Relevant pericardial effusion caused by cytomegalovirus infection in an immunocompetent patient: a case report

Cytomegalovirus infection is known to cause symptomatic disease in immunocompromised patients, while an infection in immunocompetent individuals normally causes few or no symptoms. We present the case of an im...

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Clinical and molecular implications of structural changes to desmosomes and corneodesmosomes

Abstract

Desmosomes provide the main intercellular adhesive properties between epidermal keratinocytes. Their distribution becomes uneven in severe dermatitis, multiple allergies and metabolic wasting syndrome due to desmoglein 1 deficiency and the loss of intercellular adhesion or acantholysis. When keratinocytes differentiate from granular cells into cornified cells, desmosomes are transformed into corneodesmosomes and can provide stronger intercellular adhesion. Degradation of corneodesmosomes is a tightly regulated process involving a number of proteases and their inhibitors. Peripheral corneodesmosomes are protected from proteolytic degradation by the tight junction-related structures around them, and this construction provides the basis for the normal basket weave-like structure of the stratum corneum. In Netherton syndrome, which is caused by an absence of the protease inhibitor lymphoepithelial Kazal-type-related inhibitor, premature degradation of corneodesmosomes occurs due to the overactivation of proteases involved in corneodesmosome degradation. Inflammatory peeling skin disease is caused by the absence of corneodesmosin, a unique component of corneodesmosomes. In this disease, corneodesmosomes are structurally abnormal, and their adhesiveness is compromised, which leads to intercellular splitting between the stratum corneum and stratum granulosum. The better we understand desmosome and corneodesmosome ultrastructure in normal and diseased skin, the clearer the physiological and pathological mechanisms of epidermal integrity become.

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Possible role of plasmacytoid dendritic cells in pityriasis lichenoides

Summary

Background

Plasmacytoid dendritic cells (pDCs) and their product, type I interferons (IFNs), have been implicated in the pathogenesis of several skin disorders characterized by an interface dermatitis (ID) pattern, such as lichen planus (LP). A type I IFN signature has previously been documented in pityriasis lichenoides (PL). Although pDCs are known to be the main source and most potent producers of local type I IFNs, their role in PL has not been investigated.

Aim

To investigate the role of pDCs in PL.

Methods

In total, 20 cases of PL and 20 comparable cases of LP were immunohistochemically tested for pDC occurrence and type I IFN production using anti-blood-derived dendritic cell antigen-2 (BDCA2; a specific pDC marker) and anti-myxovirus protein A (anti-MxA) antibodies (indirect marker of pDC activity), respectively. MxA is a well-established surrogate marker for local type 1 IFN production. A semiquantitative scoring system was used.

Results

pDCs were present in all 40 cases with no statistically significant difference between the two groups. MxA expression was intense and diffuse in the majority of PL and LP cases.

Conclusions

pDCs constitute a central component of the inflammatory infiltrate in PL, suggesting that PL shares with the other entities that exhibit an ID a common pDC-driven process through type I IFN production, which ultimately leads to the cytotoxic attack.

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Moyamoya tipping point: fatal bilateral MCA territory infarction following cocaine abuse

Description  

An adult Caucasian man with a history of polysubstance abuse was found unresponsive by the nursing staff at his rehabilitation centre and intubated by emergency medical services. On examination, he was stuporous, his eyes did not open to stimulation, his pupils were reactive, localised to pain with bilateral upper extremities and demonstrated triple flexion to noxious stimuli in the bilateral lower extremities. Urine toxicology was positive for cocaine metabolites. A CT scan of the head was performed, which showed possible hypodensities in the bilateral temporal lobes. MRI of the brain was performed to further characterise these hypodensities, and it revealed bilateral middle cerebral artery (MCA) infarction and generalised cerebral oedema (figure 1). CT angiogram of the head at this point was performed, which showed narrowing of both MCAs and possible moyamoya pattern on the left (figure 2). This moyamoya-like vascular change was suggested by narrowing of the left MCA and hypervascular lenticulostriate...

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Role of modified Eloesser flap in the treatment of bronchopleural fistula caused by pulmonary coccidioidomycosis

Description

Coccidioidomycosis is a fungal infection by the Coccidioides genus and is usually caused by inhalation of the spores. Patients with diabetes are more likely to present with severe lung disease, especially cavitary lesions.1 2 We depict the case of a 47-year-old man with uncontrolled type 2 diabetes mellitus who presented with a right pulmonary lung abscess due to coccidioidomycosis and underwent a right thoracotomy with partial right upper lobe resection. Intraoperatively the pleura was found to be thickened, and the upper lobe had multiple adhesions and was perforated, creating a purulent bronchopleural fistula. He developed recurrent right-sided empyema due to the fistula and an attempt at a second thoracotomy was unsuccessful. After placement of three failed endobronchial valves, he ultimately had a tunnelled pleural catheter placed. Two weeks later the patient began draining frank pus from the site and a modified Eloesser flap...

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Vanadium allergy following total knee arthroplasty

Allergic reactions to metals following joint arthroplasty represent a rare and poorly understood phenomenon. Much is still unknown regarding the natural history of this complication, and how it can best be prevented and managed. We present a case of a 68-year-old woman who underwent a left total knee arthroplasty for treatment of osteoarthritis. After an initial uneventful postoperative course, she developed a troublesome erythematous rash both around the incision site and over her trunk. Blood testing revealed no evidence of infection and clinically her prosthesis was functioning well. Skin patch testing revealed positive results for vanadium (+) and palladium (+). Her cutaneous symptoms are currently being managed conservatively and have shown a partial response to topical steroids. Revision surgery remains a long-term treatment option should conservative therapy fail; however, it would require a custom-made prosthesis as no standard tibial component is free from vanadium.

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Megaduodenum in a 59-year-old man: a very late postoperative complication after duodenal atresia

Intestinal malformations are common defects of the newborn, treated in experienced centres. Reports on long-term follow-up and associated complications are scarce, possibly leading to misinterpretation of clinical signs and symptoms in adulthood. To prevent treatment errors, it is important that physicians are aware of long-term complications of intestinal malformations.

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Stent-assisted coil embolization on down-the-barrel view with spring-shaped microcatheter in patient with M1 ultrawide necked circumferential aneurysm

Herein, we describe a technique for stent-assisted coil embolization with a spring-shaped microcatheter in a patient with an M1 ultrawide-necked circumferential aneurysm in the middle cerebral artery (MCA). A 49-year-old man was referred for treatment of an incidentally detected M1 large-circumference aneurysm on magnetic resonance angiography. Subsequent digital subtraction angiography revealed an 18.2x16.5 mm ultrawide-necked circumferential aneurysm on the distal M1 portion of the left MCA, and we planned stent-assisted coil embolization using a spring-shaped microcatheter. After we deployed the stent, we performed coil embolization under the down-the-barrel view by pulling out the microcatheter little by little. Using this technique, we could fill the coil mass evenly into the aneurysmal sac around the stent. And there were no immediate or delayed complications after the procedure. Stent-assisted coiling using a spring-shaped microcatheter is a useful and safe technique for treating ultrawide-necked circumferential aneurysm or fusiform aneurysms.

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Retroperitoneal bile leak after laparoscopic cholecystectomy

Bile duct injury (BDI) is a well-recognised complication of laparoscopic cholecystectomy (LC). Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. This manifests as non-specific abdominal pain and fever occurring several days after the surgery. It can be managed by laparoscopic washout with or without bile duct repair. We present a rare case of retroperitoneal bile leak post-LC. The mechanism of injury here was likely partial avulsion from excessive traction of the cystic duct during intraoperative cholangiogram. Diagnosing retroperitoneal bile leak can be difficult because it is extremely rare and the presenting symptoms can be similar to an intraperitoneal bile leak. A high index of clinical suspicion is required. In cases of suspected bile leak, any mismatch between the exploratory laparoscopic findings and imaging findings should alert surgeons to consider the rare possibility of a retroperitoneal bile leak.

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Continuous subcutaneous levetiracetam in end-of-life care

Seizures constitute a determining aspect in quality of life and are frequently challenging in palliative care—a field where treatment has yet to be standardised. Levetiracetam—a new generation anticonvulsant—has proved efficacy both through oral, as well as intravenous administration in the general population. This case reports on the use of continuous subcutaneous levetiracetam to effectively control seizures in a terminally ill patient without patent oral route.

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Unusual skin mass (primary cutaneous mucinous carcinoma)

Primary mucinous carcinoma of the skin is a rare malignant tumour of sweat gland origin. Diagnostic concerns include its deceptively benign appearance in some cases and the difficulty in differentiating it from secondary mucinous carcinoma of skin metastasising from a primary source elsewhere. A case of a 75-year-old man is reported who presented with a slowly growing painless mass near the lateral canthus of the right eye for about 2 years. Clinically, a diagnosis of basal cell carcinoma was made whereas histopathology revealed mucinous carcinoma of the skin. The primary source of the tumour could not be found on detailed physical examination and laboratory investigations. Immunohistochemistry, performed later, was consistent with primary cutaneous mucinous carcinoma.

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An adult case with shigellosis-associated encephalopathy

A 45-year-old man was presented at the emergency department with altered neurological status and a 1-day history of diarrhoea and fever. The patient's sexual history revealed multiple male partners. As bacterial meningitis or viral encephalitis was suspected, treatment was started accordingly. Cerebrospinal fluid investigations only showed a slight increase of leucocytes, and microbiological studies remained negative. Stool culture revealed Shigella flexneri, after which Shigella-associated encephalopathy was suspected. The patient recovered quickly with antibiotic treatment. The incidence of Shigella infections in the Western world is rising due to sexual transmission among men who have sex with men. Shigella-induced encephalopathy is a notorious complication among children with a severe form known as the Ekiri syndrome, though rarely seen in adults. This is the second report of encephalopathy in an adult with S. flexneri enteric infection.

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Angiodysplastic Sturge Weber syndrome

Description

A 3-year-old boy presented with global developmental delay, abnormal craniofacial growth and left focal seizures since infancy. He was the first child of a non-consanguineous couple with unremarkable perinatal period. Family history was non-contributory. On examination, he had macrocephaly (head circumference 55 cm, >3 z-score), extensive port-wine stain distributed bilaterally over the face and the trunk, cloverleaf-shaped skull with facial distortion (figure 1A), marked gingival hyperplasia with dental malocclusion (figure 1B), bilateral blue sclera with tortuous engorged veins, brisk muscle stretch reflexes, left hemiparesis and bilateral Babinski's sign. The rest of the systemic examination was unremarkable. A clinical diagnosis of angiodysplastic variant of Sturge Weber syndrome (SWS) with extensive bilateral facial and truncal port-wine stain, glaucoma and focal epilepsy was considered. CT of the brain revealed right-sided subcortical tram-track calcification and concordant parenchymal volume loss (figure 1C). MRI of the brain showed right-sided...

