < 0.001). Analysis of covariance was conducted to control for potential confounders. There was no difference between the groups in absolute score changes for Nasal Obstruction Symptom Evaluation-Portuguese (NOSE-p) (−50.5 vs. −47.6; P = 0.723), Rhinoplasty Outcome Evaluation (ROE) (47 vs. 44.8; P = 0.742), and all World Health Organization Quality of Life Scale-Abbreviated (WHOQOL-bref) score domains (P > 0.05). There were no differences between the groups regarding presence of the complications. Surgical duration was higher in the EPIT group (212 minutes ± 7.8 vs. 159.1 ± 5.6; P ? 0.001).

Conclusions

Turbinate reduction through EPIT during primary rhinoseptoplasty did not improve short-term general and specific QOL outcomes. The use of EPIT increases surgical time considerably without improving QOL scores. There was no difference in postoperative incidence of complications, suggesting that EPIT is a safe technique.

Level of Evidence

1b. Laryngoscope, 2017

http://ift.tt/2v1wVrj

Predictors of complicated airway foreign body extraction

Objectives

To evaluate outcomes of foreign body aspiration (FBA) and to investigate surgeon and hospital volume as risk factors for a complicated course.

Study Design

Retrospective case series.

Methods

Children with FBA in a multihospital network were identified from January 2005 to September 2015. Demographic information, surgeon, and hospital location were reviewed. Mean operative time and hospital length of stay were recorded. Cases requiring intensive care unit admission, hospital stay greater than 24 hours, need for more than one bronchoscopy, operative time greater than 1 hour, or death were considered "complicated."

Results

A total of 450 cases of airway foreign body extraction were performed. Patient ages ranged from 0.6 to 18.8 years, with a median age of 1.9 years. Bronchoscopy with foreign body extraction was performed by 55 different surgeons at 11 different facilities. There were one to 24 surgeons for each facility, with an average number of 5.4 surgeons per facility. A total of 88 (19.6%) cases were considered complicated, including five (1.1%) deaths. Increased rates of complications were seen with unwitnessed aspiration (P = 0.008) and hyperlucency (P < 0.001) or infiltrates (P = 0.001) on chest radiographs. No significant association was found between surgeon type or facility as related to a complicated case.

Conclusions

Unwitnessed aspiration events and abnormalities on chest radiograph may be associated with a more complicated course in children with FBA. This multihospital study identified a low number of procedures by many surgeons; however, surgeon and hospital volume did not significantly correlate with higher complication rates.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2uI4qUh

Disparities in sinonasal squamous cell carcinoma short- and long-term outcomes: Analysis from the national cancer database

Objectives/Hypothesis

To examine sociodemographic, hospital-specific, and disease-related characteristics in relation to outcomes in sinonasal squamous cell carcinoma (SCC).

Study Design

The National Cancer Database was queried for location codes corresponding to the nasal cavity and paranasal sinuses and histology codes representing SCC malignancy. Multivariate analyses were performed against short- and long-term outcomes (overall survival, days to discharge, 30-day readmission, and 30- and 90-day mortality).

Results

The database included 5,584 sinonasal SCC patients with an overall median survival of 53.5 months (95% confidence interval [CI]: 49.7-57.8). On multivariate analysis, uninsured, Medicaid, and Medicare were independently associated with worse overall survival compared to private insurance (hazard ratio [HR]: 1.49, 95% CI: 1.22-1.82, P < .001; HR: 1.57, 95% CI: 1.34-1.85, P < .001; and HR: 1.14, 95% CI: 1.01-1.29, P = .03, respectively). Both Medicaid and Medicare were also associated with increased 30-day mortality (HR: 1.36, 95% CI: 1.76-143.29, P = .02; HR: 8.27, 95% CI: 1.66-70.88, P = .02, respectively), and Medicaid patients spent more time in the hospital following surgery (difference in days to discharge: HR: 2.09, 95% CI: 0.57-3.61, P < .01). Compared to white race, other race was associated with improved overall survival (HR: 0.79, 95% CI: 0.63-0.99, P = .04) but increased 30-day readmissions (HR: 3.85, 95% CI: 1.58-8.38, P < .01). Hispanic ethnicity was associated with increased 30-day readmissions (HR: 2.35, 95% CI: 1.08-4.75, P = .02]. The highest income bracket (≥$63,000) was associated with fewer hospital readmissions (HR: 0.33, 95% CI: 0.13-0.79, P = .01).

Conclusions

Sociodemographic and economic differences in outcomes of patients with sinonasal SCC cancer exist. An understanding of these differences may help minimize disparities in oncologic treatment.

Level of Evidence

2c. Laryngoscope, 2017

http://ift.tt/2v1f7wv

The cost of being clean: A cost analysis of nasopharyngoscope reprocessing techniques

Objective

Nasopharyngoscopes are an essential instrument to otolaryngologists; reprocessing them in a high-value manner is paramount. Although several different techniques for reprocessing exist, all methods yield similar effectiveness. Given equivalent effectiveness outcomes, a cost analysis of four nasopharyngoscope reprocessing techniques was performed.

Study Design

Cost-minimization analysis.

