Transfusion practices in traumatic brain injury

Purpose of review The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. Recent findings Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. Summary Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion. Correspondence to Victoria A. McCredie, MBChB, PhD, Department of Critical Care Medicine, 2nd Floor McLaughlin Rm 411-J, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, Canada M5T 2S8. Tel: +1 416 302 1959; e-mail: Victoria.McCredie@uhn.ca Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Staff and family response to end-of-life care in the ICU

Purpose of review End-of-life (EOL) care can be stressful for clinicians as well as patients and their relatives. Decisions to withhold or withdraw life-sustaining therapy vary widely depending on culture, beliefs and organizational norms. The following review will describe the current understanding of the problem and give an overview over interventional studies. Recent findings EOL care is a risk factor for clinician burnout; poor work conditions contribute to emotional exhaustion and intent to leave. The impact of EOL care on families is part of the acute Family Intensive Care Unit Syndrome (FICUS) and the Post Intensive Care Syndrome–Family (PICS-F). Family-centered care (FCC) acknowledges the importance of relatives in the ICU. Several interventions have been evaluated, but evidence for their effectiveness is at best moderate. Some interventions even increased family stress. Interventional studies, which address clinician burnout are rare. Summary EOL care is associated with negative outcomes for ICU clinicians and relatives, but strength of evidence for interventions is weak because we lack understanding of associated factors like work conditions, organizational issues or individual attitudes. In order to develop complex interventions that can successfully mitigate stress related to EOL care, more research is necessary, which takes into account all potential determinants. Correspondence to Dr Konrad Reinhart, ML, Senior Professor, Jena University Hospital, Chairman Global Sepsis Alliance, Paul-Schneider-Street 2, 07747 Jena, Germany. E-mail: konrad.reinhart@med.uni-jena.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Pediatric trauma transfusion and cognitive aids

Purpose of review Trauma is the most common cause of pediatric mortality. Much of the research that led to life-saving interventions in adults, however, has not been replicated in the pediatric population. Children have important physiologic and anatomic differences from adults, which impact hemostasis and transfusion. Hemorrhage is a leading cause of death in trauma, and children have important differences in their coagulation profiles. Transfusion strategies, including the massive transfusion protocol and use of antifibrinolytics, are still controversial. In addition to the blood that is lost from the injury itself, trauma leads to inflammation and to a dysfunction in hemostasis, causing coagulopathy. Recent findings In one study in which children suffered from mainly blast and penetrating injuries in a combat setting (PEDTRAX trial), the early administration of tranexamic acid was associated with decreased mortality. Some authors suggest that this result may not apply to blunt trauma, which is much more common in children in noncombat settings. Using thromboelastography to guide the administration of recombinant Factor VIIa has been done in selected cases and may represent a future avenue of research. Summary This article explores new research from the past year in pediatric trauma, starting with the physiologic differences in pediatric red blood cells and coagulation profiles. We also looked at the dramatic change in thinking over the past decade in the tolerable level of anemia in critically ill pediatric patients, as well as scales for determining the need for massive transfusion and exploring if the concepts of damage control resuscitation apply to children. Other strategies, such as avoiding hypothermia, and the selective administration of antifibriniolytics, are important in pediatric trauma as well. Future research that is pediatric focused is needed for the optimal care of our youngest patients. Correspondence: Anna Clebone, MD, Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Ave. MC-4028, Chicago, IL 60637, USA. Tel: +773 702 6700; e-mail: aclebone@dacc.uchicago.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Spirituality at the end of life

Purpose of review There is increasing emphasis on medical care of the whole patient. This holistic approach encompasses supporting the spiritual or religious needs of the patient. Particularly at the end of life, spiritual concerns may come to the fore as patients recognize and accept their impending death. Physicians may also recognize this spiritual distress but may not be clear on how to provide spiritual support. Recent findings Tools to screen for spiritual concerns are available for physicians to use. Some physicians wish to go further, supporting patients at the end of life in their spiritual quest. Other physicians express concern about causing more distress to patients in a time of significant need. Descriptions of educational tools, as well as the difference between spiritual generalists and spiritual specialists have emerged. Integration of chaplains into the medical team caring for patients at the end of life will also enhance care of the whole patient. Summary The increasing emphasis on whole patient care is leading to increasing focus on spiritual concerns of patients. Although not every patient has an interest in spiritual conversation, most do and medical teams will need to become more educated about appropriate spiritual engagement. Correspondence to Cynthiane J. Morgenweck, MD, MA, Center for Bioethics and Medical Humanities, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. Tel: +1 414 955 8498; e-mail: cmorg@mcw.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized. Accepted for publication October 27, 2017. Funding: The Perioperative Quality Initiative (POQI) meeting received financial assistance from the American Society for Enhanced Recovery (ASER). Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). For the Perioperative Quality Initiative (POQI) 2 Workgroup, see Supplemental Digital Content, Appendix 1, http://ift.tt/2n5LfOn. Reprints will not be available from the authors. Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu. © 2018 International Anesthesia Research Society

