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Τρίτη 2 Ιανουαρίου 2018
CRISPR/Cas9 Editing of the Mouse Thra Gene Produces Models with Variable Resistance to Thyroid Hormone
http://ift.tt/2DTxgkN
The Hobnail Variant of Papillary Thyroid Carcinoma: Clinical/Molecular Characteristics of a Large Monocentric Series and Comparison with Conventional Histotypes
Thyroid , Vol. 0, No. 0.
http://ift.tt/2EFuAbR
Stable Isotope Pharmacokinetic Studies Provide Insight into Effects of Age, Sex, and Weight on Levothyroxine Metabolism
Thyroid , Vol. 0, No. 0.
http://ift.tt/2DWwmEq
Position Statement of the Spanish Academy of Dermatology and Venereology on Teledermatology
Treatment of Malignant Cutaneous Adnexal Neoplasms
Practical Management of Immunosuppressants in Dermatology
Economic Impact of Atopic Dermatitis in Adults: A Population-Based Study (IDEA Study)
Correlation Between Incisional Biopsy Histological Subtype and a Mohs Surgery Specimen for Nonmelanoma Skin Cancer
Clinical Research in Dermatology and Venereology in Spanish Research Centers in 2005 Through 2014: Results of the MaIND Study
Prospective Single-Center Observational Study of the Allergenic Potential of Mercromina Film and Other Common Antiseptics in Patients With Contact Dermatitis
Intralymphatic Histiocytosis: A Report of 2 Cases
Large, Long-standing Tumor on the Scalp and Ipsilateral Lymphadenopathy
Pseudoverrucous Lesions of Recent Appearance on the Vulva
Slow-Growing Pink Papule
The Good and Bad News About New Drugs for Treating Alopecia Areata
Type I Keystone Island Flap
A Pink Tumor: Angiolymphoid Hyperplasia With Eosinophilia
Male breast cancer mimicking melanoma
Cutaneous Infiltration due to Waldenström Macroglobulinemia
Lupus Erythematosus Affecting the Genitalia: An Unusual Site
Effects of Acoustic Environment on Tinnitus Behavior in Sound-Exposed Rats
Abstract
Laboratory studies often rely on a damaging sound exposure to induce tinnitus in animal models. Because the time course and ultimate success of the induction process is not known in advance, it is not unusual to maintain sound-exposed animals for months while they are periodically assessed for behavioral indications of the disorder. To demonstrate the importance of acoustic environment during this period of behavioral screening, sound-exposed rats were tested for tinnitus while housed under quiet or constant noise conditions. More than half of the quiet-housed rats developed behavioral indications of the disorder. None of the noise-housed rats exhibited tinnitus behavior during 2 months of behavioral screening. It is widely assumed that the "phantom sound" of tinnitus reflects abnormal levels of spontaneous activity in the central auditory pathways that are triggered by cochlear injury. Our results suggest that sustained patterns of noise-driven activity may prevent the injury-induced changes in central auditory processing that lead to this hyperactive state. From the perspective of laboratory studies of tinnitus, housing sound-exposed animals in uncontrolled noise levels may significantly reduce the success of induction procedures. From a broader clinical perspective, an early intervention with sound therapy may reduce the risk of tinnitus in individuals who have experienced an acute cochlear injury.
http://ift.tt/2CsiDca
5 tips for securing a patient's airway
One of the first concerns an EMS provider should have about a patient with significant facial trauma is whether the patient has a patent airway and will be able to maintain that airway. Bleeding, soft tissue swelling, broken teeth and other fractures can all create partial or complete obstruction to the patient's airway. Care must be paid to how the airway is managed in these patients to strike ...
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Clinical scenario: Patient with facial trauma
Rescue 7, Engine 2, respond Code 3 to the intersection of Maple and Division. Multiple callers are reporting a cyclist struck by a vehicle at that location. You arrive on scene where law enforcement is already maintaining manual stabilization of the patient's head and neck. According to the first arriving officer, witnesses state that the patient was riding his bicycle through the intersection ...
http://ift.tt/2EEhueV
Why Thyroid Health Should Matter to All, Especially Women
Hypothyroidism is the most common form of thyroid malfunctions, affecting up to 15 percent of Americans in cases ranging from mild to those requiring medication, according to the American Thyroid Association (ATA). The diagnoses have been climbing because technology has enabled lab tests to recognize milder conditions that weren't recognized previously, says Dr. Elizabeth Pearce, associate professor of medicine at the Boston University School of Medicine and the president-elect of the ATA. January has been designated thyroid awareness month by the ATA.
The post Why Thyroid Health Should Matter to All, Especially Women appeared first on American Thyroid Association.
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Clinical Thyroidology High-Impact Articles
FREE ACCESS through January 12, 2018
Read Now:
Does Having Exophthalmic Graves' Disease Increase a Patient's Risk of Suicide?
Stephen W. Spaulding
Higher Serum FT4 Level Within the Reference Range, but Not Serum TSH, Is Associated With the Development of Atrial Fibrillation
Angela M. Leung
Shear-Wave Elastography in Thyroid Nodules Fails to Discriminate Between Benign and Malignant Tumors
Stephanie A. Fish
FDG-Avid Thyroid Incidentalomas on PET-CT Ordered for Other Malignancies Have No Prognostic Significance in a Large Retrospective Cohort
Martin Biermann
The post Clinical Thyroidology High-Impact Articles appeared first on American Thyroid Association.
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Effects of Acoustic Environment on Tinnitus Behavior in Sound-Exposed Rats
Abstract
Laboratory studies often rely on a damaging sound exposure to induce tinnitus in animal models. Because the time course and ultimate success of the induction process is not known in advance, it is not unusual to maintain sound-exposed animals for months while they are periodically assessed for behavioral indications of the disorder. To demonstrate the importance of acoustic environment during this period of behavioral screening, sound-exposed rats were tested for tinnitus while housed under quiet or constant noise conditions. More than half of the quiet-housed rats developed behavioral indications of the disorder. None of the noise-housed rats exhibited tinnitus behavior during 2 months of behavioral screening. It is widely assumed that the "phantom sound" of tinnitus reflects abnormal levels of spontaneous activity in the central auditory pathways that are triggered by cochlear injury. Our results suggest that sustained patterns of noise-driven activity may prevent the injury-induced changes in central auditory processing that lead to this hyperactive state. From the perspective of laboratory studies of tinnitus, housing sound-exposed animals in uncontrolled noise levels may significantly reduce the success of induction procedures. From a broader clinical perspective, an early intervention with sound therapy may reduce the risk of tinnitus in individuals who have experienced an acute cochlear injury.
http://ift.tt/2CsiDca
Erratum to “Experience with a simplified eucapnic voluntary hyperventilation (EVH) device for diagnosis of exercise-induced bronchospasm”
In the abstract P205, "Experience with a simplified eucapnic voluntary hyperventilation (EVH) device for diagnosis of exercise-induced bronchospasm" (Ann Allergy Asthma Immunol. 2017;119(Suppl 1):S50-S51), the first author was mistakenly left off the abstract. The author list should read: C. Randolph1, R. Rosenthal*2, 1. Waterbury, CT; 2. Great Falls, VA.