Methods

Four techniques were evaluated: 1) an automated reprocessor using peracetic acid (Steris System 1; Steris Canada Inc., Mississauga, Canada), 2) an automated reprocessor using ortho-phthalaldehyde (OPA) (Cidex OPA; Advanced Sterilization Products, Johnson and Johnson Inc., Markham, Canada), 3) a manually performed accelerated hydrogen peroxide bath (Revital-Ox; Steris Canada Inc.), and 4) a chlorine dioxide wipe (Tristel Trio Wipes System; Tristel plc, Cambridgeshire, U.K.). The costing perspective was a third-party payer that was adjusted to 2014 Canadian dollars. The base-case scenario used an annual volume of 4,153 reprocessing events in a tertiary care setting, and a scenario analysis assessed the impact of volume and capital expense.

Results

The cost per reprocessing event for the Steris (Steris Canada Inc.) automated endoscope reprocessing, Cidex OPA (Advanced Sterilization Products), Revital-Ox (Steris Canada Inc.), and Tristel Trio Wipes (Tristel plc) were $20.58, $14.20, $9.57, and $13.14, respectively. Scenario analysis demonstrated the Tristel Trio Wipes System (Tristel plc) was the least expensive method in practices with low reprocessing volumes (a threshold of less than 6 events per day, or 22 per week), whereas the Revital-Ox (Steris Canada Inc.) system was least expensive at higher volumes and became substantially more so as volumes increased.

Conclusion

A manual accelerated hydrogen peroxide bath offers the least costly approach to nasopharyngoscope reprocessing. The convenience and portability of the Tristel Trio (Tristel plc) system may be a good alternative for low reprocessing volumes, or when rapid turnaround is necessary.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2uIyFdV

Should infants who fail their newborn hearing screen undergo cytomegalovirus testing?

http://ift.tt/2v0SYyG

Factors associated with patient no-show rates in an academic otolaryngology practice

Objectives/Hypothesis

Factors affecting access to healthcare is an expanding area of research. This study seeks to identify factors associated with no-show rates in an academic otolaryngology practice to improve clinical efficiency and patient access to care.

Study Design

Retrospective review.

Methods

A retrospective review of scheduled clinical appointments from February 1, 2015 to January 30, 2016 at a single academic otolaryngology department was performed. Statistical analysis was completed to examine the association of no-show rates with the following: otolaryngology subspecialty, clinic location (e.g., main campus vs. satellite), patient demographic factors, attending seniority, temporal factors, insurance types, rurality, and visit type.

Results

There was an overall no-show rate of 20% for 22,759 scheduled clinic visits. Satellite clinics had the highest no-show rates at 25% (P < .001). New patient visits had the highest no-show rate at 24% (P < .001). Among subspecialties, facial plastic surgery had the lowest no-show rate (12.6%), whereas Pediatrics had the highest (23%) (P < .001). No significant association between gender and no-show rates was observed (P = .29), but patients over 60 years old had the lowest no-show rate (12.7%, P < .0001). Patients with Medicaid (28%), Medicare (15.3%), and commercial insurance (12.9%) had significantly different overall no-show rates (P < .0001).

Conclusions

Increased clinic no-show rates are associated with satellite clinics, new patient visits, younger age, and insurance type. No-show rates varied among subspecialties. Further investigation is warranted to assess barriers to appointment compliance and to develop interventions to improve access to care.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2uIlw4r

Long-Term Safety and Effectiveness of Adalimumab for Moderate to Severe Psoriasis: Results from 7-Year Interim Analysis of the ESPRIT Registry

Abstract

Introduction

ESPRIT (NCT00799877) is an ongoing 10-year international prospective observational registry evaluating the long-term safety and effectiveness of originator adalimumab in routine clinical practice for adult patients with chronic plaque psoriasis. Herein, we report the long-term safety, effectiveness, and patient-reported outcomes (PROs) following adalimumab treatment over the first 7 years of the ESPRIT registry.

Methods

All treatment-emergent (All-TE) adverse events (AE) since the initial (first ever) dose of adalimumab were assessed. Physician Global Assessment (PGA) and PROs (PROs for US patients only) were evaluated during registry participation.

Results

As of 30 November 2015, 6051 patients in the ESPRIT registry were analyzed, representing 23,660.1 patient-years (PY) of overall adalimumab exposure. The incidence rates for All-TE serious AEs, serious infections, and malignancies were 4.4, 1.0, and 1.0 events per 100 PY (E/100PY), respectively. The standardized mortality ratio for TE deaths in the registry was 0.27 (95% CI 0.18–0.38). During the registry's first 7 years, PGA "clear" or "minimal" was achieved by >50% of patients at each annual visit, and among US patients, the mean improvement from baseline in different PROs was maintained.

Conclusion

No new safety signals were identified during the first 7 years of the registry, and safety was consistent with the known safety profile of adalimumab. The number of TE deaths was below the expected rate. During the registry's first 7 years, most of the patients remained free of All-TE cardiovascular events, serious infections, and malignancy. As-observed effectiveness of adalimumab and improvements from baseline in PROs were maintained through 7 years of registry participation.

Funding

Abbvie.