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Intravitreal bevacizumab for postviral fever retinitis: a novel approach for early resolution of macular oedema

Severe macular oedema causing marked loss of vision is seen in cases of retinitis developing postviral fever. The use of antivascular endothelial growth factor agents for macular oedema and submacular fluid secondary to viral retinitis has not been studied or well established in the past. We report a case series of two patients of postviral retinitis with severe macular oedema resistant to steroid therapy, treated with intravitreal bevacizumab. The patients showed significant symptomatic improvement in the visual acuity. The retinitis lesions resolved slowly and macular oedema regressed. Bevacizumab appears to be a safe and useful agent to manage macular oedema subsequent to postviral retinitis. An early resolution of macular oedema helps in the preservation of visual acuity which left untreated can cause severe visual loss.

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Abnormal deep dorsal vein resulting in veno-occlusive erectile dysfunction

A 59-year-old man with a 6-year history of erectile dysfunction presented to the andrology outpatient clinic. Multimodality assessment with ultrasound, MRI venography and fluoroscopic venography demonstrated an aberrant emissary vein arising from the corporal bodies causing venogenic erectile dysfunction. Selective coil embolisation of the collateral vein resulted in an almost immediate and sustained improvement in his erections.

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Anterior choroidal artery infarction

Description 

A 38-year-old male patient with a history of hypertension presented with left hemiplegia, hemianaesthesia and hemianopia. MRI of the brain showed anterior choroidal artery (AchA) territory infarct (figure 1). MRI brain angiography and 2D echo were normal. Serum fasting lipid profile, sugar levels, thyroid studies, serum homocysteine levels and antinuclear antibody (ANA), double-stranded deoxyribonucleic acid (DsDNA) and antiphospholipid antibody (APLA) were negative. Trans-oesophageal echocardiography and Holter monitoring were normal. Workup for sickle cell anaemia was negative.

Figure 1

Axial diffusion weighted MRI shows restricted diffusion in (A,B) right lateral thalamus, posterior limb of internal capsule; hippocampal gyrus and uncus and (C) paraventricular corona radiata and uncus. (D) Coronal T2 image showing involvement of same areas.

The territory of AchA is shown in figure 2.1

Figure 2

(A) Anterior choroidal artery originates from internal carotid artery...

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Sacral bone cyst treatment resulting in paraplegia

Description

A 50-year-old man with a stage 1 solitary right sacral plasmacytoma complained of a sharp, burning lower back pain with radiation into his right lower extremity which worsened with movement. He had initially undergone localised radiation therapy, but the pain did not resolve. Postradiation CT-guided biopsy showed persistence of malignant plasma cells, and he then underwent seven cycles of VRD (dexamethasone, lenalidomide and bortezomib) chemotherapy. After chemotherapy, an 18-fluorodeoxyglucose-positron emission tomography/CT scan showed a new area of uptake in the right sacral ala near the initial plasmacytoma. A subsequent CT-guided biopsy was non-diagnostic, and repeat imaging at the time of presentation showed no interval growth. The lesion was believed to be a residual cyst with inflammatory changes from radiotherapy. Examination revealed no neurological deficits. The patient's pain was thought to be secondary to the cyst (figure 1) and was not relieved with physical therapy, duloxetine...

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Efficacy of a Home-Based Exercise Program After Thyroidectomy for Thyroid Cancer Patients

Thyroid , Vol. 0, No. 0.


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Gender Differences in the Association Between Synthetic Cannabinoid Use and Teen Dating Violence Victimization

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


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Retrospective audit of patients referred for further treatment following Mohs surgery for non-melanoma skin cancer

Abstract

Background/Objectives

To describe the characteristics, subsequent management and outcomes of patients referred for further management following Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

Methods

Retrospective analysis of patients referred to a quaternary cancer centre from 2000 to 2015.

Results

In total, 83 lesions in 82 patients were referred for further management; 52 (62%) were SCC and 80 (96%) were located in the head and neck. Reasons for referral included high-risk disease for consideration for adjuvant radiotherapy (37/83, 45%), inadequate resection (28/83, 34%) or recurrence following previous MMS (15/83, 17%). Fewer than 40% of the 69 referrals received from MMS surgeons included photos or an operative report and diagram.

There was discordance in pathology opinion in 11 (13%) of cases. Histopathology from MMS was reviewed in eight cases and there was discordance with the in-hospital pathology opinion in six of these. In-hospital re-excision was performed in 19 cases and in five of these the pathology report on the paraffin-sectioned re-excised tissue was discordant with prior MMS assessment. Significantly, two cases were associated with a misinterpretation of lymphocytic infiltrate as residual disease in patients with chronic lymphocytic leukaemia (CLL).

Conclusion

This study highlights some of the challenges and limitations of MMS. Early referral for multidisciplinary management is recommended when MMS resection margins are inadequate or uncertain, especially for high-risk SCC. We recommend that referrals be accompanied by histological material, as well as a detailed report with operative photos and diagrams. CLL can pose an intraoperative diagnostic challenge. Discrepancies in the interpretation of MMS slides present an opportunity for improvement, and our findings support the role of ongoing quality assurance programs.

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Wideband acoustic absorbance in children with Down syndrome

Publication date: Available online 10 January 2018
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Alessandra Spada Durante, Mayara Santos, Nayara M.C. de F. Roque, Marcella S. Gameiro, Katia de Almeida, Osmar Mesquita de Sousa Neto
IntroductionTympanometry is currently the most frequently used tool for assessing the status of the middle ear, commonly assessed using a single 226Hz tone. However, the use of the Acoustic Immittance Measures with a wideband stimulus is a promising high-resolution evaluation, especially in individuals known to have middle ear alterations, such as Down syndrome patients.ObjectiveThe aim of this study was to analyze the acoustic absorbance measurements in children with DS.MethodsCross-sectional study, approved by the institution's ethics committee. Data were collected from 30 children, with a mean age of 8.4 years, 15 with Down syndrome (DS-study group) and 15 children with typical development and no hearing complaints (control group). Energy absorbance was measured at frequencies of 226–8000Hz at ambient pressure and at peak pressure as a function of frequency using TITAN equipment. Statistical analysis was performed using the established level of statistical significance of 5%.ResultsWith the 226Hz probe tone, 30 ears of the control group and 22 of the study group exhibited Type A tympanograms, whereas Type B was observed in eight children in the study group. The mean acoustic absorbance ratio of the study group was lower than that of the control group at frequencies centered at 2520Hz (p=0.008) for those with normal tympanometry results, and 226–4000Hz (p<0.03) for those with a Type B tympanometry curve.ConclusionThe low energy absorption in the presence of normal tympanograms in children with DS may suggest middle ear abnormalities.



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Medical Marijuana: Current Concepts, Pharmacological Actions of Cannabinoid Receptor Mediated Activation, and Societal Implications

Abstract

Purpose of Review

The purpose of the following review is to summarize the history and current policies related to marijuana use and prevalence, basic and clinical science pharmacological literature regarding efficacy, subpopulations of concern, and varying policies regarding its use at present.

Recent Findings

With the increasingly widespread utilization of marijuana, there is also a growing complexity of public health policy, regulation, and necessity to further assess the medical indications and adverse long-term effects of marijuana use.

Summary

Health care providers as well as the general public must be prepared to become familiar and up-to-date with medical literature, legislation, and educational material regarding medical marijuana.

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Orthognathic surgery in Melnick–Needles syndrome: a review of the literature and report of two siblings

Publication date: Available online 12 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): J.E. O'Connell, B. Bourke, G.J. Kearns
Melnick–Needles syndrome (MNS) is a rare congenital X-linked dominant skeletal dysplasia, characterized by exophthalmos, a prominent forehead, and mandibular hypoplasia and retrognathism. Dental features may include anodontia, hypodontia, or oligodontia. Increased collagen content, unpredictable collagen synthesis, and abnormal bony architecture have raised concerns regarding bone splitting intraoperatively and bone healing postoperatively. This report describes the cases of two sisters with MNS, who successfully underwent orthognathic surgery consisting of bilateral mandibular ramus osteotomies combined with advancement genioplasty and iliac crest bone grafting, to correct the classical MNS facial deformity of mandibular retrognathia.



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Effectiveness and safety of foam sclerotherapy with 5% ethanolamine oleate in the treatment of low-flow venous malformations in the head and neck region: a case series

Publication date: Available online 10 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): M.C. Ribeiro, S. de Mattos Camargo Grossmann, M.B.F. do Amaral, W.H. de Castro, T.P. Navarro, R.J. Procopio, T.A. da Silva, C. de Nazaré Alves de Oliveira Kato, R.A. Mesquita
The aim of this study was to evaluate the effectiveness and safety of 5% ethanolamine oleate (EO) foam in the treatment of low-flow venous malformations in the head and neck region. Seventeen consecutive patients (six male, 11 female) and 34 low-flow venous malformations were enrolled. The vascular anomalies ranged between 20mm and 80mm in size. The typical clinical indication was a swelling (88.2%) with a purple colour (85.3%); the most frequent location was the tongue (23.5%). Ethanolamine oleate foam was produced via the Tessari method and applied at 10mg per 1cm to the vascular anomalies. This process resulted in the highest clinical healing score in 64.7% of cases, and half of the patients reported a high level of satisfaction (score >9). In the majority of cases (88.2%), the patients reported that the pain immediately postoperative was mild or moderate. There were direct relationships between vascular anomaly size and the volume of EO applied, the number of sessions, and healing (P<0.05). No recurrence was observed during 6 months of follow-up. This case series showed the effectiveness and safety of 5% EO foam for the treatment of venous malformations in the head and neck region.