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Incidence of anterior disc displacement without reduction of the temporomandibular joint in patients with dentofacial deformity
The aim of this study was to investigate the incidence of anterior disc displacement without reduction (ADDwoR) of the temporomandibular joint (TMJ) in patients with dentofacial deformity. Eighty-eight female patients (176 joints) with skeletal class III malocclusion and 33 female patients (66 joints) with skeletal class II malocclusion, with or without anterior open bite and asymmetry, were evaluated. Magnetic resonance imaging (MRI) of the TMJ was used to diagnose ADDwoR. A statistical analysis was performed to examine the relationship between ADDwoR and skeletal structure.
http://ift.tt/2qizU1Q
Bleaching and enamel surface interactions resulting from the use of highly-concentrated bleaching gels
Publication date: March 2018
Source:Archives of Oral Biology, Volume 87
Author(s): Guillermo Grazioli, Lisia Lorea Valente, Cristina Pereira Isolan, Helena Alves Pinheiro, Camila Gonçalves Duarte, Eliseu Aldrighi Münchow
Tooth bleaching is considered a non-invasive treatment, although the use of highly-concentrated products may provoke increased surface roughness and enamel demineralization, as well as postoperative sensitivity. Thus, the aim of this study was to investigate whether hydrogen peroxide (H2O2) concentration would affect tooth bleaching effectiveness and the enamel surface properties. Enamel/dentin bovine specimens (6 × 4 mm) were immersed in coffee solution for 7 days and evaluated with a spectrophotometer (Easyshade; baseline), using the CIEL*a*b* color parameters. Hardness was measured using a hardness tester. The specimens were randomly assigned into four groups: one negative control, in which the specimens were not bleached, but they were irradiated with a laser-light source (Whitening Lase II, DMC Equipments); and three groups using distinct H2O2 concentration, namely LP15% (15% Lase Peroxide Lite), LP25% (25% Lase Peroxide Sensy), and LP35% (35% Lase Peroxide Sensy), all products from DMC. The bleached specimens were also irradiated with the laser-light source. After bleaching, all specimens were evaluated using scanning electron microscopy (SEM). pH kinetics and rate was monitored during bleaching. The data were analyzed using ANOVA and Tukey's test (p < 0.05). All bleaching gels produced similar color change (p > 0.05). Concerning hardness, only the LP25% and LP35% significantly reduced hardness after bleaching; also, there was a progressive tendency for a greater percentage reduction in hardness with increased H2O2 concentration of the gel (R2 = 0.9973, p < 0.001). SEM showed that LP25% and LP35% produced an etching pattern on enamel with prism rods exposure. In conclusion, H2O2 concentration above the 15% level does not increase bleaching effectiveness, and may increase the possibility for alteration of enamel hardness, surface morphology, and acidity of the medium. When using H2O2-based bleaching agents, dental practitioners should choose for less concentrated gels, e.g., around the 15% level.
http://ift.tt/2CvO5Fj
Bleaching and enamel surface interactions resulting from the use of highly-concentrated bleaching gels
Publication date: March 2018
Source:Archives of Oral Biology, Volume 87
Author(s): Guillermo Grazioli, Lisia Lorea Valente, Cristina Pereira Isolan, Helena Alves Pinheiro, Camila Gonçalves Duarte, Eliseu Aldrighi Münchow
Tooth bleaching is considered a non-invasive treatment, although the use of highly-concentrated products may provoke increased surface roughness and enamel demineralization, as well as postoperative sensitivity. Thus, the aim of this study was to investigate whether hydrogen peroxide (H2O2) concentration would affect tooth bleaching effectiveness and the enamel surface properties. Enamel/dentin bovine specimens (6 × 4 mm) were immersed in coffee solution for 7 days and evaluated with a spectrophotometer (Easyshade; baseline), using the CIEL*a*b* color parameters. Hardness was measured using a hardness tester. The specimens were randomly assigned into four groups: one negative control, in which the specimens were not bleached, but they were irradiated with a laser-light source (Whitening Lase II, DMC Equipments); and three groups using distinct H2O2 concentration, namely LP15% (15% Lase Peroxide Lite), LP25% (25% Lase Peroxide Sensy), and LP35% (35% Lase Peroxide Sensy), all products from DMC. The bleached specimens were also irradiated with the laser-light source. After bleaching, all specimens were evaluated using scanning electron microscopy (SEM). pH kinetics and rate was monitored during bleaching. The data were analyzed using ANOVA and Tukey's test (p < 0.05). All bleaching gels produced similar color change (p > 0.05). Concerning hardness, only the LP25% and LP35% significantly reduced hardness after bleaching; also, there was a progressive tendency for a greater percentage reduction in hardness with increased H2O2 concentration of the gel (R2 = 0.9973, p < 0.001). SEM showed that LP25% and LP35% produced an etching pattern on enamel with prism rods exposure. In conclusion, H2O2 concentration above the 15% level does not increase bleaching effectiveness, and may increase the possibility for alteration of enamel hardness, surface morphology, and acidity of the medium. When using H2O2-based bleaching agents, dental practitioners should choose for less concentrated gels, e.g., around the 15% level.
http://ift.tt/2CvO5Fj
For Five Cancers, Screening Skews Risk Factors
Cancer risk factors are typically based on characteristics at the time of diagnosis. In a new essay, a pair of major figures on the US cancer scene explain why that is a problem when cancers are detected by testing.
Medscape Medical News
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FDA OKs Device for Diabetic Foot Ulcer Treatment
Sanuwave's dermaPACE system uses extracorporeal shock waves to mechanically stimulate and heal wounds.
FDA Approvals
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Trends in early hospital readmission after kidney transplantation, 2002 to 2014: a population-based multi-center cohort study
ABSTRACTBackgroundEarly hospital readmission (EHR) is associated with morbidity, mortality, and significant health care costs. However, trends over time in EHR events in kidney transplant recipients have not been examined. We conducted a population-based cohort study using linked health care databases from Ontario, Canada to determine whether the EHR incidence has changed from 2002 to 2014 in kidney transplant recipients.MethodsWe defined EHR as an unplanned admission for any reason to an acute care hospital within 30 days of being discharged from the hospital for transplantation; admissions for elective procedures were excluded.ResultsWe included 5437 kidney transplant recipients. More recently transplanted recipients (2011 to 2014 vs. 2002 to 2004) were older and more likely to have coronary artery disease. A total of 1128 (20.7%) kidney transplant recipients experienced an EHR. There was no trend in EHR across eras with a 30-day cumulative incidence of 23.0%, 21.4%, 18.4%, and 21.0% (P for trend =0.197) for the years 2002 to 2004, 2005 to 2007, 2008 to 2010, and 2011 to 2014, respectively. In the multivariable Cox proportional hazards model, we found no association between era of transplant and EHR. When examining variation in EHR across the 6 adult transplant centers we found the 30-day cumulative incidence varied significantly from 15.5% to 27.1% (P
http://ift.tt/2qcPDiT
http://ift.tt/2qcPDiT
Comparison of DNA Damage and Oxidative Stress in Patients Anesthetized With Desflurane Associated or Not With Nitrous Oxide: A Prospective Randomized Clinical Trial
BACKGROUND: Little is known about the effects of desflurane associated or not with nitrous oxide (N2O) on oxidative stress and patient genetic material. The aim of this study was to compare the effects of anesthesia maintained with desflurane associated or not with N2O on DNA damage (as a primary outcome) and oxidative stress (as a secondary outcome) in patients who underwent an elective minimally invasive surgery. METHODS: This prospective randomized clinical trial analyzed 40 patients of both sexes with an American Society of Anesthesiologists physical status I who were 18–50 years of age and scheduled for septoplasty. The patients were randomly allocated into 2 groups according to anesthesia maintenance as follows: desflurane (n = 20) or desflurane/N2O (n = 20). Blood samples were collected before anesthesia (T1 = baseline), 1.5 hours after anesthesia induction (T2), and on the morning of the postoperative first day (T3). Basal and oxidative DNA damage (determined using formamidopyrimidine DNA glycosylase to detect oxidized purines and endonuclease III to detect oxidized pyrimidines) were evaluated using the comet assay. Oxidative stress markers were evaluated based on lipid peroxidation (by assessing 4-hydroxynonenal and 8-iso-prostaglandin F2α [8-isoprostane] using enzyme linked immunosorbent immunoassay), protein carbonyls (assessed by enzyme linked immunosorbent immunoassay), and antioxidant defense (ferric-reducing antioxidant power by spectrophotometry). The effect size was expressed as the mean differences between groups and the corresponding 95% confidence interval (CI). RESULTS: There was no significant mean difference between groups in relation to DNA damage (−1.7 [95% CI, −7.0 to 3.5]), oxidized DNA pyrimidines (−1.8 [95% CI, −12.5 to 8.9]) and purines (−1.9 [95% CI, −13.9 to 10.1]), 4-hydroxynonenal (−0.2 [95% CI, −2.8 to 2.4]), 8-isoprostane (549 [95% CI, −2378 to 3476]), protein carbonyls (0.2 [95% CI, −2.1 to 2.3]), or ferric-reducing antioxidant power (24 [95% CI, −52.0 to 117.2]). CONCLUSIONS: The coadministration of 60% N2O with desflurane did not seem to impair the effects on DNA or the redox status compared with desflurane anesthesia, suggesting that both studied anesthetic techniques can be suitable options for healthy individuals who undergo minimally invasive surgery lasting at least 1.5 hours. However, due to the low power of the study, more research is necessary to confirm our findings. Accepted for publication November 2, 2017. Funding: Supported by grant 2013/16842-0 from the São Paulo Research Foundation (FAPESP). F.R.N. was granted a scholarship from the National Council for Scientific and Technological Development-CNPq (2014–2015) and from the Coordination of Improvement for Higher Education Personnel-CAPES (2016), and J.R.C.B. received a fellowship from CNPq (303673/2015-0). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). This report was previously presented in part at Euroanaesthesia 2016, London, United Kingdom, May 28-30, 2016. Clinical trial number: the Brazilian Clinical Trials Registry (RBR-6jg23g; Trial Identification UTN Number: U1111-1150-0903). Registry URL: http://ift.tt/2CG5pp6. Reprints will not be available from the authors. Address correspondence to Mariana G. Braz, PhD, Department of Anesthesiology, Botucatu Medical School, São Paulo State University (UNESP), Professor Mário Rubens G. Montenegro Av, 18618–687, Botucatu, SP, Brazil. Address e-mail to mgbraz@hotmail.com. © 2017 International Anesthesia Research Society
http://ift.tt/2DTjnmB
http://ift.tt/2DTjnmB
Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study
BACKGROUND: Dexmedetomidine provides smooth and hemodynamically stable emergence at the expense of hypotension, delayed recovery, and sedation. We investigated the optimal dose of dexmedetomidine for prevention of cough, agitation, hypertension, tachycardia, and shivering, with minimal side effects. METHODS: In this prospective, randomized, double-blind trial, 216 adult patients were randomly assigned to dexmedetomidine 1 µg/kg (D 1), 0.5 µg/kg (D 0.5), 0.25 µg/kg (D 0.25), or control (C). During emergence, cough, agitation, hemodynamic parameters, shivering, time to extubation, and sedation scores were recorded. RESULTS: A total of 190 patients were analyzed. The respective incidences for the groups D 1, D 0.5, and D 0.25 versus group C were 48%, 64%, and 64% vs 84% for cough—corrected P
http://ift.tt/2CEDYM3
http://ift.tt/2CEDYM3
Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different?