Trial Registration

ClinicalTrials.gov identifier, NCT00799877.

http://ift.tt/2uOL7F1

More Than a Decade of Misdiagnosis of Alternating Hemiplegia of Childhood with Catastrophic Outcome

Alternating hemiplegia of childhood (AHC) is a distinct clinical disorder characterized by recurrent episodes of hemiplegia, abnormal ocular movement, and progressive developmental delay. It is an extremely rare genetic disorder related to ATP1A3 gene mutations. In this paper, we present a case of AHC in which the diagnosis was missed for many years until severe hypoxic brain insult occurred from prolonged status epilepticus. Not only we are presenting an interesting clinical entity and radiological images, but also we are shedding the light on a rare genetic disease with catastrophic sequelae. The challenges in diagnosis and treatment lead to a poor outcome as seen in our case. Although early recognition and accurate diagnosis and treatment of the disease may not change the outcome, counseling of the family may change their expectation and reduce their frustration. Referral to a center with expertise in genetic disorders and access to genetic laboratories is of paramount importance in the diagnosis of this disease. Due to the rarity of this disease in Saudi Arabia, a genotype-phenotype correlation is not feasible.

http://ift.tt/2i50fvU

HSV-1 Encephalitis: High Index of Clinical Suspicion, Prompt Diagnosis, and Early Therapeutic Intervention Are the Triptych of Success—Report of Two Cases and Comprehensive Review of the Literature

Herpes Simplex Virus (HSV) encephalitis is an acute infectious disease of the Central Nervous System (CNS), usually affecting the limbic structures, the median temporal cortex, and the orbitofrontal regions. Its annual incidence has significantly increased over the last 20 years and the mortality rate is 7%, if early diagnosed and treated, and 70%, if left untreated, while it is associated with high rates of morbidity. It should be noted that even when Cerebrospinal fluid (CSF) analysis seems normal, imaging studies are not specific and HSV Polymerase Chain Reaction (PCR) test is negative; the clinician should be more aggressive, if clinical presentation is indicative for HSV encephalitis, by administrating acyclovir early after patient's admission. The latter may be a vital intervention for the patient, modifying the patient's clinical course. Through the presentation of two cases of HSV-1 encephalitis that we managed in our department over the last 1 year and after systematic and comprehensive research of the relevant literature, we aim at showing the crucial role of medical history and physical examination, along with the high index of clinical suspicion, in order to make promptly the diagnosis and administer timely intravenous acyclovir, limiting the possibility of complications during the disease's course.

http://ift.tt/2vHX28L

Pemetrexed-induced lower limb pseudocellulitis

http://ift.tt/2v1JJOE

Hyperammonaemic encephalopathy following an uncomplicated surgery

A 59-year-old woman who underwent an uncomplicated exploratory laparotomy, adhesiolysis, small bowel resection and anterolateral thigh flap had a complicated postoperative period characterised by wound dehiscence and poor nutritional intake. 29 days postoperatively, a tremor developed in her upper limbs associated with weakness. Her Glasgow Coma Scale (GCS) fell to 4 and she was transferred to the intensive care unit. The patient was reviewed by multiple specialists and multiple differentials were considered and eliminated. Eventually, investigations revealed hyperammonaemic encephalopathy, being a result of low arginine and potentially small intestinal bacterial overgrowth. Following treatment with sodium benzoate, sodium phenylbutyrate and arginine along with haemodialysis and rifaximin, GCS and hyperammonaemia rapidly improved. She was stepped down to surgical high-dependency unit, continued arginine therapy with total parenteral nutrition and percutaneous endoscopic gastrostomy feeds. She was discharged with regular follow-up from surgeons and biochemistry and continues oral arginine therapy.

http://ift.tt/2uOgTBY

Ventrain: from theory to practice. Bridging until re-tracheostomy

Imminent upper airway obstruction due to life-threatening tracheal stenosis of any cause is challenging. A 77-year-old woman, with a history of temporal tracheostomy for prolonged mechanical ventilation, presented with life-threatening tracheal stenosis to the emergency department. After failed intubation with a 5.0 mm internal diameter endotracheal tube, the patient was ventilated via a tube exchanger using Ventrain. Ventrain is a manual ventilation device that, in addition to oxygen supply during inspiration, initiates expiration by actively removing gas from the lungs by suction. Despite the nearly obstructed airway the patient was adequately ventilated with 'permissive' hypercarbia of 50 mm Hg and Saturation of peripheral Oxygen (SpO₂) 95%–98% until surgical re-tracheostomy was performed. The haemodynamic stability of the patient indicated that the active expiration prevented intrapulmonary pressure build-up by air trapping and subsequent barotrauma and/or haemodynamic deterioration, which may well be observed during traditional jet ventilation especially in case of a completely obstructed airway.

http://ift.tt/2weIrUN

Adrenal myelolipoma(s) as presenting manifestation of subclinical Cushings disease (eutopic ACTH-dependent Cushings syndrome)

Primary adrenal myelolipomas, relatively rare benign tumours of the adrenal cortex are typically unilateral, hormonally inactive and asymptomatic, hence often diagnosed as 'adrenal incidentaloma'. Bilateral adrenal myelolipomas, in particular, may be associated with underlying endocrinopathies associated with elevated circulating adrenocorticotropic hormone (ACTH) concentration. Subclinical cortisol hypersecretion, irrespective of its ACTH dependency, does not manifest typical clinical phenotype of hypercortisolemia, and thus termed subclinical Cushing's syndrome. In this article, hormonal evaluation in a middle-aged woman with diabetes, hypertension and incidentally discovered unilateral adrenal myelolipoma revealed underlying subclinical Cushing's disease. Abdominal CT revealed another tiny focus in the contralateral adrenal gland, probably representing incipient myelolipoma.