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Age Does Not Affect Metoprolol’s Effect on Perioperative Outcomes (From the POISE Database)

BACKGROUND: Perioperative β-blockade reduces the incidence of myocardial infarction but increases that of death, stroke, and hypotension. The elderly may experience few benefits but more harms associated with β-blockade due to a normal effect of aging, that of a reduced resting heart rate. The tested hypothesis was that the effect of perioperative β-blockade is more significant with increasing age. METHODS: To determine whether the effect of perioperative β-blockade on the primary composite event, clinically significant hypotension, myocardial infarction, stroke, and death varies with age, we interrogated data from the perioperative ischemia evaluation (POISE) study. The POISE study randomly assigned 8351 patients, aged ≥45 years, in 23 countries, undergoing major noncardiac surgery to either 200 mg metoprolol CR daily or placebo for 30 days. Odds ratios or hazard ratios for time to events, when available, for each of the adverse effects were measured according to decile of age, and interaction term between age and treatment was calculated. No adjustment was made for multiple outcomes. RESULTS: Age was associated with higher incidences of the major outcomes of clinically significant hypotension, myocardial infarction, and death. Age was associated with a minimal reduction in resting heart rate from 84.2 (standard error, 0.63; ages 45–54 years) to 80.9 (standard error, 0.70; ages >85 years; P

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Using the Ventrain With a Small-Bore Catheter: Ventilation or Just Oxygenation?

No abstract available

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The Effects of Agrin Isoforms on Diabetic Neuropathic Pain in a Rat Streptozotocin Model

BACKGROUND: Diabetes mellitus affects 9.3% of the US population and increases risks of surgery and complications. Diabetic neuropathic pain (DNP), one of the main consequences of diabetes mellitus, is extremely difficult to treat. Current medications yield limited benefits and/or have severe adverse effects. Therefore, new, effective treatment is needed. METHODS: Streptozotocin at 55 mg/kg was injected intraperitoneally in rats to induce diabetes mellitus. Diabetic rats exhibiting neuropathic pain underwent intrathecal injection of purified agrin proteins at various doses and were then tested for tactile allodynia to evaluate whether DNP was inhibited. The agrin effects were also analyzed with patch-clamp recording on spinal cord slices. RESULTS: Fifty–kilo Dalton agrin (Agr50) at 0.2 and 2 ng suppressed DNP when given intrathecally, while 25- and 75-kDa agrin (Agr25, Agr75) had little effect. The suppressive effect of Agr50 lasted 4 hours after a single bolus injection. The difference in effects of Agr50 on mean withdrawal threshold (4.6 ± 2.2 g before treatment to 26 ± 0 g after treatment) compared with that of Agr25 (4.9 ± 2.0 g to 4.9 ± 2.0 g) and Agr75 (5.3 ± 2.3 g to 9.2 ± 2.5 g) was highly significant (P

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Electroencephalography and Brain Oxygenation Monitoring in the Perioperative Period

Maintaining brain function and integrity is a pivotal part of anesthesiological practice. The present overview aims to describe the current role of the 2 most frequently used monitoring methods for evaluation brain function in the perioperative period, ie, electroencephalography (EEG) and brain oxygenation monitoring. Available evidence suggests that EEG-derived parameters give additional information about depth of anesthesia for optimizing anesthetic titration. The effects on reduction of drug consumption or recovery time are heterogeneous, but most studies show a reduction of recovery times if anesthesia is titrated along processed EEG. It has been hypothesized that future EEG-derived indices will allow a better understanding of the neurophysiological principles of anesthetic-induced alteration of consciousness instead of the probabilistic approach most often used nowadays. Brain oxygenation can be either measured directly in brain parenchyma via a surgical burr hole, estimated from the venous outflow of the brain via a catheter in the jugular bulb, or assessed noninvasively by near-infrared spectroscopy. The latter method has increasingly been accepted clinically due to its ease of use and increasing evidence that near-infrared spectroscopy–derived cerebral oxygen saturation levels are associated with neurological and/or general perioperative complications and increased mortality. Furthermore, a goal-directed strategy aiming to avoid cerebral desaturations might help to reduce these complications. Recent evidence points out that this technology may additionally be used to assess autoregulation of cerebral blood flow and thereby help to titrate arterial blood pressure to the individual needs and for bedside diagnosis of disturbed autoregulation. Accepted for publication December 8, 2017. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Thomas W. L. Scheeren, MD, PhD, Department of Anaesthesiology, University Medical Center Groningen, PO Box 30 001, 9700 RB Groningen, the Netherlands. Address e-mail to t.w.l.scheeren@umcg.nl. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Comparison of Intranasal Dexmedetomidine and Oral Pentobarbital Sedation for Transthoracic Echocardiography in Infants and Toddlers: A Prospective, Randomized, Double-Blind Trial