BACKGROUND: Routine monitoring of postoperative patients with pulse oximetry–based surveillance monitoring has been shown to reduce adverse events. However, there is some concern that pulse oximetry is limited in its ability to detect deterioration quickly enough to allow for intervention in patients receiving supplemental oxygen. To address such concerns, this study expands on the current limited knowledge of differences in desaturation and respiratory rate characteristics between patients breathing room air and those receiving supplemental oxygen. METHODS: PPulse oximetry–derived data and patient characteristics were used to examine overnight desaturation patterns of 67 postoperative patients who were receiving either supplemental oxygen or breathing room air. The 2 modalities with respect to the speed of desaturation, in addition to magnitude and duration of desaturation events, are compared. Night-time pulse rate, oxygen saturation, respiratory rate, and the transition times from normal oxygen saturation levels to desaturated states are also compared. The behavior of respiratory rate in proximity to desaturation events is described. Statistical methods included multivariable regression and inverse probability of treatment weighted to adjust for any imbalance in patient characteristics between the oxygen and room air patients and linear mixed effect models to account for clustering by patient. RESULTS: The study included 33 patients on room air and 34 receiving supplemental oxygen. The speed of desaturation was not different for room air versus oxygen for 2 types of desaturation (adjusted % difference, 95% confidence interval [CI]: type I; 22.4%, -51.5% to 209%; P = .67, type II; -17.3%, -53.8% to 47.6%; P = .52). Patients receiving supplemental oxygen had a higher mean oxygen saturation (adjusted difference, 95% CI, 2.4 [0.7–4.0]; P = .006). No differences were found for the average overnight respiratory or pulse rate, or proportion of time in desaturation states between the 2 groups. The time to transition from a normal oxygen saturation (92%) to 88% or below was not longer for supplemental oxygen patients (P = .42, adjusted difference 26.1%: 95% CI, -28.1% to 121%). Respiratory rates did not differ between the overall mean and desaturation or recovery phases or between the oxygen and room air group. CONCLUSIONS: In this study, desaturation characteristics did not differ between patients receiving supplemental oxygen and breathing room air with regard to speed, depth, or duration of desaturation. Transition time for desaturations to reach low oxygen saturation alarms was not different, while respiratory rate remained in the normal range during these events. These findings suggest that pulse oximetry–based surveillance monitoring for deterioration detection can be used equally effectively for patients on supplemental oxygen and for those on room air. Accepted for publication November 9, 2017. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Funding: This project was supported by Grant Number P30HS024403 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Andreas H. Taenzer, MS, MD, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756. Address e-mail to andreas.h.taenzer@dartmouth.edu. © 2017 International Anesthesia Research Society
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http://ift.tt/2DTaPw2
American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Patient-Reported Outcomes in an Enhanced Recovery Pathway
Patient-reported outcomes (PROs) are measures of health status that come directly from the patient. PROs are an underutilized tool in the perioperative setting. Enhanced recovery pathways (ERPs) have primarily focused on traditional measures of health care quality such as complications and hospital length of stay. These measures do not capture postdischarge outcomes that are meaningful to patients such as function or freedom from disability. PROs can be used to facilitate shared decisions between patients and providers before surgery and establish benchmark recovery goals after surgery. PROs can also be utilized in quality improvement initiatives and clinical research studies. An expert panel, the Perioperative Quality Initiative (POQI) workgroup, conducted an extensive literature review to determine best practices for the incorporation of PROs in an ERP. This international group of experienced clinicians from North America and Europe met at Stony Brook, NY, on December 2–3, 2016, to review the evidence supporting the use of PROs in the context of surgical recovery. A modified Delphi method was used to capture the collective expertise of a diverse group to answer clinical questions. During 3 plenary sessions, the POQI PRO subgroup presented clinical questions based on a literature review, presented evidenced-based answers to those questions, and developed recommendations which represented a consensus opinion regarding the use of PROs in the context of an ERP. The POQI workgroup identified key criteria to evaluate patient-reported outcome measures (PROMs) for their incorporation in an ERP. The POQI workgroup agreed on the following recommendations: (1) PROMs in the perioperative setting should be collected in the framework of physical, mental, and social domains. (2) These data should be collected preoperatively at baseline, during the immediate postoperative time period, and after hospital discharge. (3) In the immediate postoperative setting, we recommend using the Quality of Recovery-15 score. After discharge at 30 and 90 days, we recommend the use of the World Health Organization Disability Assessment Scale 2.0, or a tailored use of the Patient-Reported Outcomes Measurement Information System. (4) Future study that consistently applies PROMs in an ERP will define the role these measures will have evaluating quality and guiding clinical care. Consensus guidelines regarding the incorporation of PRO measures in an ERP were created by the POQI workgroup. The inclusion of PROMs with traditional measures of health care quality after surgery provides an opportunity to improve clinical care. Accepted for publication November 3, 2017. Funding: The Perioperative Quality Initiative meeting received financial assistance from the American Society for Enhanced Recovery. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu. © 2017 International Anesthesia Research Society
http://ift.tt/2CFknLV
http://ift.tt/2CFknLV
Adductor Canal Block With Continuous Infusion Versus Intermittent Boluses and Morphine Consumption: A Randomized, Blinded, Controlled Clinical Trial
BACKGROUND: Based on the assumption that relatively large volumes of local anesthetic optimize an adductor canal block (ACB), we theorized that an ACB administered as repeated boluses would improve analgesia without compromising mobility, compared with a continuous infusion. METHODS: We performed a randomized, blinded, controlled study, including patients scheduled for total knee arthroplasty with spinal anesthesia. Patients received 0.2% ropivacaine via a catheter in the adductor canal administered as either repeated intermittent boluses (21 mL/3 h) or continuous infusion (7 mL/h). The primary outcome was total (postoperative day [POD], 0–2) opioid consumption (mg), administered as patient-controlled analgesia. Pain, ambulation, and quadriceps muscle strength were secondary outcomes. RESULTS: We randomized 110 patients, of whom 107 were analyzed. Total opioid consumption (POD, 0–2) was a median (range) of 23 mg (0–139) in the bolus group and 26 mg (3–120) in the infusion group (estimated median difference, 4 mg; 95% confidence interval [CI], −13 to 5; P = .29). Linear mixed-model analyses revealed no difference in pain during knee flexion (mean difference, 2.6 mm; 95% CI, −2.9 to 8.0) or at rest (mean difference, 1.7 mm; 95% CI, −1.5 to 4.9). Patients in the bolus group had improved quadriceps sparing on POD 2 (median difference, 7.4%; 95% CI, 0.5%–15.5%). However, this difference was not present on POD 1 or reflected in the ambulation tests (P > .05). CONCLUSIONS: Changing the mode of administration for an ACB from continuous infusion to repeated intermittent boluses did not decrease opioid consumption, pain, nor