http://ift.tt/2uOz5LG

Hepatosplenic schistosomiasis: playing hide-and-seek with an elusive parasite

A 27-year-old man of Eritrean origin presented with persistent left-sided abdominal pain. Initial investigation showed signs of liver fibrosis, portal hypertension and splenomegaly. A diagnosis of hepatosplenic schistosomiasis was suspected on grounds of elevated total IgE, grey area antischistosomiasis antibodies and the high endemic status of his native country. However, repeated microscopy of faecal and urine samples, as well as rectal biopsies, failed to demonstrate schistosomal eggs. Finally, the diagnosis of hepatosplenic schistosomiasis was established through demonstration of a Schistosoma mansoni egg in a liver biopsy taken in an attempt to clarify the cause of the above findings. The patient had recently been treated for uncomplicated malaria. Lowered schistosomiasis worm/egg burden and hence reduced sensitivity of classic microscopy-based schistosomiasis testing was attributed to the antischistosomal activity of the antimalarial chemotherapy.

http://ift.tt/2weinJq

Myoepithelioma of the Parotid Gland: A Case Report with Review of the Literature and Classic Histopathology

Myoepithelioma is a rare salivary gland neoplasm. They most commonly affect the major and minor salivary glands with the parotid gland being the most common, approximately 40%. Only 1% of all salivary gland neoplasms are myoepitheliomas. Myoepithelioma is usually a benign tumor arising from neoplastic myoepithelial or basket cells which are found between the basement membrane and the basal plasma membrane of acinar cells. They also contain multiple cellular elements. We present a case of a 73-year-old female with myoepithelioma of the parotid gland, an extremely rare neoplasm. There have been approximately 42 cases reported through 1985 and fewer than 100 cases through 1993. We will discuss the clinical presentation, pathophysiology, diagnosis, and treatment of such neoplasms.

http://ift.tt/2vIc7au

Comparison and Interpretability of the available Urticaria Activity Scores

Abstract

The urticaria activity score (UAS) is the gold standard for assessing disease activity in patients with chronic spontaneous urticaria (CSU). Two different versions, the UAS7 and UAS7_TD, are currently used in clinical trials and routine care. To compare both versions and to obtain data on their interpretability, 130 CSU patients applied both versions and globally rated their disease activity as none, mild, moderate, or severe. UAS7 and UAS7_TD values correlated strongly (r=0.90, P<0.001). Interquartile ranges for UAS7 and UAS7TD values for mild, moderate and severe CSU were 11-20 and 10-24, 16-30 and 16-32, and 27-37 and 28-40. UAS7 values were slightly, but significantly lower as compared to UAS7_TD values (mean difference: 1.6±4.6, P<0.001). This difference was driven by lower wheal subscores (2.1±3.5, P<0.001) and was most pronounced in patients with severe CSU (2.5±5.6, P<0.01). The UAS7/UAS7_TD ratio was 0.96±0.21 and did not differ significantly between mild, moderate and severe CSU.

http://ift.tt/2vHWyiY

Akute Komplikationen vaskulärer Anomalien im Kindesalter

Zusammenfassung

Angeborene und erworbene Gefäßanomalien sind im Kindesalter häufig. Neben überwiegend harmlosen vaskulären Hautveränderungen gibt es andere, die aufgrund ihrer potenziell bedrohlichen Komplikationen sofort behandlungsbedürftig sind. Beispielhaft soll auf 3 Anomalien und ihre typischen Komplikationen eingegangen werden. Bei Säuglingshämangiomen können drohende Obstruktion und schmerzhafte Ulzerationen eine unmittelbare Therapie erforderlich machen. Beim kaposiformen Hämangioendotheliom kann es zu einer lebensbedrohlichen Verbrauchskoagulopathie kommen, beim Klippel-Trenaunay-Syndrom im Verlauf zu Thrombosen, einer lokalisierten Koagulopathie und zu Superinfektionen.

http://ift.tt/2uHUdHy

Commentary: Estrogen Receptor Expression in Melanoma

Abstract

Sexual hormones share a common cholesterol derived steroid backbone and comprise estrogens, gestagens and androgens. They elicit numerous physiological and pathological functions; e.g. androgens are known to contribute to prostatic cancer development, whereas estrogens are of major importance in the pathogenesis of breast cancer. In 1986, presence of estrogen receptors (ER) on breast cancer cells was described as one of the first biomarkers in oncology [1].

http://ift.tt/2w00vlW

Case report of cutaneous protothecosis caused by Prototheca wickerhamii designated as genotype 2 and current status of human protothecosis in Japan

Abstract

An 85-year-old Japanese woman presented with infiltrative erythema and ulceration on the extensor surface of her right forearm. Direct microscopic examination demonstrated spherical and morula-like sporangia, while histopathology revealed numerous microorganisms with a mulberry-like appearance in the dermis. Staining of the microorganisms also showed mulberry-like sporangia that resembled the spokes of a wheel. The isolated yeast-like microorganism had been identified as Prototheca wickerhamii genotype 2 in another independent study on the basis of its morphological, biochemical and genetic analysis. This case of protothecosis was recorded in Kyushu, Japan, and oral treatment with itraconazole 200 mg/day for 2 months was effective. Herein, we also summarize and analyze 39 cases of human protothecosis reported in Japan since the first record in 1983.

http://ift.tt/2fJTMWD

Case–control study of chronic low-level exposure of inorganic arsenic species and non-melanoma skin cancer