BACKGROUND: Acquisition of transthoracic echocardiographic (TTEcho) images in children often requires sedation. The optimal sedative for TTEcho has not been determined. Children with congenital heart disease are repeatedly exposed to sedatives and anesthetics that may affect brain development. Dexmedetomidine, which in animals alters brain structure to a lesser degree, may offer advantages in this vulnerable population. METHODS: A prospective, randomized, double-blind trial enrolled 280 children 3–24 months of age undergoing outpatient TTEcho, comparing 2.5 µg·kg−1 intranasal dexmedetomidine to 5 mg·kg−1 oral pentobarbital. Rescue sedation, for both groups, was intranasal dexmedetomidine 1 µg·kg−1. The primary outcome was adequate sedation within 30 minutes without rescue sedation, assessed by blinded personnel. Secondary outcomes included number of sonographer pauses, image quality in relation to motion artifacts, and parental satisfaction. RESULTS: Success rates with a single dose were not different between sedation techniques; 85% in the pentobarbital group and 84% in the dexmedetomidine group (P = .8697). Median onset of adequate sedation was marginally faster with pentobarbital (16.5 [interquartile range, 13–21] vs 18 [16–23] minutes for dexmedetomidine [P = .0095]). Time from drug administration to discharge was not different (P = .8238) at 70.5 (64–83) minutes with pentobarbital and 70 (63–82) minutes with dexmedetomidine. Ninety-five percent of sedation failures with pentobarbital and 100% of dexmedetomidine failures had successful rescue sedation with intranasal dexmedetomidine. CONCLUSIONS: Intranasal dexmedetomidine was comparable to oral pentobarbital sedation for TTEcho sedation in infants and did not increase the risk of clinically important adverse events. Intranasal dexmedetomidine appears to be an effective "rescue" sedative for both failed pentobarbital and dexmedetomidine sedation. Dexmedetomidine could be a safer option for repeated sedation in children, but further studies are needed to assess long-term consequence of repeated sedation in this high-risk population. Accepted for publication December 1, 2017. Funding: This research was funded by a grant from the Children's Heart Association of Cincinnati and departmental support. The authors declare no conflicts of interest. Clinical trial registration: NCT02250820. LMA is a registered trademark of Teleflex Incorporated or its affiliates. Reprints will not be available from the authors. Address correspondence to Jeffrey W. Miller, MD, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH. Address e-mail to Jeff.Miller@cchmc.org. © 2018 International Anesthesia Research Society

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Free flaps for head and neck cancer in paediatric and neonatal patients

Purpose of review To review recent literature on the subject of free tissue transfer options in paediatric head and neck surgery, with a particular emphasis on highlighting the advantages and disadvantages of different reconstructions in the paediatric patient. Recent findings Free tissue transfer in paediatric patients is predictable and applicable for a wide range of congenital and acquired defects in the head and neck. The free fibula flap is a mainstay of mandibular reconstruction and allows excellent implant-supported prosthodontic rehabilitation and growth potential at the recipient site with little or no donor site morbidity. Other less commonly explored options include the deep circumflex iliac artery flap, scapula flap and medial femoral condyle flap. The gracilis mucle remains the mainstay for facial reanimation with other options including pectoralis minor, rectus abdominis, extensor digitorum brevis and latissimus dorsi. There are compelling arguments for centralization of services and creative strategies in postoperative rehabilitation (e.g. play therapy). Summary Free flaps in paediatric patients are a viable option and may even have advantages relative to adults because of the absence of atherosclerosis, purported lower risk of vasospasm and proportionally larger vessel size. Transfer earlier in life maximizes functional potential and 'normalizes' treatment. Correspondence to Ross Elledge, Specialty Registrar (ST6) in Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, West Midlands, UK. Tel: +44(0)78 758 28359;. E-mail: rosselledge@doctors.net.uk Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Evidence establishing a link between prenatal and early-life stress and asthma development