mobility. Accepted for publication October 24, 2017. Funding: This work was supported by an unrestricted research grant from Smiths Medical (St Paul, MN). In addition, Smiths Medical provided the portable infusion pumps used in this trial. The company had no input or influence into any aspect of study conceptualization, design, data analysis, or reporting of the study. None of the authors have a personal financial interest in this research. Conflicts of Interest: See Disclosures at the end of the article. The abstract has been accepted for presentation at the annual meeting of the American Society of Regional Anesthesia, San Francisco, CA, January 6–8, 2017, and at the IX SIMPAR-ISURA SIMPAR-ISURA (Study In Multidisciplinary Pain Research-International Symposium of Ultrasound for Regional Anesthesia and Pain Medicine) Congress, Florence, Italy, March 29 to April 1, 2017. Clinical trial number: Clinicaltrials.gov Identifier: NCT02539628. Ethics committees approval: H-2-2014-114. Pia Jaeger and Jonas Baggesgaard share first authorship. Reprints will not be available from the authors. Address correspondence to Pia Jaeger, MD, PhD, Department of Anaesthesia 4231, Centre of Head and Orthopaedics, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen E, Denmark. Address e-mail to pia.therese.jaeger@regionh.dk. © 2017 International Anesthesia Research Society
http://ift.tt/2DSU1We
http://ift.tt/2DSU1We
Airway Management by Laryngeal Mask Airways for Cervical Tracheal Resection and Reconstruction: A Single-Center Retrospective Analysis
BACKGROUND: Supraglottic airway devices (SADs) may have advantages over endotracheal intubation for tracheal resection and reconstruction in cases of severe and proximally located subglottic stenosis. This retrospective case series examines the feasibility of using SADs as a novel approach to airway management in tracheal resections. METHODS: All patients who were managed with SADs for cervical tracheal resection and reconstruction during the study period (2010–2015) in our university hospital were included. To examine the feasibility of airway management with SADs for tracheal resection, medical records were obtained from our institution's electronic database and reviewed. RESULTS: SADs were used in 10 patients who had extensive tracheal stenosis and a high prevalence of severe comorbidities. SAD insertion and subsequent positive pressure ventilation were successful in all patients, although 1 patient with preoperative respiratory failure had persistent hypercarbia. During the phase of resection and reconstruction, high-frequency jet ventilation was used to ensure adequate oxygenation. There were no intraoperative complications related to anesthetic management, apart from transient hypercarbia during and after jet ventilation. Most patients (n = 6; 60%) had an uneventful postoperative course. In this high-risk cohort, postoperative complications (ie, vocal cord edema, postoperative hemorrhage, pneumonia) occurred in 4 patients (40%). CONCLUSIONS: This retrospective case series demonstrates the feasibility of using supraglottic airways alongside high-frequency jet ventilation for airway management in at least some cases of cervical tracheal resection and reconstruction. However, the small number of cases examined limits conclusions regarding indications, contraindications, and periprocedural safety. Accepted for publication November 13, 2017. Funding: None. The authors declare no conflicts of interest. Patient consent: Requirement waived by institutional review board. Ethics approval: Approval by institutional review board of the University Hospital Witten/Herdecke, Medical Center Cologne-Merheim, Board supervisor: Professor Maune. Reprints will not be available from the authors. LMA is a registered trademark of Teleflex Incorporated or its affiliates. Address correspondence to Mark Schieren, MD, Department of Anesthesiology and Intensive Care Medicine, Medical Centre Cologne, University Witten/Herdecke, Ostmerheimer Strasse 200, 51109 Cologne, Germany. Address e-mail to mark.schieren@uni-wh.de. © 2017 International Anesthesia Research Society
http://ift.tt/2CEL0R3
http://ift.tt/2CEL0R3
American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery
The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period. Accepted for publication October 27, 2017 Funding: The Perioperative Quality Initiative (POQI) meeting received financial assistance from the American Society for Enhanced Recovery (ASER). Conflicts of Interest: See Disclosures at the end of the article. For the Perioperative Quality Initiative (POQI) 2 Workgroup, see Appendix 1. Reprints will not be available from the authors. Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu. © 2017 International Anesthesia Research Society
http://ift.tt/2DTcXUT
http://ift.tt/2DTcXUT
Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe
BACKGROUND: Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe. METHODS: In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization. RESULTS: The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were
http://ift.tt/2CEKS41
http://ift.tt/2CEKS41
Prophylactic Platelet Transfusions for Critically Ill Patients With Thrombocytopenia: A Single-Institution Propensity-Matched Cohort Study
BACKGROUND: Thrombocytopenia is frequently encountered in critically ill patients, often resulting in prophylactic transfusion of platelets for the prevention of bleeding complications. However, the efficacy of this practice remains unclear. The objective of this study was to determine the relationship between prophylactic platelet transfusion and bleeding complications in critically ill patients. METHODS: This is a retrospective cohort study of adults admitted to surgical, medical, or combined medical-surgical intensive care units (ICUs) at a single academic institution between January 1, 2009, and December 31, 2013. Inclusion criteria included age ≥18 years and a platelet count measured during ICU admission. Propensity-matched analyses were used to evaluate associations between prophylactic platelet transfusions and the outcomes of interest with a primary outcome of red blood cell transfusion in the ensuing 24 hours and secondary outcomes of ICU and hospital-free days and changes in sequential organ failure assessment scores. RESULTS: A total of 40,693 patients were included in the investigation with 3227 (7.9%) receiving a platelet transfusion and 1065 (33.0%) for which platelet transfusion was prophylactic in nature. In propensity-matched analyses, 994 patients with prophylactic platelet transfusion were matched to those without a transfusion. Patients receiving prophylactic platelets had significantly higher red blood cell transfusion rates (odds ratio 7.5 [5.9–9.5]; P
http://ift.tt/2DTcXnR
http://ift.tt/2DTcXnR
Heating and Cooling Rates With an Esophageal Heat Exchange System
BACKGROUND: The Esophageal Cooling Device circulates warm or cool water through an esophageal heat exchanger, but warming and cooling efficacy in patients remains unknown. We therefore determined heat exchange rates during warming and cooling. METHODS: Nineteen patients completed the trial. All had general endotracheal anesthesia for nonthoracic surgery. Intraoperative heat transfer was measured during cooling (exchanger fluid at 7°C) and warming (fluid at 42°C). Each was evaluated for 30 minutes, with the initial condition determined randomly, starting at least 40 minutes after induction of anesthesia. Heat transfer rate was estimated from fluid flow through the esophageal heat exchanger and inflow and outflow temperatures. Core temperature was estimated from a zero-heat-flux thermometer positioned on the forehead. RESULTS: Mean heat transfer rate during warming was 18 (95% confidence interval, 16–20) W, which increased core temperature at a rate of 0.5°C/h ± 0.6°C/h (mean ± standard deviation). During cooling, mean heat transfer rate was −53 (−59 to −48) W, which decreased core temperature at a rate of 0.9°C/h ± 0.9°C/h. CONCLUSIONS: Esophageal warming transferred 18 W which is considerably less than the 80 W reported with lower or upper body forced-air covers. However, esophageal warming can be used to supplement surface warming or provide warming in cases not amenable to surface warming. Esophageal cooling transferred more than twice as much heat as warming, consequent to the much larger difference between core and circulating fluid temperature with cooling (29°C) than warming (6°C). Esophageal cooling extracts less heat than endovascular catheters but can be used to supplement catheter-based cooling or possibly replace them in appropriate patients. Accepted for publication October 20, 2017. Funding: This work was supported by Advanced Cooling Therapy (Chicago, IL). Conflicts of Interest: See Disclosures at the end of the article. Institutional review board: Cleveland Clinic Institutional Review Board, 9500 Euclid Ave, Desk OS01, Cleveland, OH 44195. E-mail: IRBCOI@ccf.org. This study was registered at ClinicalTrials.gov. Reprints will not be available from the authors., Address correspondence to Daniel I. Sessler, MD, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave—P77, Cleveland, OH 44195. Address e-mail to DS@OR.org. © 2017 International Anesthesia Research Society