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Facial morphology and growth following surgery for congenital midline cervical cleft patients

Publication date: Available online 17 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): Y. Fan, H. Matthews, N. Kilpatrick, P. Claes, J. Clement, A. Penington
Congenital midline cervical cleft (CMCC) is a rare condition that consists of a cutaneous midline neck lesion with a sinus extending inferiorly towards the sternum. A fibrous band that extends superiorly to the mandible is a consistent feature of the condition. Restriction of growth of the mandible, possibly due to incomplete removal of the band, is the most significant long-term problem. It remains unclear whether early removal of the fibrous band might allow catch-up growth of the mandible. This study utilized non-invasive three-dimensional photographs to objectively evaluate the facial growth of six CMCC patients. The growth of these CMCC patients was compared to the average growth of age- and sex-matched controls from a database of three-dimensional facial photographs of clinically normal subjects. After surgical removal of the fibrous cord, CMCC patients experience growth in the chin at the same rate as in the normal population; no evidence was found for catch-up growth. As a result, individuals with CMCC are likely to require further surgical intervention to correct the residual retrognathia on completion of facial growth. Early excision of the lesion including aggressive resection of the fibrous band is still recommended, as this should optimize the early growth of the mandible in infancy.



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Impact of crack cocaine use on the occurrence of oral lesions and micronuclei

Publication date: Available online 12 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): R.P. Antoniazzi, F.B. Lago, L.C. Jardim, M.R. Sagrillo, K.L. Ferrazzo, C.A. Feldens
The aim of this study was to investigate the occurrence of oral lesions and micronuclei in crack cocaine users. A cross-sectional study was conducted involving 106 crack users and 106 non-users matched for age, sex, and tobacco use. Socio-demographic characteristics, the consumption of psychoactive substances, and the occurrence of fundamental lesions were investigated. Cellular changes in the oral mucosa (karyolysis, karyorrhexis, 'broken egg' events, and micronuclei) were determined by exfoliative cytology for 54 participants in each group. Crack users had a greater occurrence of fundamental lesions (P=0.001). Furthermore, they had higher mean occurrences of micronuclei (17.25 vs. 3.80), karyolysis (12.39 vs. 9.46), and karyorrhexis (30.39 vs. 10.11) (number per 1000 cells) than non-users (all P<0.05). No difference between the groups was found with regard to broken egg events (P>0.05). After controlling for confounding variables, fundamental lesions were 2.02-fold more frequent and micronuclei were 3.54-fold more frequent in crack users. Crack use was found to be associated with clinical and cellular changes in the oral mucosa. These findings can contribute to the planning of health care for individuals who are dependent on street drugs.



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The ability of topical and systemic statins to increase osteogenesis around dental implants: a systematic review of histomorphometric outcomes in animal studies

Publication date: Available online 17 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): V. Moraschini, D.C.F. Almeida, J.A. Calasans-Maia, M. Diuana Calasans-Maia
The purpose of this systematic review was to evaluate the quantitative histomorphometric outcomes of animal studies investigating statins as a pro-osteogenic agent to enhance the osseointegration of dental implants. Some animal studies have suggested a beneficial action of statins on bone tissue. Electronic and manual literature searches, without date or language restriction, ​​were performed by two independent review authors up to February 2017. Eligibility criteria included animal trials quantitatively analysing the pro-osteogenic effect of statins on dental implants. The quality of the included studies was assessed using the ARRIVE guidelines. The search and selection process yielded 12 studies, published between 2004 and 2015. The experimental animals models used were rats and dogs. The statins used in the studies were simvastatin and fluvastatin, which were administered locally or systemically, or applied to the implant surface. All of the selected studies showed a statistically significant positive effect of statins on bone formation around implants. The mean quality assessment score (ARRIVE) of the studies was 11.5±2.27 out of a possible total of 25 points. The histomorphometric data from available preclinical studies suggest a positive effect of statins on increasing osteogenesis around dental implants.



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Reconstruction of the mandibular condyle using the microvascular lateral femoral condyle flap

Publication date: Available online 17 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): S. Enzinger, H. Bürger, A. Gaggl
The lateral femoral condyle (LFC) flap is a new flap first reported in 2015 for the treatment of osteomyelitis in hand surgery. This paper introduces a technique of osteochondral LFC flap harvest for mandibular condyle reconstruction and reports on the use of this flap in temporomandibular joint reconstruction. For condyle resection, a pre-auricular approach saving the temporal artery and vein is performed. A step osteotomy technique is used for condyle resection. LFC harvesting starts with dissection of the popliteal artery and vein. The superior genicular artery and vein are identified and followed along their periosteal branches. An osteochondral flap according to the condyle defect is harvested from the anterior pole of the knee. The flap is banded according to the defect and fixed to the mandibular neck with three miniscrews. Follow-up computed tomography scans should be performed at 1 week, 6 months, and 1year after surgery. The case of a 58-year-old female patient with osteomyelitis of the left mandibular condyle after multiple preoperative therapies is reported. The LFC flap technique was used for left condyle reconstruction, resulting in good functional and morphological outcomes at the 6-month postoperative follow-up. In conclusion, the osteochondral LFC flap is a new and promising technique for mandibular condyle reconstruction for special indications.



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Survey of patient experiences of orthognathic surgery: health-related quality of life and satisfaction

Publication date: Available online 17 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): A. Al-Asfour, M. Waheedi, S. Koshy
The objective of this study was to assess changes in patient quality of life (QoL) after orthognathic surgery at the Kuwait University Dental Clinic. A self-administered Arabic version of the Orthognathic Quality of Life Questionnaire (OQLQ) and two different visual analogue scales (VAS) were used. Sixty-six patients participated (63.6% female). The deformities were corrected by bimaxillary jaw surgery (83.3%), Le Fort I (9.1%), and bilateral sagittal split osteotomy (7.6%). The most important reasons given for undertaking the surgery were facial aesthetics (80.3%) and bite correction (75.8%). Of the patients who had reported moderate to high levels of problems pre-surgery, the majority reported improvements in facial appearance (91.3%), appearance of the teeth (97.0%), biting (96.3%), chewing (92.3%), and eating function (76.5%). Overall, 93.9% of patients reported better conditions after surgery, and the satisfaction level was very high (VAS 91.6%). The VAS score for QoL increased significantly from pre-surgery (73.0%) to post-surgery (93.6%) (P=0.0001). The OQLQ score was also significantly decreased after surgery, reflecting improvements in the 'social aspects of dentofacial deformity', 'facial aesthetics', 'oral function', and 'awareness of dentofacial aesthetics' domains (P=0.0001). Overall, the patients who underwent orthognathic surgery were satisfied and had improved QoL. The satisfaction rate in the present study reflects successful treatment with orthognathic surgery.



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Small size of metastatic lymph nodes with extracapsular spread greatly impacts treatment outcomes in oral squamous cell carcinoma patients

Publication date: Available online 17 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): C. Michikawa, T. Izumo, J. Sumino, T. Morita, Y. Ohyama, Y. Michi, N. Uzawa
Extracapsular spread (ECS) of metastatic lymph nodes from oral carcinoma is the most significant prognostic predictor of a poor treatment outcome. However, only a few reports on prognostic factors in ECS-positive cases have been investigated. To address this problem, a detailed examination of ECS pathology was conducted to determine the prognostic factors of oral squamous cell carcinoma (OSCC) with ECS of metastatic lymph nodes. This study involved 63 OSCC patients with at least one pathologically metastatic node with ECS. Among the 229 metastatic lymph nodes, 149 exhibited ECS. Univariate analysis revealed that a poor outcome and recurrence were significantly associated with the number of ECS-positive nodes, density of ECS, and the minor axis of the smallest ECS-positive node. However, multivariate analysis identified only small size of ECS-positive nodes as a significant and independent factor predicting recurrence and a poor outcome. Thus, small size of ECS-positive nodes is the most important prognostic indicator for OSCC with ECS in metastatic lymph nodes. The classification of ECS status using the minor axis of ECS-positive nodes may be useful for further prediction of a poorer prognosis in OSCC cases. Standardization of ECS diagnosis and multicenter prospective studies will be required to confirm and refine these findings.



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Safety of BCG Vaccination in Pediatric Liver Transplant Recipients.

No abstract available

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Causes, Preventability, and Cost of Unplanned Rehospitalizations Within 30 Days of Discharge Following Lung Transplantation.

Background: Unplanned rehospitalizations (UR) within 30 days of discharge are common following lung transplantation. It is unknown whether UR represent preventable gaps in care or necessary interventions for complex patients. The objective of this study was to assess the incidence, causes, risk factors, and preventability of UR following initial discharge after lung transplantation. Methods: This was a single-center prospective cohort study. Subjects completed a modified Short Physical Performance Battery (SPPB) to assess frailty at listing and at initial hospital discharge after transplantation and the State-Trait Anxiety Inventory (STAI) at discharge. For each UR a study staff member and the patient's admitting or attending clinician used an ordinal scale (0, not; 1, possibly; 2, definitely preventable) to rate readmission preventability. A total sum score >=2 defined a preventable UR. Results: Of the 90 enrolled patients, 30 (33.3%) had an UR. The single most common reasons were infection (7 (23.3%)) and atrial tachyarrhythmia (5 (16.7%)). Among the 30 UR, 9 (30.0%) were deemed preventable. UR that happened before day 30 were more likely to be considered preventable than those between days 30-90 (30.0% versus 6.2%, p = 0.04). Discharge frailty, defined as SPPB

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Association of Cold Ischemia Time with Acute Renal Transplant Rejection.

Background: Kidney transplantation holds much promise as a treatment of choice for patients with end stage kidney disease. The impact of cold ischemia time (CIT) on acute renal transplant rejection (ARTR) remains to be fully studied in a large cohort of renal transplant patients. Methods: From the Organ Procurement and Transplantation Network database, we analyzed 63,798 deceased donor renal transplants performed between 2000-2010. We assessed the association between CIT and ARTR. We also evaluated the association between recipient age and ARTR. Results: 6,802 patients (11%) were clinically diagnosed with ARTR. Longer CIT was associated with an increased risk of ARTR. After multivariable adjustment, compared with recipients with CIT=24h. The association of CIT and ARTR was more pronounced in patients undergoing re-transplantation: compared with recipients with CIT=24h. Additionally, older age was associated with a decreased risk of ARTR. Compared with recipients 18-29 years old, the relative risk of ARTR was 0.50 (95% confidence interval 0.45, 0.57) in recipients >=60 years old. Longer CIT was also associated with increased risk of death-censored graft loss. Compared with recipients with CIT=24h. Conclusions: Prolonged CIT is associated with an increased risk of ARTR and death-censored graft loss. Older age was associated with a lower risk of ARTR. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Quantifying Frailty in Post Lung Transplant Patients - Can We Predict Who Will Need Readmission?.