Purpose of review The objective of this review is to provide an update on our evolving understanding of the effects of stress in pregnancy and during early development on the onset of asthma-related phenotypes across childhood, adolescence, and into early adulthood. Recent findings Accumulating evidence over the past 2 decades has established that prenatal and early-life psychological stress and stress correlates (e.g., maternal anxiety or depression) increase the risk for childhood respiratory disorders. Recent systematic reviews and meta-analyses including numerous prospective epidemiological and case–control studies substantiate a significant effect of prenatal stress and stress in early childhood on the development of wheeze, asthma, and other atopic-related disorders (eczema and allergic rhinitis), with many studies showing an exposure–response relationship. Offspring of both sexes are susceptible to perinatal stress, but effects differ. The impact of stress on child wheeze/asthma can also be modified by exposure timing. Moreover, coexposure to prenatal stress can enhance the effect of chemical stressors, such as prenatal traffic-related air pollution, on childhood respiratory disease risk. Understanding complex interactions among exposure dose, timing, child sex, and concurrent environmental exposures promises to more fully characterize stress effects and identify susceptible subgroups. Although the link between perinatal stress and childhood asthma-related phenotypes is now well established, pathways by which stress predisposes children to chronic respiratory disorders are not as well delineated. Mechanisms central to the pathophysiology of wheeze/asthma and lung growth and development overlap and involve a cascade of events that include disrupted immune, neuroendocrine, and autonomic function as well as oxidative stress. Altered homeostatic functioning of these integrated systems during development can enhance vulnerability to asthma and altered lung development. Summary Mechanistic studies that more comprehensively assess biomarkers reflecting alterations across interrelated stress response systems and associated regulatory processes, in both pregnant women and young children, could be highly informative. Leveraging high-throughput systems-wide technologies to include epigenomics (e.g., DNA methylation, microRNAs), transcriptomics, and microbiomics as well as integrated multiomics are needed to advance this field of science. Understanding stress-induced physiological changes occurring during vulnerable life periods that contribute to chronic respiratory disease risk could lead to the development of preventive strategies and novel therapeutic interventions. Correspondence to Rosalind J. Wright, MD, MPH, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA. Tel: +1 212 241 5287; fax: +1 212 289 8569; e-mail: rosalind.wright@mssm.edu Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Wiring taste receptor cells to the central gustatory system

Abstract

Taste receptor cells in the tongue are epithelial in nature and turnover frequently. Taste receptor cell-associated neurons carrying bitter, sweet or sour signals never turnover and are hardwired to specific gustatory centers in the brain. How can ever-changing bitter or sweet receptors find never-changing neurons that must match the specificity of the signal? This article reviews a recent paper published in Nature (Lee et al., 2017, 548:330-333) that identified two molecules belonging to the semaphorin axon guidance family of molecules (SEMA3A and SEMA7A) that help maintain the "labelled line principle" between peripheral bitter or sweet receptors and their respective central projection area in the gustatory center.

This article is protected by copyright. All rights reserved.

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Evidence establishing a link between prenatal and early-life stress and asthma development

Purpose of review The objective of this review is to provide an update on our evolving understanding of the effects of stress in pregnancy and during early development on the onset of asthma-related phenotypes across childhood, adolescence, and into early adulthood. Recent findings Accumulating evidence over the past 2 decades has established that prenatal and early-life psychological stress and stress correlates (e.g., maternal anxiety or depression) increase the risk for childhood respiratory disorders. Recent systematic reviews and meta-analyses including numerous prospective epidemiological and case–control studies substantiate a significant effect of prenatal stress and stress in early childhood on the development of wheeze, asthma, and other atopic-related disorders (eczema and allergic rhinitis), with many studies showing an exposure–response relationship. Offspring of both sexes are susceptible to perinatal stress, but effects differ. The impact of stress on child wheeze/asthma can also be modified by exposure timing. Moreover, coexposure to prenatal stress can enhance the effect of chemical stressors, such as prenatal traffic-related air pollution, on childhood respiratory disease risk. Understanding complex interactions among exposure dose, timing, child sex, and concurrent environmental exposures promises to more fully characterize stress effects and identify susceptible subgroups. Although the link between perinatal stress and childhood asthma-related phenotypes is now well established, pathways by which stress predisposes children to chronic respiratory disorders are not as well delineated. Mechanisms central to the pathophysiology of wheeze/asthma and lung growth and development overlap and involve a cascade of events that include disrupted immune, neuroendocrine, and autonomic function as well as oxidative stress. Altered homeostatic functioning of these integrated systems during development can enhance vulnerability to asthma and altered lung development. Summary Mechanistic studies that more comprehensively assess biomarkers reflecting alterations across interrelated stress response systems and associated regulatory processes, in both pregnant women and young children, could be highly informative. Leveraging high-throughput systems-wide technologies to include epigenomics (e.g., DNA methylation, microRNAs), transcriptomics, and microbiomics as well as integrated multiomics are needed to advance this field of science. Understanding stress-induced physiological changes occurring during vulnerable life periods that contribute to chronic respiratory disease risk could lead to the development of preventive strategies and novel therapeutic interventions. Correspondence to Rosalind J. Wright, MD, MPH, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA. Tel: +1 212 241 5287; fax: +1 212 289 8569; e-mail: rosalind.wright@mssm.edu Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Celiac disease associated with aplastic anemia in a 6-year-old girl: a case report and review of the literature

Celiac disease may present with hematological abnormalities including long-standing anemia. Both aplastic anemia and celiac disease have a similar underlying autoimmune process but an association between the t...