Abstract

A significant relationship between arsenic exposure and non-melanoma skin cancer (NMSC) is well known. The toxicity of arsenics which develop NMSC is dependent on their species. Accordingly, total arsenic levels are unreliable for risk assessment of NMSC. However, there are few studies on quantitative exposure assessment of arsenic species in NMSC patients. To validate the contribution of each arsenic species to NMSC, we compared the creatinine-adjusted urinary concentration of arsenic species in NMSC patients and community controls. A total of 124 biopsy-proven NMSC cases and 125 age- and sex-matched community controls, drinking tap water with low-level arsenic concentration (<5 μg/L), were included in the study. High-performance liquid chromatography and inductively coupled plasma mass spectrometry were used for the measurement. The NMSC group was found to have significantly higher levels of total inorganic arsenic, trivalent and pentavalent arsenic and monomethylarsonic acid than the control group. Total arsenic, organic arsenic and dimethylarsonic acid levels were lower in the NMSC group. We suggest that inorganic arsenic species, trivalent arsenic and pentavalent arsenic may influence the prevalence of NMSC, in spite of these levels being lower than the Agency for Toxic Substances and Disease Registry-recommended standard or the levels reported by other highly contaminated areas and neighboring countries in East Asia. Furthermore, it also suggests that total arsenic level cannot represent the risk of NMSC.

http://ift.tt/2i4Jp0q

Pseudoangiosarcomatous squamous cell carcinoma of the skin: A need for a more rigorous nomenclature for histopathological variants of squamous cell carcinoma

Abstract

Over the years, squamous cell carcinomas (SCC) that mimicked vascular lesions have been encompassed within different classifications and the underlying etiopathogenic mechanisms have been interpreted in different ways by different authors. Here, we present a case of SCC with pseudovascular areas in the right leg of a 96-year-old woman with chronic venous insufficiency. Histopathological examination closely resembled an angiosarcoma, but the immunohistochemical negativity for endothelial markers and the strong positivity for the pancytokeratin marker AE1/AE3 revealed the epithelial nature of the neoplasm. After a comprehensive review of all similar previously published cases, we believe that it is necessary to separate SCC with pseudoluminal structures composed of glandular-like areas (pseudoglandular or adenoid SCC) from those mimicking vascular lumina (pseudovascular and pseudoangiosarcomatous SCC). We would like to emphasize that acantholytic SCC, a definitive variant of SCC, can be further classified into the common or ordinary subtype of acantholytic SCC, that shows solid nests containing numerous acantholytic atypical keratinocytes without any mimickers for specific structures, and pseudoglandular, pseudovascular and pseudoangiosarcomatous subtypes when glandular or vascular structures are mimicked, respectively.

http://ift.tt/2fJZ1FR

Routine detection of serum anti-desmocollin autoantibodies is only useful in patients with atypical pemphigus

http://ift.tt/2v0FfrG

Infant feeding patterns and eczema in children in the first 6 years of life

Abstract

Background

Modes of infant feeding such as direct and indirect breastfeeding, and formula feeding, and their combinations may play a role in child health.

Objective

The aim was to investigate which feeding patterns in the first six months pose risks for eczema/skin allergy in children up to 6 years compared to direct breastfeeding for at least 3 months.

Methods

The Infant Feeding Practices Study II in the United States and its 6-year follow-up provided data on feeding modes in infancy and doctor's diagnosed eczema/skin allergy in the first 6 years of life (1,387 infants), based on parental reports. Different feeding patterns were identified. Log-linear models were used to estimate prevalence ratios (PRs) of feeding patterns for doctor's diagnosed eczema/skin allergy in the first 6 years of life, adjusting for confounders.

Results

Compared to 'direct breastfeeding for at least 3 months' (DBF3m), the combination of direct feeding at the breast (DBF), pumping and feeding breast milk (BM), and formula (FF) in the first months' (DBF/BM/FF) showed a statistically significant higher risk for eczema/skin allergy in the first 6 years of life (PR= 1.46), adjusting for confounders. DBF combined with BM for the first 3 months followed by mixed feeding also had an increased risk (PR=1.26), though not statistically significant. Formula feeding introduced since birth had no effect on eczema. Among the confounders, paternal eczema and race/ethnicity (Hispanic vs White) were associated with a higher risk of eczema/skin allergy.

Conclusions & Clinical Relevance

Mixed infant feeding may carry a higher risk of eczema/skin allergy compared to direct feeding at the breast. The recent epidemic of pumping and feeding in the United States and the use of mixed infant feeding modes requires additional studies to provide appropriate and renewed assessments of the risks of feeding modes for the future development of allergies.

http://ift.tt/2w0S3md

Concomitant carotid aplasia and basilar artery occlusion in a child with PHACES syndrome

We report a case of an 8-year-old girl with posterior fossa abnormalities, haemangioma, arterial lesions, cardiac abnormalities or coarctation of the aorta and eye abnormalities syndrome with right carotid aplasia and complete basilar occlusion. The patient initially presented at 2.5 weeks of age with a growing right facial haemangioma involving segments 1, 3 and 4. Initial MRI at 2.5 weeks of age revealed an extraconal right orbital haemangioma without posterior fossa abnormalities and MR angiography (MRA) 3 weeks later showed right internal carotid aplasia. A follow-up MRA and cerebral angiography at 8 years of age revealed a complete occlusion of the basilar artery that was not appreciated on previous imaging. Neurological function remains normal, meeting all age-appropriate milestones.

http://ift.tt/2wdSjxM

Massive epidermal vulval cyst: an unusual late complication of female genital mutilation

Vulval epidermal cysts are rare and infrequently described in literature. They present a difficult diagnostic dilemma and surgical challenges. They most commonly occur as a late complication of female genital mutilation (FGM) and manifest as a primary condition. We present a case of a large vulval epidermal inclusion cyst, lined by vulval squamous epithelium, in a woman with a background of FGM who was referred with suspected vulval cancer. We discuss the clinical presentation, MRI findings, surgical treatment and outcome.