http://ift.tt/2CIwp7m
http://ift.tt/2CIwp7m
Axillary Temperature, as Recorded by the iThermonitor WT701, Well Represents Core Temperature in Adults Having Noncardiac Surgery
BACKGROUND: Core temperature can be accurately measured from the esophagus or nasopharynx during general anesthesia, but neither site is suitable for neuraxial anesthesia. We therefore determined the precision and accuracy of a novel wireless axillary thermometer, the iThermonitor, to determine its suitability for use during neuraxial anesthesia and in other patients who are not intubated. METHODS: We enrolled 80 adults having upper abdominal surgery with endotracheal intubation. Intraoperative core temperature was measured in distal esophagus and was estimated at the axilla with a wireless iThermonitor WT701 (Raiing Medical, Boston MA) at 5-minute intervals. Pairs of axillary and reference distal esophageal temperatures were compared and summarized using linear regression and repeated-measured Bland–Altman methods. We a priori determined that the iThermonitor would have clinically acceptable accuracy if most estimates were within ±0.5°C of the esophageal reference, and suitable precision if the limits of agreement were within ±0.5°C. RESULTS: There were 3339 sets of paired temperatures. Axillary and esophageal temperatures were similar, with a mean difference (esophageal minus axillary) of only 0.14°C ± 0.26°C (standard deviation). The Bland–Altman 95% limits of agreement were reasonably narrow, with the estimated upper limit at 0.66°C and the lower limit at −0.38°C, thus ±0.52°C, indicating good agreement across the range of mean temperatures from 34.9°C to 38.1°C. The absolute difference was within 0.5°C in 91% of the measurements (95% confidence interval, 88%–93%). CONCLUSIONS: Axillary temperature, as recorded by the iThermonitor WT701, well represents core temperature in adults having noncardiac surgery and thus appears suitable for clinical use. Accepted for publication September 29, 2017. Funding: This work was supported by the Raiing Medical, Boston, MA. None of the authors has a personal financial interest in this research. The sponsor was not involved in data analysis or interpretation. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Yuguang Huang, MD, Department of Anesthesiology, Peking Union Medical College Hospital (PUMCH), 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China. Address e-mail to garybeijing@163.com (www.OR.org). © 2017 International Anesthesia Research Society
http://ift.tt/2CFkkjd
http://ift.tt/2CFkkjd
Severe macroglossia after posterior fossa and craniofacial surgery in children
Publication date: Available online 1 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): J. Bouaoud, A. Joly, A. Picard, B. Thierry, E. Arnaud, S. James, I. Hennessy, B. McGarvey, P. Cairet, A. Vecchione, E. Vergnaud, C. Duracher, R.H. Khonsari
Massive swelling of the tongue can occur after posterior fossa and craniofacial surgery. Several hypotheses have been proposed to explain the occurrence of such severe postoperative macroglossia, but this phenomenon is still poorly understood. Severe postoperative macroglossia can be a life-threatening condition due to upper airway obstruction. Three cases of severe postoperative macroglossia that occurred after cervical spine, craniofacial, and posterior fossa surgical procedures are reported here. These cases required specialized maxillofacial management and a prolonged stay in the intensive care unit. Causal factors involved in this condition are reported, in order to highlight appropriate prevention and treatment options adapted to the management of paediatric patients. An overview of the current literature on severe postoperative macroglossia in paediatric populations is also provided.
http://ift.tt/2A7u5nr
Alopecia Areata: Who Gets Screened for Thyroid Disease?
Many children with alopecia areata get screened for thyroid disease. But do they all need to be?
CHOP Expert Commentary
http://ift.tt/2Cspgu9
Erratum to “Experience with a simplified eucapnic voluntary hyperventilation (EVH) device for diagnosis of exercise-induced bronchospasm”
Source:Annals of Allergy, Asthma & Immunology
http://ift.tt/2lExyFG
Study of Anlotinib Plus Irinotecan in Patients With Esophageal Squamous Cell Carcinoma
Condition: Esophageal Squamous Cell Carcinoma
Interventions: Drug: Anlotinib Plus Irinotecan; Drug: Irinotecan
Sponsor: The First Affiliated Hospital of Zhengzhou University
Not yet recruiting
http://ift.tt/2Cued4c
Interventions: Drug: Anlotinib Plus Irinotecan; Drug: Irinotecan
Sponsor: The First Affiliated Hospital of Zhengzhou University
Not yet recruiting
http://ift.tt/2Cued4c
Feasibility of Multi-Spectral Endoscopic Imaging for Detection of Early Neoplasia in Barrett's Oesophagus
Conditions: Barrett Esophagus; Esophageal Neoplasms; Reflux Esophagitis
Intervention: Device: Endoscopy with Polyscope (Polydiagnost TM) coupled with Multi-Spectral Imaging light-source
Sponsor: University of Cambridge
Not yet recruiting
http://ift.tt/2C9PoX7
Intervention: Device: Endoscopy with Polyscope (Polydiagnost TM) coupled with Multi-Spectral Imaging light-source
Sponsor: University of Cambridge
Not yet recruiting
http://ift.tt/2C9PoX7
PLD Combined With Cisplatin in the Treatment of Advanced Poorly Differentiated Thyroid Carcinoma
Condition: Poorly Differentiated Thyroid Carcinoma
Interventions: Drug: PLD; Drug: Cisplatin
Sponsor: CSPC ZhongQi Pharmaceutical Technology Co., Ltd.
Recruiting
http://ift.tt/2CDr94T
Interventions: Drug: PLD; Drug: Cisplatin
Sponsor: CSPC ZhongQi Pharmaceutical Technology Co., Ltd.
Recruiting
http://ift.tt/2CDr94T
Safety and Efficacy of Ulinastatin for Reducing Radiation-Induced Oral Mucositis in Nasopharyngeal Carcinoma Patients
Condition: Oral Mucositis (Ulcerative) Due to Radiation
Interventions: Drug: Cisplatin; Radiation: Intensity Modulated Radiation Therapy; Drug: Ulinastatin
Sponsors: Sun Yat-sen University; Cancer Hospital of Guangzhou Medical University; First People's Hospital of Foshan; People's Hospital of Zhongshan; Fifth Affiliated Hospital, Sun Yat-Sen University
Not yet recruiting
http://ift.tt/2CctN0k
Interventions: Drug: Cisplatin; Radiation: Intensity Modulated Radiation Therapy; Drug: Ulinastatin
Sponsors: Sun Yat-sen University; Cancer Hospital of Guangzhou Medical University; First People's Hospital of Foshan; People's Hospital of Zhongshan; Fifth Affiliated Hospital, Sun Yat-Sen University
Not yet recruiting
http://ift.tt/2CctN0k
Pigmented epithelioid melanocytoma with nodal melanosis: A rare cause of cystic cervical lymphadenopathy
Abstract
Background
Head and neck malignancies often present as firm, solid nodal masses. However, malignancies arising from Waldeyer's Ring may give rise to cystic lymph nodes.
Methods
A 57-year-old man was referred for left-sided neck swelling of 2 weeks' duration. A CT scan revealed an enlarged cystic cervical node at level 5A/B and he underwent excision biopsy.
Results
Histology reported nodal fibrosis with melanophages. Further examination revealed a black nodule on his back where he had wide excision and the histology confirmed pigmented epithelioid melanocytoma.