No abstract available

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Do Patients Supported With Continuous-Flow Left Ventricular Assist Device (CF-LVADS) Have a Sufficient Risk of Death to Justify a Priority Allocation? A Propensity-score Matched Analysis of Patients Listed In UNOS Status 2.

Background: Outcomes of Continuous Flow Left Ventricular Assist Devices (CF-LVADs) as bridge to transplant have significantly improved. The question has arisen whether patients on CF-LVADs have an increased risk of death on the waiting list as to justify a priority allocation (status 1). The aim of this study was to compare the survival following implantation of CF-LVADs to the survival on the waiting list for patients initially listed in United Network for Organ Sharing (UNOS) status 2. Methods: All patients >18 years listed for Heart Transplantation (HT) in the United States between 2011 and 2013 in UNOS status 2 with no mechanical circulatory support at time of listing were analyzed. Patients were divided into two groups depending on whether they received a new CF-LVAD while listed (CF-LVAD group) or not (NO-LVAD) and were further matched on their Propensity Score (PS) in a 1:2 ratio. Results: Two hundreds and eighty-seven CF-LVAD patients were matched to 574 NO-LVAD patients. Survival after CF-LVAD was significantly lower at 24-month compared to waiting list (75.4+4.4 versus 91.2+8.9%, p

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Race, Risk, and Willingness of End-stage Renal Disease Patients Without Hepatitis C (HCV) to Accept an HCV-infected Kidney Transplant.

Background: Despite effective antiviral treatment, hundreds of kidneys from deceased donors with hepatitis C virus (HCV) are discarded annually. Little is known about the determinants of willingness to accept HCV-infected kidneys among HCV-negative patients. Methods: At 2 centers, 189 patients undergoing initial or reevaluation for transplant made 12 hypothetical decisions about accepting HCV-infected kidneys in which we systematically varied expected HCV cure rate, allograft quality and wait-time for an uninfected kidney. Results: Only 29% of participants would accept an HCV-infected kidney under all scenarios, while 53% accepted some offers and rejected others, and 18% rejected all HCV-infected kidneys. Higher cure rate (OR 3.49, 95% CI 2.33-5.24 for 95% vs. 75% probability of HCV cure), younger donor (OR 2.34, 95% CI 1.91-2.88 for a 20-year-old vs. a 60-year-old hypertensive donor), and longer wait for an uninfected kidney (OR 1.43, 95% CI 1.22-1.67 for 5 vs. 2 years) were associated with greater willingness to accept an HCV-infected kidney. Black race modified the effect of HCV cure rate, such that willingness to accept a kidney increased less for blacks vs. whites as the cure rate improved. Patients >60 years and prior kidney recipients showed greater willingness to accept an HCV-infected organ. Conclusions: Most patients will consider an HCV-infected kidney in some situations. Future trials using HCV-infected kidneys may enhance enrollment by targeting older patients and prior transplant recipients, but centers should anticipate that black patients' acceptance of HCV-infected kidneys will be reduced compared to white patients. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

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The Authors' Reply.

No abstract available

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Important Facts About Organ Donation and OPO Performance.

No abstract available

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Impact of Willingness to Accept Hepatitis C Seropositive Kidneys Among Hepatitis C RNA-positive Waitlisted Patients.

Background: Kidney transplantation from hepatitis C seropositive (HCV+) donors may benefit hepatitis C RNA-positive (RNA+) candidates, but it is unclear how the willingness to be listed for and accept such kidneys affects waitlist and transplant outcomes. Methods: In a single-center retrospective analysis, HCV+ transplant candidates (N=169) listed from March 2004 to February 2015 were evaluated. All RNA+ candidates were offered the option to be listed for HCV+ donors. RNA- candidates were listed only for HCV- donors. Results: Fifty-seven patients (51% of all RNA+ transplant candidates) willing to accept HCV+ donors were listed for both HCV+ and HCV- donor kidneys. During 6-yr follow up, 43 of 57 (75%) patients accepting HCV+ vs. 19 of 55 (35%) patients not accepting HCV+ received a deceased donor kidney transplant (DDKT, P

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Prospective Assessment of Adenovirus Infection in Pediatric Kidney Transplant Recipients.

Background: Adenovirus infection is associated with graft dysfunction and graft loss in in pediatric cardiac, lung, and liver transplants in prior retrospective studies, but data in pediatric kidney transplant recipients is limited. Methods: We conducted a prospective single-center cohort study of 75 consecutive pediatric kidney transplant recipients who underwent monthly screening for adenovirus viremia and symptom assessment for 2 years posttransplant. Results: Adenovirus viremia was detected in eleven (14.7%) patients at a median onset of 173 (IQR 109-310) days posttransplant; six (8%) had asymptomatic viremia and five (6.7%) had symptomatic disease (2 with hematuria and 3 with an acute febrile respiratory illness). Viremic patients did not differ from nonviremic patients in age, immunosuppression management, or CMV or EBV serostatus, but were more likely to develop CMV viremia during the first 2 years posttransplant. No patient had an increase in creatinine from baseline during the time of adenovirus viremia. In a Cox proportional hazards regression, subclinical adenovirus viremia was not associated with a faster time to a 30% decline in eGFR. Conclusion: Adenovirus infection is common among pediatric kidney transplant recipients and frequently causes symptomatic disease; however, symptoms are often mild and are not associated with a decline in graft function. Routine monitoring for adenovirus viremia in pediatric kidney transplant recipients may not be warranted. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Alpha-fetoprotein Slope >7.5 ng/ml/month Predicts Micro-vascular Invasion and Tumor Recurrence after Liver Transplantation for Hepatocellular Carcinoma.

Background: Rising alpha-fetoprotein (AFP) is a potential marker of worse prognosis after liver transplant (LT) for hepatocellular carcinoma (HCC), but prior studies relied on only two data points and were imprecise in assessing AFP slope. The aim of this study was to examine the association between AFP slope and post-LT HCC recurrence, with AFP slope estimated from multiple data points over time. Methods: Our cohort included 336 patients undergoing LT with MELD exception for HCC within Milan criteria from 2003-2013. Most (98%) had pre-LT loco-regional therapy (LRT). AFP slope was estimated by fitting a regression line to the AFP levels over time. Results: The 1- and 5-year post-LT survival was 94% and 77% and 1- and 5-year recurrence-free probabilities were 95% and 86%, respectively. In univariate analysis, HCC recurrence was significantly associated with microvascular invasion (HR 13.1, pMilan criteria (HR 8.9, p7.5 ng/mL/month (HR 3.9, p=0.005), and female gender (HR 2.3, p=0.01). In multivariable analysis of factors known prior to LT, 3 tumor nodules (HR 7.6, p7.5 (HR 3.0, p=0.03) were significantly associated with HCC recurrence. AFP slope >7.5 was also associated with microvascular invasion (OR 6.8, p=0.008). Conclusions: AFP slope increasing >7.5 ng/mL/month despite LRT is associated with post-LT HCC recurrence and may serve as a surrogate for microvascular invasion. These findings support incorporating changes in the AFP into candidate selection for LT. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Towards Systematic Screening for Persistent Hepatitis E Virus (HEV) Infections in Transplant Patients.

Background: Persistent hepatitis E virus genotype 3 (HEV G3) infections affect solid organ transplant (SOT) recipients and haematopoietic stem cell transplant (HSCT) recipients, but the burden in these cohorts in the UK is unknown. We established an audit to determine the point prevalence of HEV viraemia in SOT and HSCT patients in the UK and compare different testing approaches to inform screening strategies. Methods: Between 5th January and 21st September 2016, 3044 patients undergoing therapeutic drug monitoring at a single transplant centre were screened for HEV RNA in minipools. A total of 2822 patients who could be characterised included 2419 SOT patients, 144 HSCT patients and 259 patients with no available transplant history. HEV RNA-positive samples were characterised by serology and genomic phylogeny. HEV antigen (HEV-Ag) testing was performed on RNA-positive samples, 420 RNA-negative samples and 176 RNA-negative blood donor samples. Results: Nineteen of 2822 patients were viraemic with G3 HEV giving a prevalence of 0.67%. The median alanine aminotransferase (ALT) was significantly higher in the HEV viraemic patients (p

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Ethical Analysis and Policy Recommendations Regarding Domino Liver Transplantation.

Due to the widening gap between supply and demand, patients who need a liver transplant due to metabolic disease may be asked to serve as domino liver donors-to have their native liver transplanted into another candidate. We here analyze the ethical problems surrounding informed consent for the implant and explant procedures in transplant candidates who will serve as domino donors, using the case of a child with maple syrup urine disease. We discuss the need for two distinct consent processes separated in time to ensure that potential domino donors (or their surrogates) give a truly voluntary consent. We propose a Domino Donor Advocate - based on the concept of the Independent Living Donor Advocate to help the patient and/or his or her surrogates consider the risks, benefits and alternatives. Finally, we evaluate the Organ Procurement and Transplantation Network policy regarding "therapeutic organ donation" and propose several modifications to ensure that the decision by the potential domino donor (and/or his or her surrogate) is voluntary and informed. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Superior Hypertension Management in Pediatric Kidney Transplant Patients After Native Nephrectomy.

Background: Native nephrectomy in pediatric kidney transplant recipients is performed for multiple indications. Posttransplant hypertension requiring medical management is common and the effect of native nephrectomy on posttransplant hypertension is poorly studied. Our aim is to evaluate the impact of native nephrectomy on posttransplant hypertension. Methods: 136 consecutive pediatric kidney transplant recipients from 2007 to 2012 were studied at a single institution and divided into 2 groups: no nephrectomy and native nephrectomy (unilateral and bilateral nephrectomy). Antihypertensive medication use was evaluated prior to nephrectomy/transplant, at discharge from transplant and at 1-, 3- and 5-years posttransplant. Results: In a bivariate analysis, nephrectomy was associated with a significant reduction in the percentage of patients requiring antihypertensive medication at the time of discharge (27.3%) and 1 year posttransplant (10.7%) as compared to patients without nephrectomy (71.7%, and 50%, respectively, p

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Adipocytokines in Steatotic Liver Surgery/Transplantation.