http://ift.tt/2uNMbJr

Migration of a Kirschner wire into the lung with shoulder dislocation

Description

A 69-year-old female was presented with right shoulder pain due to chronic anterior shoulder dislocation. She underwent an operation for arthroscopic rotator cuff repair (figure 1). Rotator cuff repair was not possible due to massive rotator cuff tears and the glenohumeral joint was not stable. After reduction, therefore, temporary fixation of the glenohumeral joint was performed with two 3.0 mm Kirschner wires (K-wires) (figure 2). One wire was removed due to superficial infection 17 days after the surgery. As a result, the humeral head was dislocated, and the remaining wire migrated into her lung (figure 3). Chest CT showed pulmonary contusion without evidence of pneumothorax (figure 4). Fourteen days later, the K-wire was removed carefully with fluoroscopic guidance to prevent haemorrhage and pneumothorax. Forty-two months postoperatively, the humeral head remained dislocated with modest relief of joint pain. Chest function is normal without...

http://ift.tt/2wdB9At

Ureaplasma parvum causing life-threatening disease in a susceptible patient

A 56-year-old man with lymphoma developed orchitis followed by septic arthritis of his right glenohumeral joint. Synovial fluid cultures were negative but PCR amplification test was positive forUreaplasmaparvum. The patient was treated with doxycycline. Two and a half years later, the patient presented with shortness of breath and grade III/IV diastolic murmur on auscultation. Echocardiography revealed severely dilated left heart chambers, severe aortic regurgitation and several mobile masses on the aortic valve cusps suspected to be vegetations. He underwent valve replacement; valve tissue culture was negative but the 16S rRNA gene amplification test was positive for U. parvum.

He was treated again with doxycycline. In an outpatient follow-up 1 year and 3 months later, the patient was doing well. Repeated echocardiography showed normal aortic prosthesis function.

http://ift.tt/2uOeKGA

The use of cardiac MRI in a rare case of primary mural endocarditis

Description

A 47-year-old-man with a history of intravenous drug use and recent diagnosis of T-cell lymphoma returned to the emergency department 1 week after initiation of chemotherapy with complaint of left olecranon swelling. Admission vital signs included body temperature of 36.6°C, blood pressure 108/65, heart rate 76 and respiratory rate 18. Physical examination of the left olecranon revealed that it was warm and indurated. An X-ray of the left olecranon and aspiration of the swelling confirmed bursitis. Both the aspiration culture and blood cultures demonstrated methicillin-resistant Staphylococcus aureus. A transthoracic echocardiogram was subsequently performed revealing a large echodensity in the left ventricular apex (figure 1; see online and ). The patient refused to undergo a transoesophageal echocardiogram due to its invasive approach. Therefore, a cardiac MRI (CMRI) was obtained to evaluate the lesion. The CMRI demonstrated left ventricular ejection fraction 65%, no valvular vegetations and two linear...

http://ift.tt/2fKCQz6

Congenitally corrected transposition of great arteries

Description

A 60-year-old woman initially presented 8 years ago with atypical chest pain and palpitations. Her 12-lead ECG demonstrated complete heart block, following which she underwent dual-chamber pacemaker implantation. She also had transthoracic echocardiogram, which was felt to be technically difficult due to body habitus. She was diagnosed to have mild mitral valve regurgitation, due to mild mitral valve prolapse, and was kept under annual surveillance. There was no other significant medical history. Her last TTE was done a year ago and she had been symptom-free up to her recent clinic visit. Her repeat TTE showed apically displaced Ebstein-like left atrioventricular valve (AV) with tricuspid valve morphology (confirmed by three-dimensional (3D) echo) and heavily trabeculated morphologically right ventricle on the left side of the heart (figures 1, 2, 3 and 4, online and ). Her systemic ventricle was mild to moderately impaired, and the tricuspid, left AV was moderately regurgitant. There are no obvious shunt and no...

http://ift.tt/2i42Sy9

Fungating groin mass in a woman with a history of follicular lymphoma

Description

A 49-year-old woman with no significant medical history presented to her primary care provider for an evaluation of a new lump in her groin. She was found to have enlarged inguinal lymph nodes on the right side, and underwent extensive work-up, including testing for HIV, hepatitides, Epstein-Barr virus, cytomegalovirus and chest imaging. They were all unremarkable. Given persistence of the lymphadenopathy, the patient underwent a fine needle aspiration of one of the lymph nodes with pathology revealing a diagnosis of low-grade follicular lymphoma. Given the natural history of this slow-growing tumour, she was maintained on an observational protocol but unfortunately lost to follow-up.

Three years later, the patient presented to the emergency department for complaints of generalised malaise as well as an enlarging right groin mass. Physical examination revealed a fungating mass with purulent drainage and an impressively pungent smell in the right inguinal area (figure...

http://ift.tt/2fKVWp7

Spleno-renal artery transposition in a solitary functioning kidney for treatment-resistant hypertension and acute kidney injury

Renal Artery Stenosis (RAS) is an important cause of treatment-resistant hypertension. Uncontrolled hypertension with RAS can cause progressive chronic kidney disease (CKD) leading to end-stage kidney disease. Therapeutic revascularisation can be helpful in appropriate circumstances where pharmaceutical intervention has failed and significant renovascular disease contributes to resistant hypertension. We present an interesting case of a Caucasian male with peripheral vasculopathy, abdominal aortic aneurysm (AAA), single functioning kidney and ostial RAS caused by stent struts from an endovascular AAA stent graft. He had escalating medications requirement, with repeated failed attempts at percutaneous radiological intervention that led to an episode of contrast-induced acute kidney injury (AKI), before undergoing successful surgical revascularisation by a splenic artery transposition graft to the left renal artery that was performed to improve kidney function and the blood pressure. This report highlights the challenges faced with regard to the management of severe hypertension and progressive CKD.