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Payback: The Custom of Assault and Rape of Sistergirls and Brotherboys; Australia's Trans and Sex/Gender Diverse First Peoples

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


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A Group Lifestyle Intervention Program Is Associated with Reduced Emergency Department Presentations for People with Metabolic Syndrome: A Retrospective Case–Control Study

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


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Relationship of Circulating miRNAs with Insulin Sensitivity and Associated Metabolic Risk Factors in Humans

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


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Cover Image

The cover image, by P. Aïdan et al., is based on the Technical Note Bilateral vagal automatic periodic stimulation in single-incision transaxillary robotic total thyroidectomy, DOI 10.1111/coa.12698.

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Author Guidelines

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Issue Information

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Endoscopic ultrasonography (EUS)-guided laser ablation (LA) of adrenal metastasis from pancreatic adenocarcinoma

Abstract

Endoscopic ultrasonography (EUS)-guided laser ablation (LA) is potentially applicable to tumours in the left lobe of the liver and pancreas. This report seeks to introduce the novel use of EUS-guided LA for left adrenal metastases from pancreatic adenocarcinoma. A 70-year-old female was referred to our hospital for dull abdominal pain and tiredness for 1 month. Computed tomography (CT) discovered a 1.0 × 1.7 cm mass in the area of the left adrenal gland. The lesion was highly suspicious for metastasis due to her history of pancreatic adenocarcinoma 1 year ago, which was removed through radical surgery. Intraoperative frozen-section pathology revealed a tumour invading the left adrenal gland. The left adrenal mass was clearly visualised on EUS and exhibited irregular hyper-enhancement during contrast. The tumour was successfully treated by four sessions of EUS-guided LA. After the procedure, symptomatic relief was achieved and remained. At the 4-month follow-up, contrast-enhanced CT revealed that the volume of the target was significantly decreased. Here, we introduced a new method for left adrenal metastasis using thermal ablation through EUS. As a potential alternative access to the percutaneous approach, EUS-guided LA may provide a minimally invasive treatment to relieve the tumour burdens and symptoms when applied accurately.

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Bridge flap repair for central nasal dorsum defect

Abstract

Surgery of the nose to remove skin cancer often requires the use of local flaps. We present a defect after the extirpation of a previously incompletely excised infiltrative squamous cell carcinoma, which we repaired with a Bridge flap, a bipedicled and subcutaneous islanded flap whose excellent vascularity allows reliable reconstruction and rapid mobilisation, with dependable results.

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Hidradenitis suppurativa, a review of pathogenesis, associations and management. Part 2

Abstract

Hidradenitis suppurativa is a chronic, painful, autoinflammatory condition resulting in nodules, abscesses and sinus tracts. We present an evidence-based review providing new understanding of the pathogenesis of hidradenitis suppurativa and associated comorbidities. By the nature of their speciality, dermatologists are uniquely positioned to investigate and treat patients.

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Seltene Differenzialdiagnose therapierefraktärer cervikaler Lymphadenitis und Fieber bei einem Kind

Laryngo-Rhino-Otol
DOI: 10.1055/s-0044-100258

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Full text

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HPV bei Oropharynxkarzinomen in der 8. Ausgabe der TNM-Klassifikation

Laryngo-Rhino-Otol
DOI: 10.1055/s-0043-123028

Die 8. Ausgabe der TNM-Klassifikation ist seit dem 01.01.2017 gültig und beinhaltet Veränderungen dieser Klassifikation für verschiedene Malignome. Solche Änderungen zeigen sich im Kopf-Hals-Bereich für Plattenepithelkarzinome des Oropharynx (OPC): es wird zwischen HPV-positiven und HPV-negativen Karzinomen unterschieden, um durch die daran adaptierte neue Stadieneinteilung die Prognose der Patienten mit OPC insgesamt besser abschätzen zu können. Die Anwendung der neuen TNM-Klassifikation beim HPV-positiven OPC führt in vielen Fällen zu einem signifikanten Downstaging von lokal fortgeschrittener (UICC III/IV) hin zu lokal begrenzter (UICC I/II) Erkrankung. Letzterem zugrundliegende Daten mit einem signifikanten Überlebensvorteil der Patienten mit HPV-positiven OPC entstammen bisher ausschließlich retrospektiven Analysen, die nicht dafür ausgelegt sind zu testen, ob deeskalierte Therapieregime den Überlebensvorteil dieser Patienten erhalten können. Dieser CME-Beitrag versucht Antworten auf offene Fragen hinsichtlich Pathologie, Tumorcharakteristik und Lebensstil-Faktoren zu geben, die für die Prognose dieser Patientenpopulation eine Rolle spielen. Nur die genaue Kenntnis aller Parameter, die die Überlebenszeiten von Patienten mit OPC beeinflussen und die präzise Interpretation vorliegender und noch zu erhebender Daten wird es ermöglichen, den Patienten entsprechend ihrem Risikoprofil die bestmögliche Therapie anzubieten und so das bestmögliche Behandlungsergebnis zu erzielen.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Durable Clinical and Immunologic Advantage of Living Donor Liver Transplantation in Children