Due to the shortage of liver grafts available for transplantation the restrictions on graft quality have been relaxed and marginal grafts such as steatotic livers are now accepted. However, this policy change has not solved the problem, because steatotic liver grafts tolerate ischemia-reperfusion injury poorly. Adipocytokines differentially modulate steatosis, inflammation, and fibrosis and are broadly present in hepatic resections and transplants. The potential use of adipocytokines as biomarkers of the severity of steatosis and liver damage to aid the identification of high-risk steatotic liver donors and to evaluate hepatic injury in the postoperative period are discussed. The hope of finding new therapeutic strategies aimed specifically at protecting steatotic livers undergoing surgery, is a strong impetus for identifying the mechanisms responsible for hepatic failure after major surgical intervention. Hence, the most recently described roles of adipocytokines in steatotic livers subject to ischemia-reperfusion injury are discussed, the conflicting results in the literature are summarized, and reasons are offered as to why strategic pharmacologic control of adipocytokines has yet to yield clinical benefits. Following this, the next steps needed to transfer basic knowledge about adipocytokines into clinical practice in order to protect marginal livers subject to ischemia-reperfusion injury are presented. Recent strategies based on adipocytokine regulation which have shown efficacy in various pathologies, and hold promise for hepatic resection and transplantation are also outlined. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Long Term Outcomes of Pediatric En Bloc Kidney Transplantation: A Single Center Experience with 25 Years Follow Up.

Background: Pediatric en bloc kidneys are considered marginal for transplantation into adults. We aimed to compare the long-term outcomes of pediatric en bloc vs. living donor kidney transplantation. Methods: A retrospective review was undertaken on pediatric en bloc and living donor kidney transplants performed at our center between 1990 and 2001. The outcomes compared between the groups included 25 year graft survival and longitudinal glomerular filtration rate (GFR). Results: There were 72 pediatric en bloc and 75 living donor kidney recipients included in the analysis. Pediatric donors were 16.9 +/- 11.2 months old and weighed 10.7+/-3.8 kg with terminal serum creatinine of 0.50+/-0.45 mg/dl. Living donors were 40.1+/-9.4 years old and serum creatinine was 0.90+/-0.16 mg/dl at the time of donation. En bloc kidney recipients had higher dialysis vintage (23.0 +/- 29.2 vs. 14.3 +/- 14.7 months, p=0.03), and longer cold ischemia time (30.5+/- 9.8 vs. 2.6 +/-0.9 hours, p

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Refractory Pain Management in Amyloid-Associated Peripheral Neuropathy.

Objective: Systemic amyloidosis is a disease that often involves multiple organ systems, including the peripheral nervous system. Patients may present with severe, refractory neuropathic pain; however, the optimal treatment approach for pain for these patients remains unclear. Case Report: A man with severe, refractory neuropathic pain in his bilateral upper and lower extremities and the trunk secondary to amyloid neuropathy is presented. Multiple medication trials, including neuropathic and opioid agents, produced considerable adverse effects and minimal relief. Scrambler therapy, a novel electrical stimulation modality, was used and was associated with substantial short-term but nonsustained benefit. Spinal cord stimulation was considered, but given his diffuse symptoms, it was deemed a less-than-optimal approach. Ultimately, an intrathecal drug delivery system was placed with infusion of hydromorphone, resulting in substantial pain reduction in all involved areas and with an improved adverse effect profile. This intervention resulted in immense improvement in the patient's quality of life, despite progression of his systemic amyloidosis. Conclusions: Severe pain in the setting of amyloid neuropathy is often difficult to treat. To our knowledge, this represents the first report of Scrambler therapy or an implanted intrathecal drug delivery system used for a patient with refractory amyloidosis-related neuropathic pain, resulting in substantial analgesic benefit and improved quality of life. Copyright (C) 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Analgesia of Combined Femoral Triangle and Obturator Nerve Blockade Is Superior to Local Infiltration Analgesia After Total Knee Arthroplasty With High-Dose Intravenous Dexamethasone.

Background and Objectives: High-dose intravenous dexamethasone reduces the postoperative opioid requirement and is often included in the multimodal analgesia strategy after total knee arthroplasty (TKA). Combined obturator nerve and femoral triangle blockade (OFB) reduces the opioid consumption and pain after TKA better than local infiltration analgesia (LIA). The question is whether preoperative high-dose intravenous dexamethasone would cancel out the superior analgesic effect of OFB compared with LIA. The aim was to evaluate the analgesic effect of OFB versus LIA after TKA when all patients received high-dose intravenous dexamethasone. Methods: Eighty-two patients were randomly assigned either to OFB or LIA after primary unilateral TKA. All patients received 16 mg dexamethasone. Primary outcome was morphine consumption via patient-controlled analgesia during the first 20 postoperative hours. Secondary outcomes were pain, nausea, dizziness, and length of hospital stay. Results: Seventy-four patients were included in the analysis. Median total intravenous morphine consumption during the first 20 postoperative hours was 6 mg (interquartile range [IQR], 2-18 mg) in the OFB group and 20 mg (IQR, 12-28 mg) in the LIA group. The 14-mg difference (95% confidence interval, 6.4-18.0 mg) was significant (P

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Anatomical Variations of the Vertebral Artery in the Upper Cervical Spine: Clinical Relevance for Procedures Targeting the C1/C2 and C2/C3 Joints.

Background and Objectives: Accidental breach of the vertebral artery (VA) during the performance of cervical pain blocks can result in significant morbidity. Whereas anatomical variations have been described for the foraminal (V2) segment of the VA, those involving its V3 portion (between the C2 transverse process and dura) have not been investigated and may be of importance for procedures targeting the third occipital nerve or the lateral atlantoaxial joint. Methods: Five hundred computed tomography angiograms of the neck performed in patients older than 50 years for the management of cerebrovascular accident or cervical trauma (between January 2010 and May 2016) were retrospectively and independently reviewed by 2 neuroradiologists. Courses of the VA in relation to the lateral aspect of the C2/C3 joint and the posterior surface of the C1/C2 joint were examined. For the latter, any medial encroachment of the VA (or one of its branches) was noted. The presence of a VA loop between C1 and C2 and its distance from the upper border of the superior articular process (SAP) of C3 were also recorded. If the VA loop coursed posteriorly, its position in relation to 6 fields found on the lateral aspects of the articular pillars of C2 and C3 was tabulated. Results: At the C1/C2 level, the VA coursed medially over the lateral quarter of the dorsal joint surface in 1% of subjects (0.6% and 0.4% on the left and right sides, respectively; P = 0.998). A VA loop originating between C1 and C2 was found to travel posteroinferiorly over the anterolateral aspect of the inferior articular pillar of C2 in 55.5% of patients on the left and 41.9% on the right side (P

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Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?.

Purpose of review: Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. Recent findings: Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value. Summary: Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes. Copyright (C) 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Withdrawal of life-sustaining therapy.

Purpose of review: The aim of this review is to examine literature relating to the withdrawal of life-sustaining therapy (WLST). Recent findings: Discussions regarding end-of-life issues in adults and children are not occurring comprehensively. Discussions relating to the WLST in the pediatric population varies by institution and may vary by race, age, health insurance, diagnosis, and severity of illness. Completing advance directives prior to placement of life-sustaining treatments is not consistent practice. With the WLST, differences in perspectives exist between medical specialties, within one specialty at different levels of training, and in physicians' ethical and psychological responses to the WLST. The timing of WLST appears to be influenced by ICU strain and communication issues. Study outcomes differ regarding the functionally favorable survival of patients who have had WLST. Universal guidelines for the WLST may not address individual patient circumstances. Summary: Discussions of end-of-life issues early in the course of a patient's health care will contribute to the healthcare team's understanding and respect of the patient's wishes. This article addresses the withdrawal of left ventricular assist devices; attending physicians and physicians-in-training perspectives of WLST; do physicians distinguish between withholding and WLST; the timing of WLST; guidelines for the process of WLST; and pediatrics and end-of-life decisions. Copyright (C) 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Traction alopecia: Symptoms and prevention

Traction alopecia is hair loss caused by tight hairstyles. Caught early, it is fully reversible and the hair can regrow. Learn more about treatment.

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The Development of a Nano-based Approach to Alleviate Cisplatin-Induced Ototoxicity

Abstract

Cisplatin-induced hearing loss is experienced by a high percentage of patients with squamous cell carcinoma undergoing cisplatin chemotherapy. A novel nano-construct capable of sequestering extracellular cisplatin was developed to combat this problem. The nano-construct consisted of superparamagnetic iron oxide nanoparticles (SPIONs) entrapped within polymeric micelles, which were formed from a glutathione diethyl ester-conjugated amphiphilic diblock copolymer. The glutathione-micelles were analyzed at the cellular level and in an organotypic study for safety evaluation. All utilized methods indicated that the micelles do not cause cellular toxicity or organ damage. The micelles' ability to reduce cisplatin-induced cytotoxicity was then probed in an in vitro model. Cisplatin was pre-treated with the novel nano-construct before being added to growing cells. When compared to cells that were exposed to untreated cisplatin, cells in the pre-treated cisplatin group showed a significant increase in cell viability. This clearly demonstrates that the construct is able to protect the cells from cisplatin cytotoxicity and makes it highly likely that the novel nano-construct will be able to play a role in the protection of the inner ear from cisplatin-induced ototoxicity.

http://ift.tt/2DlN8kc

The Development of a Nano-based Approach to Alleviate Cisplatin-Induced Ototoxicity

Abstract

Cisplatin-induced hearing loss is experienced by a high percentage of patients with squamous cell carcinoma undergoing cisplatin chemotherapy. A novel nano-construct capable of sequestering extracellular cisplatin was developed to combat this problem. The nano-construct consisted of superparamagnetic iron oxide nanoparticles (SPIONs) entrapped within polymeric micelles, which were formed from a glutathione diethyl ester-conjugated amphiphilic diblock copolymer. The glutathione-micelles were analyzed at the cellular level and in an organotypic study for safety evaluation. All utilized methods indicated that the micelles do not cause cellular toxicity or organ damage. The micelles' ability to reduce cisplatin-induced cytotoxicity was then probed in an in vitro model. Cisplatin was pre-treated with the novel nano-construct before being added to growing cells. When compared to cells that were exposed to untreated cisplatin, cells in the pre-treated cisplatin group showed a significant increase in cell viability. This clearly demonstrates that the construct is able to protect the cells from cisplatin cytotoxicity and makes it highly likely that the novel nano-construct will be able to play a role in the protection of the inner ear from cisplatin-induced ototoxicity.