http://ift.tt/2i42yPX

Bleeding ectopic duodenal varix: use of a new microvascular plug (MVP) device along with transjugular intrahepatic portosystemic shunt (TIPSS)

Ectopic varices (ECV) occur along the gastrointestinal (GI) tract outside the common variceal sites and represent 2%–5% of all GI variceal bleeds with mortality rates up to 40%. Management is challenging because of inaccessibility and increased risk of rebleeding. We report what is to our knowledge the first clinical use of a new microvascular plug (MVP) with transjugular intrahepatic portosystemic shunt (TIPSS) for a bleeding duodenal varix (DV). A 68-year-old man presented with melena. Endoscopy demonstrated a grade II varix in the second part of the duodenum with red wale sign. TIPSS was performed and portogram revealed a single DV. Poststent placement venogram revealed a persistent varix and hence a 5–7 mm MVP was deployed. Subsequent imaging showed cessation of blood through the DV. The patient had no further bleeding. TIPSS with embolisation is an effective treatment for ECV. This MVP offers advantages due to its size and compatibility and can be redeployed in case of suboptimal placement.

http://ift.tt/2fK0HiA

Fever and generalised lymphadenopathy in an HIV-positive patient: a diagnostic challenge

Fever and generalised lymphadenopathy is a common presentation of a variety of diseases and a thorough investigation is often necessary for appropriate diagnosis.

We present a 53-year-old male patient admitted with fever, weight loss of 15 kg in 3 months and abdominal discomfort. Examination was only remarkable for axillary and inguinal lymphadenopathy. Blood tests showed normocytic normochromic anaemia, cholestasis and a previously unknown HIV-1 infection with lymphocyte CD4 +count of 239 cells/mm³ and viral load 3.172.370 copies/mL. A body CT scan showed multiple axillary, mediastinal, lumbar, aortic, iliac and pelvic lymphadenopathy as well as hepatosplenomegaly. An excisional biopsy of the left axillary lymphadenopathy was performed and histology ultimately revealed multicentric Castleman's disease associated with Human Herpes Virus-8. After initiation of antiretroviral therapy, rituximab was given and progressive clinical improvement occurred.

http://ift.tt/2i5lmhS

Hydropneumothorax as an iatrogenic complication after nasogastric intubation

Description

A 62-year-old woman with history of frontotemporal dementia was admitted to a Psychiatry ward due to severe insomnia. In the morning, after the admission a nasogastric tube was placed to initiate enteral feeding and medication since she was refusing all oral intake. Later that night, she was found unresponsive, dyspnoeic and with severe hypotension. Physical examination identified clinical signs of respiratory distress and decreased vesicular breath sounds on the right hemithorax. The gasometric evaluation revealed the presence of hypoxaemia and lactic acidosis. A posteroanterior chest radiograph showed a right pleural effusion and a misplaced nasogastric tube (figure 1). A thoracic CT scan revealed the presence of a right hydropneumothorax and also identified a tube inside the trachea and the right main bronchus, which perforated the lung parenchyma and ended in the pleural cavity (figure 2).

Figure 1

Posteroanterior chest radiograph showing...

http://ift.tt/2fJV7wz

Unique case of herniated small bowel infarction within a colonic stomal prolapse

The number of permanent colostomies carried out in the United Kingdom is approximately 6400 per year1. Stomal prolapse is a known complication of colostomy formation. We presented the first case of small bowel herniation into a healthy stomal prolapse with subsequent ischaemia of the herniated bowel in a 102-year-old patient. This rare sequela of a relatively common stomal complication highlights an important consideration when faced with a large prolapse presenting acutely. It also raises an important discussion point for the management of our ever-ageing patient population.

http://ift.tt/2i4RuCh

Total alimentary canal necrosis: infarction from oesophagus to anus

Description

A middle-aged woman presented with a 12-hour history of generalised abdominal pain and septic. Her medical history included chronic alcoholism and a 40 pack-year smoking history. Laboratory tests revealed raised inflammatory markers and a macrocytosis. There were no liver, renal or clotting derangements, and haemoglobin and platelet levels were within normal limits. Blood gas analysis showed acidaemia and raised lactate. A CT scan of the abdomen revealed pneumoperitoneum, extensive portal venous gas and pneumatosis intestinalis throughout the entire imaged gut—from distal oesophagus all the way to anus—suggestive of complete intestinal necrosis (figures 1–3). The mesenteric arteries appeared patent. The patient rapidly deteriorated and died within 3 hours of admission.

Figure 1

Axial CT image of upper abdomen showing extensive portal gas, pneumoperitoneum (long arrow) and intra-abdominal free fluid (short arrow). Gastric wall intramural gas (pneumatosis) is visible.

...

http://ift.tt/2fKg76k

A case of cardiopulmonary arrest due to spontaneous coronary artery dissection in a pregnant woman

We present the case of a young pregnant woman with cardiopulmonary arrest due to acute coronary syndrome. Emergent coronary angiography (CAG) and intravascular ultrasound (IVUS) showed extensive coronary artery dissection in the left anterior descending artery, which was treated with primary percutaneous coronary intervention. After managing the heart failure and disseminated intravascular coagulation, a dead fetus was delivered via caesarean section 4 days after admission to the hospital. Follow-up CAG and IVUS at 18 months showed persistent dissection in the non-stented site; hence, another stent was implanted. Dual antiplatelet therapy was discontinued 6 months later; however, aspirin and beta-blockers were continued lifelong.

http://ift.tt/2i3XECs

A Narrative Review of Adherence to Subarachnoid Hemorrhage Guidelines.