ABSTRACTBackgroundDespite high survival in pediatric living donor liver transplantation (LDLT), only 10% of liver transplants in children in the United States are from living donors, reflecting reluctance to embrace this approach. In addition to optimal timing and graft quality, LDLT may offer immunologic benefit since most donors are haplo-identical parents. We sought to quantify the benefit of LDLT compared to deceased donor liver transplantation (DDLT) using granular clinical and immunologic outcomes over the long-term.MethodsA retrospective cohort of children (age

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Intraoperative Brief Electrical Stimulation of the Spinal Accessory Nerve (BEST SPIN) for prevention of shoulder dysfunction after oncologic neck dissection: a double-blinded, randomized controlled trial

Shoulder dysfunction is common after neck dissection for head and neck cancer (HNC). Brief electrical stimulation (BES) is a novel technique that has been shown to enhance neuronal regeneration after nerve inj...

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Dehiszenzsyndrom des oberen Bogengangs

Zusammenfassung

Einleitung

Das Bogengangsdehiszenzsyndrom („superior canal dehiscence syndrome", SCDS) ist eine relativ seltene neurotologische Erkrankung. Sie zeichnet sich durch ein heterogenes klinisches Bild aus. Kürzlich wurden vestibulär evozierte myogene Potenziale (VEMP) zur Diagnostik des SCDS etabliert. In der vorliegenden Arbeit wurde eine Fallserie von Patienten mit SCDS analysiert, mit einem Fokus auf den VEMP-Befunden.

Methoden

Vier Patienten mit SCDS wurden prospektiv mittels okulären VEMP (oVEMP) und zervikalen VEMP (cVEMP) untersucht. Dabei wurden die klinischen Befunde sowie die weiteren audiovestibulären Testergebnisse zusammengefasst und analysiert. Die diagnostische Genauigkeit der VEMP-Untersuchungen wurde evaluiert.

Ergebnisse

Die Erhöhung der oVEMP-Amplituden weist in dieser Fallserie eine Spezifität von 100 % auf. Bei allen Patienten fand sich eine normale kalorische Funktion sowie ein unauffälliger Kopfimpulstest. Zwei Patienten wiesen ein Tullio-Phänomen auf, bei 3 Patienten lag eine Autophonie vor. Die Schallleitungskomponente war bei keinem Patienten >10 dB. Ein Patient zeigte einen deutlichen Fremitusnystagmus. Bei allen Patienten zeigte sich in der Computertomographie eine knöcherne Dehiszenz des oberen Bogengangs.

Schlussfolgerung

Beim SCDS ergab sich in dieser Fallserie ein heterogenes Bild bei Anamnese und klinischer Untersuchung. Die oVEMP-Untersuchung jedoch erwies sich als der diagnostisch wertvollste Test. Darüber hinaus wird hier ein neues diagnostisches klinisches Zeichen beschrieben, der Fremitusnystagmus.

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Is amalgamated ligno-bupivacaine an answer to complicated minor oral surgical anesthesia? A randomized split-mouth double-blind clinical trial

Abstract

Purpose

The purpose of this study was to find a suitable anesthetic combination for complicated and protracted minor oral surgical procedures.

Methods

Fifty patients with bilaterally impacted deep-seated mandibular third molars were included in this study and randomly divided on the basis of anesthetic used into two groups. Group A received 2% lignocaine with 1:200,000 adrenaline while in group B, amalgamated mixture of 2% lignocaine and 0.5% bupivacaine was used. The onset time, duration of anesthetic effect, supplementary injections, pain (during local anesthetic deposition, intra and postoperatively), and postoperative analgesia were the study parameters. Chi-square and unpaired t tests were used to compare means.

Results

The onset time in both the groups was comparable and showed statistically significant difference between the duration of anesthetic effect with notable requirement of supplemental anesthetic injections in group A (54%) (p < 0.05). Pain scores also revealed a statistically significant intergroup difference (p < 0.05). Requirement of postoperative analgesics was delayed in group B.