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Errors in Figures 1, 2, and 3

In the Original Investigation titled "Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis," published online December 7, 2017, in Figure 1, the total number of studies included in quantitative synthesis (meta-analysis) should have been 36 instead of 40; in Figure 2, the r value for reasoning should have been −0.18 instead of −0.17; and in Figure 3, the numbers of participants and events for all categories were incorrect. This article has been corrected online.

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Status of Radiology Training in Otolaryngology Residency Programs

This survey study of program directors assesses the current state of radiology training in US otolaryngology residency programs.

http://ift.tt/2ET2eKB

Angiolytic Laser With or Without Polypectomy for Vocal Fold Polyps

This cohort study examines the outcomes and incidence rates of adverse events associated with in-office angiolytic laser procedures with or without concurrent polypectomy as an alternative treatment for vocal fold polyps.

http://ift.tt/2Du5jUb

Proposal for New Diagnosis for Cochlear Migraine

This Viewpoint examines the existence and features of cochlear migraine.

http://ift.tt/2EUaudl

Complex issues in new ultrasound-guided nerve blocks: how to name, where to inject, and how to publish

Abstract

The recent development of ultrasound-guide nerve block has led to innovation in anesthesia and pain clinics. However, it has also led to some complex issues, including (1) how to name a new technique, (2) the appropriateness of an intramuscular approach, and (3) how to publicize a new technique. This review addresses naming strategy, feasibility of intramuscular approach block, and methods of publication. First, researchers and authors should pay attention to appropriate nomenclature for the term 'approach', 'compartment block', and 'nerve block' for a new block. Second, it is lack of evidences to facilitate muscle injection, and adequate preparation and adherence to proper technique for intramuscular approach block should be considered; confirmation of abnormal signs at the injection area, use of a thin needle and the lowest concentration and volume of local anesthetic without supplementation with steroid or epinephrine, compressing hemostasis, and sufficient interval of the blocks. Third, adequate dissemination of information would also be necessary through publication in appropriate media. We hope this review boost reasonable development of nerve block.

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Therapieoptionen bei Sarkomen an der Wirbelsäule

Zusammenfassung

Hintergrund

Sarkome an der Wirbelsäule stellen aufgrund ihrer Heterogenität, Seltenheit und anatomischen Lage eine große Herausforderung für die Behandelnden dar.

Fragestellung

Diskutiert werden die Behandlungsmöglichkeiten (State-of-the-art).

Material und Methode

Es werden die aktuelle Literatur, Expertenmeinungen und Konsensempfehlungen internationaler Expertengremien diskutiert.

Ergebnisse

Es gibt folgende Konsensus-Empfehlungen: a) Osteosarkom: kombinierte Therapie: neoadjuvante Chemotherapie/En-bloc-Resektion/Strahlenresistenz; b) Ewing-Sarkom: kombinierte Therapie: neo- und adjuvante Chemotherapie/Restaging und Bestimmung des Regressionsgrads vor En-bloc-Resektion zwingend/En-bloc-Resektion und/oder Radiotherapie; c) Chondrosarkom: wenn möglich En-bloc-Resektion. Intensitätsmodulierte Radiotherapie scheint selektiv eine primäre oder adjuvante Option zu sein.

Etablierte Operationsverfahren (En-bloc-Resektion) kombiniert mit neuen Techniken (Implantate, Materialen/3D-Navigation), präziseren Bestrahlungsoptionen (intensitätsmodulierte Photonenbestrahlung) und Anwendung von Partikelstrahlung lassen eine Verbesserung der Therapieergebnisse erwarten.

Schlussfolgerung

Das beste Outcome haben Patienten, welche von Beginn an (bereits zur Biopsie) einem ausgewiesenen Tumorzentrum zugewiesen werden. Das Behandlungskonzept ist immer multidisziplinär.

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SBRT + Cyclophosphamide for Inoperable, Recurrent H&N

Condition:   Head and Neck Neoplasm
Intervention:   Radiation: Stereotactic body radiotherapy
Sponsor:   University Hospital, Ghent
Recruiting

http://ift.tt/2ESV88C

Intratreatment FDG-PET During Radiation Therapy for Gynecologic and Gastrointestinal Cancers

Conditions:   Cancer of the Cervix;   Vulvar Cancer;   Esophageal Cancer;   Anal Canal Cancer
Intervention:   Other: FDG PET scan
Sponsor:   Duke University
Not yet recruiting

http://ift.tt/2FNKoKd

Dual-Energy CT on Plan Quality, Dose-delivery Accuracy, and Simulated Patient Outcomes for Locally Advanced Lung and Brain Tumor Patients Treated With Proton Therapy

Conditions:   Lung Cancer;   Brain Cancer
Intervention:   Device: Siemens Somatom Definition Edge
Sponsors:   Washington University School of Medicine;   National Cancer Institute (NCI)
Not yet recruiting

http://ift.tt/2EUMxSO

The European Robotic Spinal Instrumentation (EUROSPIN) Registry

Conditions:   Degenerative Disc Disease;   Spondylolisthesis;   Spinal Stenosis;   Recurrent Disc Herniation;   Spondylodiskitis;   Spinal Tumor;   Spinal Metastases
Intervention:   Procedure: Transpedicular Instrumentation
Sponsor:   Marc Schröder
Not yet recruiting

http://ift.tt/2FPwCqi

Atrial Repolarization Waves (Ta) Mimicking Inferior Wall ST Segment Elevation Myocardial Infarction in a Patient with Ectopic Atrial Rhythm

We present a case of atrial repolarization waves from an ectopic atrial rhythm mimicking inferior ST segment elevation myocardial infarction in a 78-year-old male patient who presented with left sided chest wall and shoulder pain. His ischemic workup was negative, and the ST elevations completely resolved upon the resumption of sinus rhythm before discharge.

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High frequency jet ventilation during endolaryngeal surgery: Risk factors for complications

Microlaryngeal surgery requires teamwork between surgeons and anesthesiologists. Two main components required for this surgery are the maximal exposure of the surgical area and adequate gas exchange for safe anesthesia. Other requirements include an immobile larynx and the protection of the airway against surgical debris.

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Congenital aneurysm of both left ventricle and left atrium

Ryan F Halas, Christopher J Schmehil, Gary R Ten Eyck, James L Loker

Annals of Pediatric Cardiology 2018 11(1):97-99

This is a case of both congenital left ventricular (LV) free wall submitral aneurysm and left atrial appendage aneurysm with 6 years of clinical follow-up. Each lesion is a rare entity, and to the best of our knowledge, this is the first case in medical literature of both lesions occurring in the same patient, raising the likelihood of a common etiology. The workup was initiated in the third trimester of fetal life with irregular heart rate and abnormal fetal ultrasound and echocardiogram at that time. The patient required emergent atrial appendage plication due to blood clot formation and suffered from multiple other complications including ventricular ectopy and surgically induced pseudoaneurysm. Follow-up interval echocardiograms have revealed continued good LV function with persistent LV aneurysm. In review of the case, there were several potential in utero causes including maternal viral upper respiratory infection and bacteriuria with exposure to amoxicillin. These as well as other considerations are discussed along with a brief review of these rare lesions, usual presentation, and known associations.

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Arterial duct and pulmonary arteriovenous malformations: A shunt masking a shunt

Mario Giordano, Giuseppe Santoro, Maria Teresa Palladino, Maria Giovanna Russo

Annals of Pediatric Cardiology 2018 11(1):89-91

A 5-month-old infant, referred to our institution for percutaneous arterial duct (AD) embolization, showed multiple huge pulmonary arteriovenous malformations (PAVMs) associated with a small AD and several tiny systemic-to-pulmonary collaterals. This anatomic arrangement was a possible cause of lack of cyanosis and disproportionately higher hemodynamic relevance of the ductal shunt. The PAVMs became pathophysiologically evident immediately after the closure of AD and systemic to pulmonary artery collaterals and presented clinically with a life-threatening cyanosis. To improve the patient's clinical and hemodynamic condition, the PAVMs were closed in multiple sittings using a large number of Amplatzer Vascular Plugs (St. Jude Medical Inc., St. Paul, MN, USA). The hemodynamic burden of cardiac malformations resulting in left-to-right shunt may be magnified by the presence of PAVMs as a result of low pulmonary vascular resistance which in turn may completely mask the clinical impact of the latter. Transcatheter approach is life-saving in these complex arrangements.

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Extracorporeal membrane oxygenation in pediatric cardiac surgery: A retrospective review of trends and outcomes in Scotland

Maziar Khorsandi, Mark Davidson, Omar Bouamra, Andrew McLean, Kenneth MacArthur, Ida Torrance, Gillian Wylie, Ed Peng, Mark Danton

Annals of Pediatric Cardiology 2018 11(1):3-11

Introduction : Around 3.2%–8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is "bridgetorecovery" in most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical. Methods : A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: "endofcase" or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation ("ECPR"), and Intensive Care Unit ECMO for "failing maximal medial therapy" following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates. Results : We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42–2010 days), all survivors to hospital discharge were alive at review date. "Endofcase" ECMO showed a trend toward better survival of the three subcategories ("end of case," ECPR, and ECMO for "failing maximal medical therapy" survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177). Conclusions : Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective "endofcase" ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.

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Melody valve implantation through a recanalized occluded femoral vein

Neil D Patel, Jennifer A Su, Cheryl M Takao, Frank F Ing

Annals of Pediatric Cardiology 2018 11(1):111-113



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Comparison of skin dose measurement using nanoDot® dosimeter and machine readings of radiation dose during cardiac catheterization in children

Duraisamy Balaguru, Matthew Rodriguez, Stephanie Leon, Louis K Wagner, Charles W Beasley, Andrew Sultzer, Mohammed T Numan

Annals of Pediatric Cardiology 2018 11(1):12-16

Objectives : Direct measurement of skin dose of radiation for children using optically stimulated luminescence (OSL) technology using nanoDot® (Landauer, Glenwood, IL, USA). Background : Radiation dose is estimated as cumulative air kerma (AK) and dosearea product based on standards established for adult size patients. Body size of pediatric patients who undergo cardiac catheterization for congenital heart disease vary widely from newborn to adolescence. Direct, skindose measurement applying OSL technology may eliminate errors in the estimate. Materials and Methods : The nanoDot® (1 cm × 1 cm × flat plastic cassette) is applied to patient's skin using adhesive tape during cardiac catheterization and radiation skin doses were read within 24 hrs. nanoDot® values were compared to the currently available cumulative AK values estimated and displayed on fluoroscopy monitor. Results : A total of 12 children were studied, aged 4 months to 18 years (median 1.1 years) and weight range 5.3–86 kg (median 8.4 kg). nanoDot® readings ranged from 2.58 mGy to 424.8 mGy (median 84.1 mGy). Cumulative AK ranged from 16.2 mGy to 571.2 mGy (median 171.1 mGy). Linear correlation was noted between nanoDot® values and AK values (R2 = 0.88, R = 0.94). nanoDot® readings were approximately 65% of the estimated cumulative AK estimated using the International Electrotechnical Commission standards. Conclusions : Application of OSL technology using nanoDot® provides an alternative to directly measure fluoroscopic skin dose in children during cardiac catheterization. Our data show that the actual skin dose for children is approximately one-third lower than the AK estimated using international standards for adult size patients.