Conclusion
Cervical lymphadenopathy can rarely be due to an upper back lesion, such as pigmented epithelioid melanocytoma. Thus, routine clinical examination of the upper back should be performed in patients with cervical lymphadenopathy.
http://ift.tt/2DQbSNq
Phototherapie der entzündlichen Akne
Zusammenfassung
Verfahren der Phototherapie könnten sich als neue Ansätze der Aknebehandlung etablieren, die das Risiko bakterieller Resistenzen nicht steigern und bei günstigem Sicherheitsprofil potenziell wirksam sind. Nach aktuellen Studiendaten bewirkt die photodynamische Therapie eine Verringerung entzündlicher Läsionen und eine deutliche Verbesserung der Akne. Allerdings besteht keine Einigkeit über die optimale Durchführung im Rahmen der Aknebehandlung. Neben der topisch angewendeten photodynamischen Therapie wurden die Intense-pulsed-light-Methode (hochenergetische Lichtblitze), gepulste Farbstofflaser, Kaliumtitanylphosphatlaser, Infrarotdiodenlaser und polychromatische Lichtquellen (Rotlicht, Rot-blau-Licht) als alternative Verfahren eingeführt. Da gut konzipierte Studien zur Wirksamkeitsprüfung im Vergleich zu traditionellen Pharmakotherapien fehlen und die Methoden nicht standardisiert sind, sollten Verfahren wie Laser‑, Intense-pulsed-light- und photodynamische Therapie gegenwärtig nicht als Erstlinienbehandlung der entzündlichen Akne betrachtet werden.
http://ift.tt/2CbO85T
308 nm-Excimerlaser
Zusammenfassung
Die 308 nm-Excimerlasertherapie von Hypopigmentierungen und Vitiligo ist der herkömmlichen UV-Therapie hinsichtlich Ergebnissen und Sicherheit meist überlegen. Sie ist insbesondere vorteilhaft, wenn Herde gezielt behandelt werden können, ohne die übrige Haut zu belasten. Es sind weniger Sitzungen mit geringerer kumulativer Dosierung nötig. Verschiedene Kombinationstherapien können das Resultat verbessern, Auswahlkriterien wie früher Behandlungsbeginn und häufigere Sitzungen mit geringeren Abständen erleichtern die Entscheidung, welche Patienten wie behandelt werden sollen und wie am meisten erreicht wird.
http://ift.tt/2CbGaJV
European guidelines on perioperative venous thromboembolism prophylaxis: Day surgery and fast-track surgery
In recent years, day surgery and fast-track surgery have experienced a continuous increase in volume. Many procedures are now performed on an outpatient protocol, including general, orthopaedic, oncological, reconstructive or vascular surgery. The management of these patients is safe, but the incidence of venous thromboembolism in this population remains unknown. Several risk factors can be identified and stratified derived from studies of inpatient surgical management (e.g. Caprini score). Recommendations for thromboprophylaxis should be tailored from the assessment of both personal and procedure-related risk factors, although with a lack of evidence for application in outpatient management. For patients undergoing a low-risk procedure without additional risk factors, we recommend only general measures of thromboprophylaxis (early ambulation, optimal hydration) (Grade 1B). For patients undergoing a low-risk procedure with additional risk factors, or a high-risk procedure without additional risk factors, we recommend general measures of thromboprophylaxis (Grade 1B) and we suggest the administration of pharmacological prophylaxis with low molecular weight heparins (Grade 2B). For patients undergoing a high-risk procedure with additional risk factors we recommend general measures of thromboprophylaxis (Grade 1B) and pharmacological prophylaxis with low molecular weight heparins over other drugs (Grade 1B), or suggest specific mechanical measures in case of increased bleeding risk (Grade 2C). Pharmacological prophylaxis should last a minimum of 7 days (Grade 1B), although in selected cases of fast-track surgery, thromboprophylaxis could be limited to hospitalisation only (Grade 2C) and in specific cases of high-risk procedures, thromboprophylaxis could be extended for up to 4 weeks (Grade 2B).http://ift.tt/2DNYLfy
European guidelines on perioperative venous thromboembolism prophylaxis: Aspirin
There is a good rationale for the use of aspirin in venous thromboembolism prophylaxis in some orthopaedic procedures, as already proposed by the 9th American College of Chest Physicians' guidelines (Grade 1C). We recommend using aspirin, considering that it may be less effective than or as effective as low molecular weight heparin for prevention of deep vein thrombosis and pulmonary embolism after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (Grade 1C). Aspirin may be less effective than or as effective as low molecular weight heparins for prevention of deep vein thrombosis and pulmonary embolism after other orthopaedic procedures (Grade 2C). Aspirin may be associated with a low rate of bleeding after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (Grade 1B). Aspirin may be associated with less bleeding after total hip arthroplasty, total knee arthroplasty and hip fracture surgery than other pharmacological agents (Grade 1B). No data are available for other orthopaedic procedures. We do not recommend aspirin as thromboprophylaxis in general surgery (Grade 1C). However, this type of prophylaxis could be interesting especially in low-income countries (Grade 2C) and adequate large-scale trials with proper study designs should be carried out (Grade 1C).http://ift.tt/2EAAydO
European guidelines on perioperative venous thromboembolism prophylaxis: Cardiovascular and thoracic surgery
None of the predictive models for venous thromboembolism (VTE) prophylaxis have been designed for and validated in patients undergoing cardiothoracic and vascular surgery. The presence of one or more risk factors [age over 70 years old, transfusion of more than 4 U of red blood cells/fresh frozen plasma/cryoprecipitate, mechanical ventilation lasting more than 24 h, postoperative complication (e.g. acute kidney injury, infection/sepsis, neurological complication)] should place the cardiac population at high risk for VTE. In this context, we suggest the use of pharmacological prophylaxis as soon as satisfactory haemostasis has been achieved, in addition to intermittent pneumatic compression (IPC) (Grade 2C). In patients undergoing abdominal aortic aneurysm repair, particularly when an open surgical approach is used, the risk for VTE is high and the bleeding risk is high. In this context, we suggest the use of pharmacological prophylaxis as soon as satisfactory haemostasis is achieved (Grade 2C). Patients undergoing thoracic surgery in the absence of cancer could be considered at low risk for VTE. Patients undergoing thoracic surgery with a diagnosis of primary or metastatic cancer should be considered at high risk for VTE. In low-risk patients, we suggest the use of mechanical prophylaxis using IPC (Grade 2C). In high-risk patients, we suggest the use of pharmacological prophylaxis in addition to IPC (Grade 2B).
http://ift.tt/2DNYEk8
http://ift.tt/2DNYEk8
European guidelines on perioperative venous thromboembolism prophylaxis: Intensive care
Venous thromboembolism is a common and potentially life-threatening complication that occurs in 4 to 15% of patients admitted to ICUs despite the routine use of pharmacological prophylaxis. We therefore recommend an institution-wide protocol for the prevention of venous thromboembolism (Grade 1B). The routine use of ultrasonographic screening for deep vein thrombosis is not recommended when thromboprophylactic measures are in place (Grade 1B), as the detection of asymptomatic deep vein thrombosis may prompt therapeutic anticoagulation that may increase bleeding risk but has no proven reduction of clinically significant thrombotic events. In critically ill patients, we recommend pharmacological prophylaxis with low molecular weight heparin over low-dose heparin (Grade 1B). For critically ill patients with severe renal insufficiency, we suggest the use of low-dose heparin (Grade 2C), dalteparin (Grade 2B) or reduced doses of enoxaparin (Grade 2C). Monitoring of anti-Xa activity may be considered when low molecular weight heparin is used in these patients (Grade 2C). No study has prospectively evaluated the efficacy and safety of deep vein thrombosis prophylaxis in critically ill patients with severe liver dysfunction. Thus, the use of pharmacological prophylaxis in these patients should be carefully balanced against the risk of bleeding. For critically ill patients, we recommend against the routine use of inferior vena cava filters for the primary prevention of venous thromboembolism (Grade 1C). When the diagnosis of heparin-induced thrombocytopaenia is suspected or confirmed, all forms of heparin must be discontinued (Grade 1B). In these patients, immediate anticoagulation with a nonheparin anticoagulant rather than discontinuation of heparin alone is recommended (Grade 1C).