Conclusions

The amalgamated mixture of lignocaine and bupivacaine had equivocally rational onset and provided a more profound and in-depth anesthesia especially in complicated and protracted minor oral surgical procedures. Though this mixture is widely used in other surgical fields, its efficacy still remains unexploited and undocumented in oral and maxillofacial surgical procedures.

http://ift.tt/2Gbp1Tl

Clinical Efficacy and Safety of the EX-PRESS Filtration Device in Patients with Advanced Neovascular Glaucoma and Proliferative Diabetic Retinopathy

Background: The prognosis of conventional filtration surgery in eyes with neovascular glaucoma (NVG) is limited due to increased fibrovascular proliferation or bleeding. This study aims to evaluate the safety and efficacy of the EX-PRESS filtration device in the management of NVG associated with proliferative diabetic retinopathy (PDR). Methods: In this retrospective case series, we reviewed the medical records of patients diagnosed as having NVG associated with PDR who underwent EX-PRESS filtration surgery. The main outcome measures were: postoperative intraocular pressure (IOP), the percent of IOP drop, the number of glaucoma medications, visual acuity, and complications of surgery. Successful surgery was defined as an IOP #x3c;22 mm Hg and #x3e;5 mm Hg with or without additional glaucoma surgery, and no loss of light perception or less than a 2-line decrease on the Snellen chart of the best corrected visual acuity (BCVA). Results: Five patients (5 eyes) were included in this study. The mean preoperative IOP was 33.4 ± 5.9 mm Hg compared to an IOP of 17.0 ± 3.0 mm Hg at the last follow-up (p = 0.003). The mean number of preoperative anti-glaucoma medications was 3.8 ± 0.4 compared to 2.2 ± 1.5 (p = 0.06) at the last follow-up visit. Final visual acuity improved or stabilized within 1 Snellen line in all 5 patients. Three patients had a "hypertensive phase" (defined as an IOP #x3e;21 mm Hg during the first 6 postoperative months) which resolved within 2 months. Two patients developed a hyphema that resolved spontaneously. None of the patients experienced any serious complications. Conclusion: EX-PRESS filtration device has a good IOP-lowering effect and a low rate of complications in patients with advanced NVG associated with PDR. In addition, there was no loss of light perception or no line decrease of the BCVA.
Case Rep Ophthalmol 2018;9:61–69

http://ift.tt/2F5WNYD

Is amalgamated ligno-bupivacaine an answer to complicated minor oral surgical anesthesia? A randomized split-mouth double-blind clinical trial

Abstract

Purpose

The purpose of this study was to find a suitable anesthetic combination for complicated and protracted minor oral surgical procedures.

Methods

Fifty patients with bilaterally impacted deep-seated mandibular third molars were included in this study and randomly divided on the basis of anesthetic used into two groups. Group A received 2% lignocaine with 1:200,000 adrenaline while in group B, amalgamated mixture of 2% lignocaine and 0.5% bupivacaine was used. The onset time, duration of anesthetic effect, supplementary injections, pain (during local anesthetic deposition, intra and postoperatively), and postoperative analgesia were the study parameters. Chi-square and unpaired t tests were used to compare means.

Results

The onset time in both the groups was comparable and showed statistically significant difference between the duration of anesthetic effect with notable requirement of supplemental anesthetic injections in group A (54%) (p < 0.05). Pain scores also revealed a statistically significant intergroup difference (p < 0.05). Requirement of postoperative analgesics was delayed in group B.

Conclusions

The amalgamated mixture of lignocaine and bupivacaine had equivocally rational onset and provided a more profound and in-depth anesthesia especially in complicated and protracted minor oral surgical procedures. Though this mixture is widely used in other surgical fields, its efficacy still remains unexploited and undocumented in oral and maxillofacial surgical procedures.

http://ift.tt/2Gbp1Tl

An Unusual Case of Pinna Squamous Cell Carcinoma Arising Shortly after Resection of Atypical Fibroxanthoma

Objective. To report a unique case of pinna squamous cell carcinoma (SCC) arising shortly after resection of atypical fibroxanthoma (AFX) at the same site. Case report. An 81-year-old gentleman presented with a nodular right pinna lesion. This was excised, and histology confirmed AFX. Ten weeks later, an ulcerative lesion appeared at the resection site. This was confirmed to be SCC. Comparative analysis revealed no morphological resemblance between the initial AFX and new SCC lesion, and there was no evidence of initial misdiagnosis. Conclusion. SCC is the most common cancer involving the pinna. Whilst prolonged sun exposure is an important risk factor for SCC, chronic inflammation and wounds are other potential sources. We postulate whether SCC could have arisen from the previous scar tissue in a manner similar to Marjolin's ulcer. This would be a highly unusual finding in the pinna and to our knowledge unprecedented in the English literature.

http://ift.tt/2n5eGjF

Outcomes after free tissue transfer for composite oral cavity resections involving skin

Abstract

Background

Resections involving oral cavity mucosa, bone, and skin present a unique challenge. Optimizing outcomes often requires technically demanding reconstruction. The purpose of this study is to evaluate outcomes of several reconstructive approaches for patients with composite through-and-through defects, with a focus on the osteocutaneous radial forearm free flap (RFFF).