Over the past 2 decades, a large number of guidelines for aneurysmal subarachnoid hemorrhage (aSAH) management have been proposed. The primary aim of these "evidence-based" guidelines is to improve the care of aSAH patients by summarizing and making current knowledge readily available to clinicians. However, an investigation into aSAH guidelines, their changes along time and their successful translation into clinical practice is still lacking. We performed a literature search of historical events and subarachnoid hemorrhage guidelines using the Entrez PubMed NIH, Embase, and Cochrane databases for articles published up to November of 2016. Data were summarized for guidelines on aSAH management and cross-sectional studies of their application. A total of 11 guidelines and 10 cross-sectional studies on aSAH management were analyzed. The use of nimodipine for the treatment of SAH is the only recommendation that remained consistent across guidelines over time (r=0.82; P

http://ift.tt/2uO88b9

Cerebral Oxygen Saturation During Electroconvulsive Therapy: A Secondary Analysis of a Randomized Crossover Trial.

Background: Electroconvulsive therapy (ECT) causes acute changes in cerebral perfusion and oxygenation. Near-infrared spectroscopy is a novel, noninvasive technique to assess cerebral oxygen saturation (cSO2). We hypothesized that cSO2 increases during ECT and more so with atropine premedication and decreases when systemic desaturation (peripheral oxygen saturation 60% at any measured time point, even in those with systemic desaturation. Conclusions: ECT increased cSO2 irrespective of atropine premedication. cSO2 was lower when systemic desaturation occurred. Future studies should explore the effect of cerebral oxygenation changes during ECT on outcome of psychiatric conditions. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

http://ift.tt/2wdAbnN

Paraplegia in Subarachnoid Hemorrhage Complicated With Coarctation of Aorta: An Unusual Complication.

No abstract available

http://ift.tt/2uO86jx

The Shikani Optical Stylet as an Alternative to Awake Fiberoptic Intubation in Patients at Risk of Secondary Cervical Spine Injury: A Randomized Controlled Trial.

Background: Conventional intubation of the trachea and consequent prone positioning of anesthetized patients with cervical spine instability may result in secondary neurological injury. Historically, flexible fiberoptics used to be the chief choice for patients presenting with cervical spine instability surgery with difficult airway. Recently, the rigid optical stylets have shown promise in assisting difficult intubations. Purpose: The aim of the present study was to compare the efficacy of Shikani optical stylet (SOS) with the flexible fiberscope for awake intubation in patients with cervical spine instability. Patients and Methods: In total, 60 adult patients diagnosed with cervical instability or at risk of secondary cervical injury, who were planned for awake intubation and/or self-positioning prone, were registered in this study and were randomly categorized into 2 equal groups (30 patients each), a fiberoptic group and an SOS group, followed by assessment of coughing and gagging during intubation, time to successful intubation, number of attempts for successful intubation, and hemodynamic parameters. Results: As regards time to successful intubation, statistically significant differences were detected between the 2 studied groups, with the fiberoptic group having significantly longer intubation time than the Shikani group, whereas no statistically significant differences were recorded between the 2 groups with regard to the first-attempt success, the mean heart rate value, the mean arterial blood pressure, coughing, and occurrence of complications. Conclusion: This study validates the efficacy of both SOS and flexible fiberoptic bronchoscope for awake oral intubation in patients with cervical spine instability. SOS has been found to be more effective in reducing time to intubation. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

http://ift.tt/2wdLA70

Poor sleep is highly associated with house dust mite allergic rhinitis in adults and children

Sleep disorders are often underreported to physicians by patients with allergies. This study aimed to characterize the sleep disorders associated with respiratory allergy to house dust mites (HDM) at the time ...

http://ift.tt/2v0ke0e

Amelioration of atopic-like skin conditions in NC/Tnd mice by topical application with distilled Alpinia intermedia Gagnep extracts

Abstract

Alpinia intermedia, a perennial plant that belongs to the Zingiberaceae family, has been used in folk medicine for a long time in the southern region of Japan. Because skin care is an effective approach that enables patients to manage their atopic dermatitis (AD), various herbal ingredients with few adverse effects have been evaluated for use in AD patients in recent years. In this study, we examined whether distilled extracts obtained from A. intermedia were beneficial for AD-like skin conditions in NC/Tnd mice. Topical application with the A. intermedia extracts significantly reduced the severity of AD, transepidermal water loss and scratching behavior in the mice. Supplementation of the extracts to cell cultures suppressed the expression of Tslp mRNA in PAM212 keratinocytes, degranulation in bone marrow-derived cultured mast cells (BMCMC), and neurite outgrowth in PC12 cells and dorsal root ganglia. In addition, the component analysis revealed that β-pinene was a major constituent of the A. intermedia extracts. The inhibitory effects of β-pinene both in vivo and in vitro were also demonstrated. These results indicate that topical application with the A. intermedia extract to the skin of NC/Tnd mice improved the condition of the skin by suppressing multiple inflammatory responses. The extracts may become novel skin-care remedies for AD patients.

http://ift.tt/2fKgaz7

Αρχειοθήκη ιστολογίου

Τετάρτη 16 Αυγούστου 2017

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Introduction