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Coronary sinus atrial septal defect without persistent left superior vena cava: Three-dimensional imaging of a rare defect

Sean Del-Rossi Quadros, Sreeja Pavithran, Ravi Agrawal, Kothandam Sivakumar

Annals of Pediatric Cardiology 2018 11(1):103-105

Coronary sinus defects refer to interatrial communications that lie out of the confines of the atrial septum and leads from left to right shunt through the ostium of the coronary sinus. When associated with persistent left superior vena cava (PLSVC), mild systemic desaturation may occur depending on the extent of unroofing of the coronary sinus. Isolated defects without PLSVC are rare. Three-dimensional echocardiographic and surgical images are presented.

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Normal reference ranges for cardiac valve cross-sectional areas in preterm infants

Lulu Abushaban, Mariappa Thinakar Vel, Jebaraj Rathinasamy, Prem N Sharma

Annals of Pediatric Cardiology 2018 11(1):17-27

Objective : To establish normal reference ranges for cardiac valve crosssectional areas (CSAs) in preterm infants and their correlation with gestational age, body weight, and chronological age. Materials and Methods : In a prospective study, 268 preterm babies fulfilling the criteria for inclusion were examined. Echocardiograms were performed to measure aortic, pulmonary, mitral, and tricuspid valve CSAs on 0–6 day (s) of life and at weekly intervals until they reached 36 weeks. Gestational age was divided into three groups, 24–27, 28–31, and 32–35 weeks, and body weight was divided into five groups, ≤999, 1000–1499, 1500–1999, 2000–2499, and ≥2500 g. Overall group differences were compared for each period of life: 0–6 days and 1–2, 3–4, and ≥5 weeks. Results : The mean gestational age was 29.8 (±2.38 standard deviation [SD]) weeks, ranging between 24 and 35 weeks, and the mean body weight was 1479 (±413 SD) g, ranging between 588 and 3380 g. All cardiac valve CSAs correlated well with body weight. A significant gradual increase was observed in all valve CSAs with body weight during each period of life. Overall, a progressive and significant increase in all valve CSAs was observed during the first 9 weeks of life. Conclusions : Cardiac valve CSAs were found to be significantly correlated with body weight. The study also provides reference data, which can be used as a normal reference tool for valve CSAs in preterm infants against gestational age, body weight, and chronological age.

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From the Editor's Desk: Congenital heart surgery in India – At the crossroads?

Krishna Subramony Iyer

Annals of Pediatric Cardiology 2018 11(1):1-2



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Evaluation of left ventricular function in obese children without hypertension by a tissue Doppler imaging study

Yazdan Ghandi, Mehrzad Sharifi, Danial Habibi, Fatemeh Dorreh, Mojtaba Hashemi

Annals of Pediatric Cardiology 2018 11(1):28-33

Background : The prevalence of obesity is increasing worldwide. Obese children without hypertension are becoming an important health challenge. Aims : Complications of obesity in adults are well established, but in obese children, cardiac dysfunction has not been reported clinically. Settings and Design : The present crosssectional study investigates subclinical systolic and diastolic dysfunction using echocardiographic modalities. Materials and Methods : Twentyfive youngsters with body mass index (BMI) >30 and 25 healthy children with BMI <25 were assigned into case and control group, respectively. In all participants, complete cardiovascular examination, electrocardiography, and echocardiography were fulfilled. Echocardiography surveys included standard, pulsed wave Doppler (PWD), and tissue Doppler imaging (TDI). Statistical Analysis Used : SPSS software, version 24. Results : The two groups were matched for age and sex. The resting heart rate and blood pressure were markedly higher in the obese group (P = 0.0001) though they were within the normal range in either category. Ejection fraction in the two groups was similar. Left ventricular (LV) mass (P = 0.0001), LV mass index (P = 0.029), left atrialtoaortic diameter ratio (P = 0.0001), and LV enddiastolic diameter (P = 0.008) were significantly greater in the case group, indicating cardiomegaly and subclinical systolic and diastolic dysfunction. Except for the aortic velocity, all PWD variables were considerably lower in the case group, suggesting subclinical diastolic dysfunction. All TDI parameters varied significantly between the two categories. There was a direct correlation between isovolumetric relaxation time and BMI. Conclusions : Obesity in children without hypertension is associated with subclinical systolic and diastolic cardiac dysfunction. We propose the evaluation of blood pressure as well as myocardial performance using PWD and TDI in all obese children without hypertension, regularly.

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Clinical presentation, management, and postnatal outcomes of fetal tachyarrhythmias: A 10-year single-center experience

Balaganesh Karmegeraj, Sushmita Namdeo, Abish Sudhakar, Vivek Krishnan, Radhamany Kunjukutty, Balu Vaidyanathan

Annals of Pediatric Cardiology 2018 11(1):34-39

Background : Limited information is available regarding the prevalence and outcomes of fetal tachyarrhythmias from the developing countries. Aims : This study aims to report referral patterns, management protocols, and pregnancy outcomes of fetuses with tachyarrhythmias reporting to a single center in South India. Methods : All fetuses with documented sustained fetal tachyarrhythmia during the study period (2008–2017) were included. Arrhythmia characterization and hemodynamic evaluation were done using fetal echocardiography. Patients were grouped into supraventricular tachycardia (SVT) and atrial flutter (AF) groups. Patient characteristics, transplacental therapy (TPT), pregnancy, and postnatal outcomes were analyzed. Results : Total of 19 fetuses included; 11 had SVT and 8 AF. Mean gestational age at referral was higher for AF (32.5 ± 3.2 vs. 29.6 ± 3.3 weeks; P = 0.05). Hydrops fetalis was present 8 (42%) fetuses; 4 in each group. TPT was instituted in 18 fetuses; 12 (66.7%) received combination therapy; 4 (21%) received direct fetal therapy. Eighteen fetuses (91%) were born alive with one intrauterine death in a fetus with SVT and severe hydrops. Seven (87.5%) fetuses with hydrops survived. Twelve patients (66.7%) were delivered in sinus rhythm. Six babies (33.3%) had tachycardia at birth requiring anti-arrhythmic therapy. All patients survived the neonatal period. Duration of trans-placental therapy (3.8 + 3.3 vs. 7.3 + 3.4 weeks) was shorter in the AF group. Conclusions : Aggressive TPT using combination of drugs achieves excellent pregnancy and postnatal outcomes in fetuses with tachyarrhythmia. Early diagnosis and prompt referral before hemodynamic decompensation is critical for ensuring optimal outcomes.

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Cost-effectiveness analysis of devices for closure of patent ductus arteriosus

KM Krishnamoorthy, Arun Gopalakrishnan

Annals of Pediatric Cardiology 2018 11(1):109-109



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Exercise performance after univentricular palliation

Sachin Talwar, Manikala Vinod Kumar, Vishnubhatla Sreenivas, Vishwa Prakash Gupta, Shiv Kumary Choudhary, Balram Airan

Annals of Pediatric Cardiology 2018 11(1):40-47

Background : The optimal timing, need for primary/staged procedure in patients undergoing univentricular palliation, is debatable. Aims : We performed this study to assess the exercise performance of patients undergoing various forms of univentricular palliation. Setting and Design : This was a retrospective, prospective comparative study conducted at a multispecialty tertiary referral center. Patients and Methods : Between January 2012 and June 2015, 117 patients undergoing either bidirectional Glenn (BDG) (n = 43) or Fontan (total cavopulmonary connection [TCPC]) (n = 74) underwent exercise testing. Statistical Analysis : Comparisons between subgroups for continuous data were made with Student's ttest if normally distributed and Wilcoxon ranksum test otherwise. Tests between subgroups for qualitative data were made with Pearson's Chisquare test. Results : Patients who underwent BDG with open antegrade pulmonary blood flow (APBF) had higher saturations (oxygen saturation [SpO2]) compared to those without it (87.5 ± 5.0% vs. 81.1 ± 4.8%; P = 0.0001). However, we found no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC (n = 42) patients demonstrated better exercise capacity (15.0 ± 7.7 vs. 11.2 ± 6.2 min; P = 0.02) and increased SpO2 on exercise (87.0 ± 8.0% vs. 83.4 ± 7.6%; P ≤ 0.05) compared to lateral tunnel TCPC (n = 32). Fenestrated TCPC (n = 30) patients had higher exercise capacity reflected by higher metabolic equivalents (METs) consumption (6.4 ± 2.3 vs. 5.2 ± 2.0 METs, P = 0.02), fewer pleural effusions (7.0 ± 3.2 vs. 9.2 ± 6.2 days, P ≤ 0.05), and lower hospital stay (9.5 ± 4.0 vs. 12.7 ± 7.7 days, P = 0.04) compared to nonfenestrated TCPC (n = 44) patients. Conclusions : We observed no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC patients had better exercise capacity but longer postoperative hospital stay and pleural effusions than patients with lateral tunnel Fontan. Fenestrated TCPC patients seemed to fare better than nonfenestrated ones. Patients undergoing TCPC had better exercise capacity than patients undergoing BDG alone.