http://ift.tt/2EBxVZw
http://ift.tt/2EBxVZw
European guidelines on perioperative venous thromboembolism prophylaxis: Neurosurgery
Although there are numerous publications addressing venous thromboembolism and its prevention in neurosurgery, there are relatively few high-quality studies to guide decisions regarding thromboprophylaxis. In patients undergoing craniotomy, we recommend that if intermittent pneumatic compression (IPC) is used, it should be applied before the surgical procedure or on admission (Grade 1C). In craniotomy patients at particularly high risk for venous thromboembolism, we suggest considering the initiation of mechanical thromboprophylaxis with IPC preoperatively with addition of low molecular weight heparin (LMWH) postoperatively when the risk of bleeding is presumed to be decreased (Grade 2C). In patients with non-traumatic intracranial haemorrhage, we suggest thromboprophylaxis with IPC (Grade 2C). For patients who have had non-traumatic intracranial haemorrhage, we suggest giving consideration to commencement of LMWH or low-dose unfractionated heparin when the risk of bleeding is presumed to be low (Grade 2C). We suggest continuing thromboprophylaxis until full mobilisation of the patient (Grade 2C). For patients undergoing spinal surgery with no additional risk factors, we suggest no active thromboprophylaxis intervention apart from early mobilisation (Grade 2C). For patients undergoing spinal surgery with additional risk factors, we recommend starting mechanical thromboprophylaxis with IPC (Grade 1C), and we suggest the addition of LMWH postoperatively when the risk of bleeding is presumed to be decreased (Grade 2C).http://ift.tt/2EzwD0T
European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly
The risk for postoperative venous thromboembolism (VTE) is increased in patients aged more than 70 years and in elderly patients presenting with co-morbidities, for example cardiovascular disorders, malignancy or renal insufficiency. Therefore, risk stratification, correction of modifiable risks and sustained perioperative thromboprophylaxis are essential in this patient population. Timing and dosing of pharmacoprophylaxis may be adopted from the non-aged population. Direct oral anti-coagulants are effective and well tolerated in the elderly; statins may not replace pharmacological thromboprophylaxis. Early mobilisation and use of non-pharmacological means of thromboprophylaxis should be exploited. In elderly patients, we suggest identification of co-morbidities increasing the risk for VTE (e.g. congestive heart failure, pulmonary circulation disorder, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy) and correction if present (e.g. anaemia, coagulopathy) (Grade 2C). We suggest against bilateral knee replacement in elderly and frail patients (Grade 2C). We suggest timing and dosing of pharmacological VTE prophylaxis as in the non-aged population (Grade 2C). In elderly patients with renal failure, low-dose unfractionated heparin (UFH) may be used or weight-adjusted dosing of low molecular weight heparin (Grade 2C). In the elderly, we recommend careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation (Grade 1C). We recommend multi-faceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, low molecular weight heparin (and/or direct oral anti-coagulants after knee or hip replacement) (Grade 1C). This article is part of the European guidelines on perioperative venous thromboembolism prophylaxis. For details concerning background, methods, and members of the ESA VTE Guidelines Task Force, please, refer to: Samama CM, Afshari A, for the ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis. Eur J Anaesthesiol 2018; 35:73–76. A synopsis of all recommendations can be found in the following accompanying article: Afshari A, Ageno W, Ahmed A, et al., for the ESA VTE Guidelines Task Force. European Guidelines on perioperative venous thromboembolism prophylaxis. Executive summary. Eur J Anaesthesiol 2018; 35:77–83.
http://ift.tt/2DQcNxw
http://ift.tt/2DQcNxw
European guidelines on perioperative venous thromboembolism prophylaxis: Patients with preexisting coagulation disorders and after severe perioperative bleeding
In patients with inherited bleeding disorders undergoing surgery, we recommend assessment of individual risk for venous thromboembolism, taking into account the nature of the surgery and anaesthetic, type and severity of bleeding disorder, age, BMI, history of thrombosis, the presence of malignancy and other high-risk comorbidities. Venous thromboembolism risk should be balanced against the increased bleeding risk associated with anticoagulant use in patients with known bleeding disorders (Grade 1C). In these patients undergoing major surgery, we recommend against routine postoperative use of pharmacological thromboprophylaxis, especially for patients with haemophilia A and B (Grade 1B). Glomerular filtration rate should be assessed before initiation of each direct oral anticoagulant, and also at least once a year or more frequently as needed, such as postoperatively before the resumption of therapeutic direct oral anticoagulant administration, when it is suspected that renal function could decline or deteriorate (Grade 1C). Reduced dosages of low molecular weight heparins may be used relatively safely during transient severe (http://ift.tt/2DMGH5q
European guidelines on perioperative venous thromboembolism prophylaxis: Surgery during pregnancy and the immediate postpartum period
Thromboembolic events in the pregnant and postpartum patient remain rare but potentially fatal complications. The aim of this section was to analyse the few prospective studies addressing the issue of thromboprophylaxis following a surgical procedure during and immediately after pregnancy, as well as national guidelines, and to propose European guidelines on this specific condition. Thromboprophylaxis is broadly recommended due to the combined risks of surgery and pregnancy or the postpartum period, regardless of the mode of delivery. We recommend prophylactic thromboprophylaxis following surgery during pregnancy or the postpartum period when they imply, as a consequence, bed rest, until full mobility is recovered (Grade 1C). Similarly, thromboprophylaxis should be used in cases of perioperative infection during pregnancy or the postpartum period. Concerning thromboprophylaxis following a caesarean section, it seems avoidable only in elective procedures in low-risk patients, after a normal pregnancy, and with an early rehabilitation protocol. The duration of thromboprophylaxis following caesarean section should be at least 6 weeks for high-risk patients, and at least 7 days for the other patients requiring anticoagulation (Grade 1C).
http://ift.tt/2ECDff1
http://ift.tt/2ECDff1
European guidelines on perioperative venous thromboembolism prophylaxis: Inferior vena cava filters
The indications for the use of an inferior vena cava filter (IVCF) in the context of deep venous thrombosis to prevent pulmonary embolism remain controversial. Despite wide use in clinical practice, great variation exists in national and international guidelines in regard to the indications. In addition, clinical practice is based on poor-quality data from trauma and bariatric surgery with a high incidence of complications. It is often difficult to assess their efficacy and lack of filter retrieval appears to be a substantial issue compared with a potential benefit by insertion of these devices. Complications usually refer to increased risk of deep venous thrombosis, filter perforation, filter penetration, filter migration, inferior vena cava occlusion and subsequently failure in pulmonary embolism prevention. Evidence from low-quality studies or registries, with small numbers of patients and conflicting findings, does not allow for a strong recommendation for or against the use of IVCFs. IVCFs should only be considered in cases of very high risk of pulmonary embolism and in perioperative situations at very high risk of bleeding, resulting in a prolonged contra-indication to pharmacological prophylaxis.
http://ift.tt/2DNYoBG
http://ift.tt/2DNYoBG
European guidelines on perioperative venous thromboembolism prophylaxis: Chronic treatments with antiplatelet agents
Antiplatelet agents (APA) are considered first-line therapy in preventing cardiovascular thrombotic events, but they are of limited value in the prophylaxis of venous thromboembolism (VTE) during the perioperative period. Consequently, many patients should receive both an APA and an anticoagulant. This combination can increase the bleeding risk and it is necessary to make some recommendations to minimise that risk. In patients receiving APA chronically, if the risk of VTE outweighs the risk of bleeding, we suggest pharmacological prophylaxis (grade 2C). In patients treated with dual antiplatelet therapy undergoing a procedure associated with a high risk of VTE, resuming both APA shortly after the procedure must be prioritised over pharmacological VTE prevention (grade 2C). If the risk of bleeding from a combination of an APA and an anticoagulant outweighs the risk of VTE, we suggest mechanical thromboprophylaxis over anticoagulant prophylaxis, without discontinuing the APA (grade 2C). Patients in whom neuraxial anaesthesia is planned, a higher rate of complications could occur if pharmacological thromboprophylaxis is administered concurrently and postoperative thromboprophylaxis initiation should be suggested (grade 2C). After surgery, the first dose of aspirin should be given once haemostasis is guaranteed (grade 2B). In the case of clopidogrel, give the drug without a loading dose between 24 and 48 h after surgery (grade 2C).
http://ift.tt/2EBwqKS
http://ift.tt/2EBwqKS
European guidelines on perioperative venous thromboembolism prophylaxis: Mechanical prophylaxis
Institutional protocols need to address the indications for pharmacological and mechanical thromboprophylaxis. The use of graduated compression stockings (GCS) and intermittent pneumatic compression (IPC) strongly differs between institutions. As a consequence, no strong recommendations can be made based on the contemporary high-level evidence. Although different clinical practices can be supported, such approaches should be part of an institutional strategy to reduce the burden of venous thromboembolism (VTE). We recommend against the use of GCS alone without pharmacological thromboprophylaxis for prevention of VTE in patients at intermediate and high risk. For patients at high risk of VTE with contraindications for pharmacological thromboprophylaxis, we recommend the use of mechanical prophylaxis and suggest the use of IPC over GCS. However, for those patients receiving pharmacological thromboprophylaxis who are without a very high risk of VTE prophylaxis, we recommend against the routine use of mechanical thromboprophylaxis either with GCS or IPC. We suggest combined mechanical and pharmacological prophylaxis in selected patients at very high risk of VTE prophylaxis and suggest IPC rather than GCS in these selected patients.