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Ominous comorbidities: Small ventricular septal defect and warm autoimmune hemolytic anemia

Elaheh Malakan Rad

Annals of Pediatric Cardiology 2018 11(1):114-116



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Impact of intensive care unit attending physician training background on outcomes in children undergoing heart operations

Priya Bhaskar, Mallikarjuna Rettiganti, Jeffrey M Gossett, Punkaj Gupta

Annals of Pediatric Cardiology 2018 11(1):48-55

Background : The existing training pathways to become a pediatric cardiac intensivist are very variable with physicians coming from varied training backgrounds of pediatric critical care, pediatric cardiology, neonatology, or pediatric anesthesia. Aim : To evaluate the impact of cardiac Intensive Care Unit (ICU) attending physician training background on outcomes in children undergoing heart operations. Setting and Design : Patients in the age group from 1 day to 18 years undergoing heart operation at a Pediatric Health Information System database participating hospital were included (2010–2015). Patients and Methods : Based on the training background of majority of attending physicians in an ICU, the participating ICUs were divided into three groups: critical care medicine (CCM), cardiology, and indeterminate. Statistical Analysis : Multivariable logistic regression models were fitted to evaluate the association of ICU physician training background with study outcomes. Results : A total of 54,935 patients from 42 ICUs were included. Of these, 31,815 patients (58%) were treated in the CCM group (26 ICUs), 19,340 patients (35%) were treated in the cardiology group (12 ICUs), and 3780 patients (7%) were treated in the indeterminate group (4 ICUs). In adjusted models, no specific group based on ICU attending physician training background was associated with lower mortality (CCM vs. cardiology, odds ratio: 0.75, 95% confidence interval: 0.48–1.18), or lower incidence of cardiac arrest, or prolonged hospital length of stay, or prolonged mechanical ventilation. Conclusions : This large observational study did not demonstrate any impact of ICU attending training background on outcomes in children undergoing heart operations.

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Transcatheter closure of postsurgical ruptured sinus of valsalva with amplatzer duct Occluder II AS™ device

Cristina Capogrosso, Giuseppe Santoro, Mario Giordano, Maria Giovanna Russo

Annals of Pediatric Cardiology 2018 11(1):86-88

Sinus of Valsalva (SV) rupture is a rare, cardiac complication after surgical repair of complex congenital heart disease. This paper reports a 4-year-old male child with double outlet right ventricle (RV) and pulmonary stenosis with superior-inferior arrangement of the ventricles, who was submitted to surgical repair using the "reparation a l'etage ventriculaire" procedure. A few months after an uneventful surgical repair, his clinical condition abruptly worsened because of the rupture of the right SV into the RV outflow tract resulting in large left-to-right shunt and RV functional impairment. To avoid surgical re-do, this late-onset complication was successfully treated by transcatheter implantation of an Amplatzer Duct Occluder Type II Additional Size™ (ADO-IIAS, St. Jude Medical Inc., St. Paul, Minnesota, USA) device.

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Prognostic value of troponin in infants with hypoplastic left heart syndrome between Stage I and II of palliation

Martin Christmann, Emanuela R Valsangiacomo Büchel, Hitendu Dave, Dietrich Klauwer, Anna Cavigelli-Brunner

Annals of Pediatric Cardiology 2018 11(1):56-59

Background : The period between stage I and II procedure for treatment of hypoplastic left heart syndrome (HLHS) bears high mortality and morbidity. Methods : We sought to analyze the prognostic value of Troponin T/I (Trop), a well-recognized marker for myocardial damage and heart failure, for predicting outcome in a retrospective analysis of 70 infants with HLHS at our institution between March 2001 and October 2014. Results : Stage I procedure consisted of Norwood I operation in 35 (50%) and Hybrid-approach in 22 (31%) patients. Palliative care was chosen for 13 (19%) patients. Trop values were collected from clinical charts and were analyzed in relation to the overall outcome. Trop was significantly higher after Norwood I operation in comparison to Hybrid-approach (median 7.1 g/l (0.7-20.9), vs 1.2 g/l (0.3-17.9), P < 0.001). Overall mortality of treated patients was 39% (22 patients). Survival was 54% (19 patients) after Norwood and 73% (16 patients) after Hybrid-approach. Independently from the procedure used, maximal Trop and initial lactate values were significantly higher in non-survivors than in survivors, with median Trop of 9 g/l (0.6-18.8) vs. 3.4 g/l (0.4-20.9), P 0.007, and median lactate of 3.7 mmol/L (1.6-25) vs. 2.9 mmol/L (0.3-14.6), p 0.03. Reinterventions were required in 17 (30%) patients, 4 (11%) after Norwood and 13 (59%) after Hybrid procedure. No correlation was found between the need for reintervention and Trop levels in the interstage period. Conclusions : Patients with HLHS have significantly higher Trop levels after Norwood procedure than after Hybrid-approach. Maximal Trop values were related to mortality, but did not correlate with the need for reinterventions.

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Discontinuity of the arch beyond the origin of the left subclavian artery in an adult: Interruption or coarctation?

Pradeep Vaideeswar, Supreet Marathe, Saranya Singaravel, Robert H Anderson

Annals of Pediatric Cardiology 2018 11(1):92-96

Congenital aortic anomalies are uncommon causes of secondary hypertension and are seldom suspected in the adult age group. We present a case of aortic interruption unexpectedly diagnosed on autopsy in a 38-year-old male who presented with cardiovascular collapse. Apart from interruption, a finding unique to our case was aneurysmal dilation of the proximal descending aorta just before the obstruction with thrombosis. We also attempt to review the literature for interrupted aortic arch in adults and clarify the nomenclature of interruption versus coarctation.

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Q fever endocarditis after right ventricle to pulmonary artery conduit insertion: Case series and review of the literature

Sundos A Alhadhoud, Mariappa Thinakar Vel, Mustafa Al Qbandi

Annals of Pediatric Cardiology 2018 11(1):60-63

Q fever (QF) is rarely reported in children. Awareness of the disease and newer diagnostic modalities have resulted in increasing recognition of unusual manifestations. We present three cases of QF endocarditis after right ventricle to pulmonary artery conduit insertion in children.

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Acquired ventricular septal defect due to infective endocarditis

Randi E Durden, Joseph W Turek, Benjamin E Reinking, Manish Bansal

Annals of Pediatric Cardiology 2018 11(1):100-102

Acquired intracardiac left-to-right shunts are rare occurrences. Chest trauma and myocardial infection are well-known causes of acquired ventricular septal defect (VSD). There have been several case reports describing left ventricle to right atrium shunt after infective endocarditis (IE). We present here a patient found to have an acquired VSD secondary to IE of the aortic and tricuspid valves in the setting of a known bicuspid aortic valve. This is the first case reported of acquired VSD in a pediatric patient in the setting of IE along with literature review of acquired left-to-right shunts.

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Hemodynamic rounds: Can we mimic a temporary pulmonary artery band in catheterization laboratory in corrected transposition of great arteries with severe tricuspid regurgitation?

Avinash Anantharaj, Kothandam Sivakumar

Annals of Pediatric Cardiology 2018 11(1):64-67

Right ventricular (RV) geometry is altered by septal shift after pulmonary artery banding. This may reduce tricuspid regurgitation (TR) and improve ventricular function in patients with corrected transposition of great arteries and systemic right ventricle. However, banding is risky in sick patients with severe RV failure. There are no predictive models in clinical practice to test this septal shift hypothesis before a risky surgery. A transcatheter model to mimic a pulmonary artery band is presented in corrected transposition of great arteries with failing right ventricle and severe TR.

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Helicobacter pylori infection and occurrence of celiac disease in subjects HLA-DQ2/DQ8 positive: A prospective study

Abstract

Background

Celiac disease (CD) occurs in subjects positive for HLA-DQ2 and/or DQ8 gene loci at any age following ingestion of gluten-containing food. An increased permeability of the mucosa allows interactions between gliadin macromolecules and genetic factors. It has been observed that Helicobacter pylori has the ability to modulate the integrity of the duodenal epithelium. We aimed to determine whether H. pylori infection may enhance the occurrence of CD in genetically susceptible subjects.

Materials and Methods

This was a prospective observational study. Patients undergoing upper endoscopy for any reason and positive for HLA-DQ2 and/or DQ8 haplotypes with or without CD were included. H. pylori infection was defined as a positive gastric histopathology and/or 13C-urea breath test. Prevalence of infection was compared between enrolled subjects with and without CD. Multiple logistic regression analysis, adjusting odds ratios for patient age, gender, smoking habit, residency, body mass index, and assumption of nonsteroidal anti-inflammatory drugs (NSAIDs) and proton-pump inhibitors (PPIs) were performed.

Results

A total of 397 genetically susceptible individuals (mean age: 37.7 ± 15.3 years; 86% women) were enrolled between October 2014 and October 2017. There were 265 (68%) patients with a diagnosis of CD. Overall, the prevalence of H. pylori infection was 33% and was similar in patients with and without CD (32% vs 36%). Adjustment for all covariates did not reveal any significant association, although adjusted odds ratio (OR) for CD was higher in female (OR = 1.302), in patients H. pylori positive (OR = 1.277), followed by use of NSAIDs (OR = 1.126), respectively. The use of PPIs appeared to be mildly protective against CD (OR = 0.644).

Conclusion

Our study did not reveal any significant relationship between H. pylori and CD risk, even taking into account other confounders. More importantly, our findings do not support a "protective" role of H. pylori infection against CD, as previously reported. Therefore, there are no reasons to avoid eradication of H. pylori also in subject genetically susceptible for CD.

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The effect of eradication of Helicobacter pylori on gastric cancer prevention in healthy asymptomatic populations

Abstract

Background

Although many epidemiologic studies have evaluated the effect of Helicobacter pylori eradication on gastric cancer, the effect is still uncertain in general populations. We evaluated whether H. pylori eradication would affect the incidence of gastric cancer in healthy asymptomatic populations.

Materials and methods

We performed a retrospective cohort study in 38 984 asymptomatic individuals, who underwent health screening examinations more than twice between 2005 and 2016. We investigated the incidence of gastric cancer among 3 groups: those without H. pylori infection (Hp-negative group), those with H. pylori eradication (eradication group), and those without H. pylori eradication (non-eradication group).

Results

The cumulative incidence of gastric cancer was 54.5 cases per 100 000 person-years during a median of 6.4 years. In a multivariate analysis using the Cox proportional hazard model, the cumulative incidence of gastric cancer in the non-eradication group was significantly higher than those in the Hp-negative (hazard ratio [HR] 4.12, P < .001) and eradication groups (HR 2.73, P = .001). However, the cumulative incidence of gastric cancer was not significantly different between the eradication and Hp-negative groups. Other risk factors for gastric cancer occurrence were age, smoking, family history of gastric cancer, and gastric atrophy. The standardized incidence ratios of the age groups above 40 and below 70 in the eradication group were all significantly decreased.

Conclusions

Helicobacter pylori eradication reduced the cumulative incidence of gastric cancer in healthy asymptomatic population, and the effect of H. pylori eradication on the prevention of gastric cancer was observed in all ages.

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