http://ift.tt/2DQbG0J
http://ift.tt/2DQbG0J
European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the obese patient
A systematic literature search was performed and patients were selected as obese patients undergoing bariatric surgery or obese patients undergoing nonbariatric surgical procedures. In addition, patients were stratified according to low risk of venous thromboembolism and high risk of venous thromboembolism (age >55 years, BMI >55 kg m−2, history of venous thromboembolism, venous disease, sleep apnoea, hypercoagulability or pulmonary hypertension). Prophylaxis of venous thromboembolism was analysed depending on the type of modality: compression devices of the lower extremities (including intermittent pneumatic compression and graduated compression stockings), pharmacological prophylaxis or inferior vena cava filters. Two prospective studies compared mechanical devices and pharmacological prophylaxis vs. a mechanical device alone without significant differences. A few randomised controlled studies and most of the prospective nonrandomised studies showed that low-dose low molecular weight heparin (3000 to 4000 anti-Xa IU 12 h−1 subcutaneously) was acceptable for obese patients with a lower risk of venous thromboembolism, but a higher dose of low molecular weight heparin (4000 to 6000 anti-Xa IU 12 h−1 subcutaneously) should be proposed for obese patients with a higher risk of venous thromboembolism. Extended prophylaxis for 10 to 15 days was well tolerated for obese patients with a high risk of venous thromboembolism in the postdischarge period. The safety and efficacy of inferior vena cava filters in bariatric surgical patients is highly heterogeneous. There were no randomised trials that analysed prophylaxis of venous thromboembolism in obese patients undergoing nonbariatric surgery. Higher doses of anticoagulants could be proposed for obese patients with a BMI more than 40 kg m−2. The lack of good quality randomised trials with a low risk of bias did not allow us to propose strong recommendations.
http://ift.tt/2EChRGX
http://ift.tt/2EChRGX
Age and Unplanned Postoperative Visits Predict Outcome after Septoplasty: A National Swedish Register Study
Objective. To study predictors of symptom relief six months after septoplasty using data from the Swedish National Septoplasty Register. Participants. This is a retrospective register study of adult patients undergoing septoplasty in Sweden in 2003–2012. Outcome. Relief of nasal symptoms was analysed in relation to age, gender, size of hospital performing the surgery, addition of turbinoplasty, and unplanned postoperative visits to the hospital due to pain, bleeding, or infection. Results. In all, 76% of the patients () rated their symptoms as "almost gone" or "gone" six months after septoplasty. With every 10-year increase in the age of the patients, the OR was 1.19, 95% CI 1.15–1.23, for a better result and 1.54, 95% CI 1.38–1.71, if the septoplasty was performed at a county hospital versus a university hospital. If there was no unplanned postoperative visit due to pain, bleeding, or infection, the OR for a better result was 1.6, 95% CI 1.39–1.85. Conclusion. In this large national cohort of septoplasties, most of the patients felt that their symptoms had gone or almost gone six months after septoplasty. Higher age, surgery at smaller hospitals, and no unplanned visits to the hospital postoperatively predicted a better outcome.
http://ift.tt/2A3r33y
Focal adhesion kinases in head and neck squamous cell carcinoma
Abstract
Background
Focal adhesion kinase (FAK) phosphorylation contributes to the regulation of growth factors that promote cellular adhesion, mobility, and survival, being a key factor in tumor development. The objective of this study was to evaluate the immunohistochemical expression patterns of FAK and its phosphorylated forms, FAK Tyr-576 and FAK Tyr-925, in head and neck squamous cell carcinoma and non-neoplastic adjacent epithelial tissue.
Methods
The percentage of immunohistochemistry stained cells and its correlation with clinicopathological variables and prognosis were determined using samples from 54 patients.
Results
FAK, FAK Tyr-576, and FAK Tyr-925 overexpression was observed in tumor zones and non-neoplastic adjacent epithelial tissue. FAK Tyr-576 immunostaining showed a relationship with tumor clinicopathological parameters. Moreover, positive immunostaining of FAK Tyr-576 in non-neoplastic adjacent epithelial tissue was associated with patients prognoses.
Conclusions
Increased expression of FAK Tyr-576 could enable identifcation of tumors with a more aggressive behavior and epithelial alterations before the appearance of clinical or histological manifestations.
This article is protected by copyright. All rights reserved.
http://ift.tt/2qbnIj3
Candida species in patients with oral dysesthesia: a comparison of carriage among oral disease states
Abstract
Objectives
Oral dysesthesia (burning mouth syndrome) is characterised by a burning-like sensation of the oral mucosa. The aetiology of this disorder is still unknown, however associations with oral fungal carriage have been proposed and applied clinically. The aim of the this study was to compare oral Candida carriage in patients with oral dysesthesia with Candida carriage in patients with other commonly diagnosed oral diseases to clarify the relationship between Candida and oral dysesthesia.
Subjects and Methods
441 patients in total including 79 patients diagnosed with oral dysesthesia were included in this study. A retrospective analysis of mycological investigations undertaken in patients with clinically diagnosed oral dysesthesia compared with other oral conditions was undertaken.
Results
Oral carriage of Candida was found in 63.3% (50 of 79) of patients with oral dysesthesia. The frequency of carriage, and oral load of Candida were not significantly increased in patients with oral dysesthesia relative to the other conditions assessed. Patients with clinical signs of fungal infection or xerostomia presented with increased carriage of Candida.
Conclusion
There is no association between oral dysesthesia and the presence or load of oral Candida.
This article is protected by copyright. All rights reserved.
http://ift.tt/2lDfn2Y
A novel succinate dehydrogenase subunit B germline variant associated with head and neck paraganglioma in a Dutch kindred: a family based study
Abstract
Objective
In the Netherlands, the majority of hereditary head and neck paragangliomas (HNPGL) are caused by germline variants in the succinate dehydrogenase genes (SDHD, SDHB, SDHAF2). Here, we evaluate a four-generation family linked to a novel SDHB gene variant with the manifestation of a HNPGL.
Design
a family based study.
Setting
The VU University Medical Center (VUmc) Amsterdam, a tertiary clinic for Otolaryngology and Head and Neck Surgery.
Participants and main outcome measures
The index patients presented with an embryonic rhabdomyosarcoma and a non-Hodgkin lymphoma. Array-based comparative genomic hybridization (aCGH) analysis and multiplex ligation-dependent probe amplification (MLPA) revealed a novel deletion of exon 1-3 in the SDHB gene, suspected to predispose to paraganglioma (PGL)/pheochromocytoma (PHEO) syndrome type 4. Subsequently, genetic counseling and DNA testing was offered to all family members at risk. Individuals that tested positive for this novel SDHB gene variant were counseled and additional clinical evaluation was offered for the identification of HNPGL and/or PHEO.
Results
The DNA of 18 family members was tested, resulting in the identification of 10 carriers of the exon 1-3 deletion in the SDHB gene. One carrier was diagnosed with a carotid body PGL and serum catecholamine excess, which was surgically excised. Negative SDHB immunostaining of the carotid body tumour confirmed that it was caused by the SDHB variant. The remaining 9 carriers showed no evidence of PGL/PHEO.
Conclusion
Deletion of exon 1-3 in the SDHB gene is a novel germline variant associated with the formation of hereditary HNPGL.
This article is protected by copyright. All rights reserved.
http://ift.tt/2qfQ4Jk
Clinical evaluation of a new laser-ablated titanium implant for bone-anchored hearing in 34 patients: 1 year experience
Abstract
In specific patient groups, i.e. children or patients with compromised bone quality, the incidence of implant loss of for bone conduction hearing implants is much higher; further implant optimization is, therefore, needed.
The new laser-ablated titanium implant for bone-anchored hearing implantation has an enlarged contact area for osseointegration compared to the standard implant, aiming to improve implant loss rates.
This retrospective multicenter study is the first to assess the performance of this implant in healthy adults 1 year after surgery.
With excellent survival rates, good soft tissue tolerability, and few complications, the implant is safe to use in healthy adults.
This article is protected by copyright. All rights reserved.
http://ift.tt/2lCekQN
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