Methods

We conducted a retrospective evaluation of the cohort of patients treated for composite through-and-through defects with cutaneous involvement who underwent free flap reconstruction from August 2012 through October 2015.

Results

Seventeen patients received a single flap (12 cases of osteocutaneous RFFF), whereas 10 patients underwent a combination of flaps. Complication rates and functional outcomes were favorable in patients who underwent osteocutaneous RFFFs. The supraclavicular artery island flap (SCAIF) was used as a second flap in 3 cases.

Conclusion

The osteocutaneous RFFF provides a valuable reconstructive option for complex composite resection defects involving skin. When 2 flaps are required, the SCAIF is a viable alternative to a second free flap or pectoralis flap.

http://ift.tt/2DzXAnL

Immunocompromised patients with metastatic cutaneous nodal squamous cell carcinoma of the head and neck: Poor outcome unrelated to the index lesion

Abstract

Background

Immunocompromised patients with metastatic cutaneous nodal head and neck squamous cell carcinoma (HNSCC) have worse outcomes compared to the immunocompetent. The purpose of this study was to investigate the characteristics of the primary cutaneous squamous cell carcinoma (SCC), nodal pathology, and outcome between these 2 groups.

Methods

Analysis of a prospective database was performed. A 2:1 pooled analysis selected 46 immunocompetent patients matched with 23 immunocompromised patients. Overall survival (OS) and relapse-free survival (RFS) were calculated using the Kaplan-Meier method.

Results

No significant difference was found in the primary tumor characteristics between the 2 groups. In the immunocompromised group, RFS (hazard ratio [HR] 2.70; P = .01) and OS (HR 2.32; P = .04) were significantly worse. Extracapsular spread was present in 100% of the immunocompromised patients.

Conclusion

No significant difference was identified in the primary cutaneous SCC between the immunocompetent and immunocompromised patients. Immunosuppression predicted worse outcome.

http://ift.tt/2F8696d

Obviating the need for sternotomy: Safety and effectiveness of microdebrider use for retrosternal goiter

Abstract

Background

Most retrosternal goiter surgical removal can be performed via a transcervical approach. However, it is often a challenging procedure, which might include sternotomy.

Methods

We describe a surgical technique using a microdebrider for intracapsular volume reduction that precedes an extracapsular thyroidectomy, thereby avoiding the need for sternotomy, with decreased morbidity and risk. The procedure is described in detail with 2 representative cases and a summary of our experience in 26 cases.

Results

Twenty-six patients with retrosternal goiters are included in our cohort. None of the patients needed a sternotomy, and no major or permanent complications occurred. The average length of hospital stay was 4.30 days after total thyroidectomy and 2.57 days after hemithyroidectomy.

Conclusion

The use of a microdebrider for intracapsular volume reduction thyroidectomy is extremely helpful for transcervical removal of retrosternal goiters in selected cases, and avoids the need for sternotomy, which is especially beneficial in elderly patients, and those with comorbidities for whom sternotomy should be avoided.

http://ift.tt/2DE4hoM

Predictors of clinical-pathologic stage discrepancy in oral cavity squamous cell carcinoma: A National Cancer Database study

Abstract

Background

Few studies have examined the frequency and survival implications of clinicopathologic stage discrepancy in oral cavity squamous cell carcinoma (SCC).

Methods

Oral cavity SCC cases with full pathologic staging information were identified in the National Cancer Database (NCDB). Clinical and pathologic stages were compared. Multivariate logistic regressions were performed to identify factors associated with stage discrepancy.

Results

There were 9110 cases identified, of which 67.3% of the cases were stage concordant, 19.9% were upstaged, and 12.8% were downstaged. The N classification discordance (28.5%) was more common than T classification discordance (27.6%). In cases of T classification discordance, downstaging is more common than upstaging (15.4% vs 12.1% of cases), but in cases of N classification discordance, the reverse is true; upstaging is much more common than downstaging (20.1 vs 8.4% of cases).

Conclusion

Clinicopathologic stage discrepancy in oral cavity SCC is a common phenomenon that is associated with a number of clinical factors and has survival implications.

http://ift.tt/2F497bK

Lymph node ratio as a prognostic factor in metastatic cutaneous head and neck squamous cell carcinoma

Abstract

Background

The prognostic impact of the size and number of nodal metastases in head and neck cutaneous squamous cell carcinoma (SCC) is well established. The purpose of this study was to validate the prognostic significance of the lymph node ratio in metastatic head and neck cutaneous SCC.

Methods

A retrospective review of 326 patients with head and neck cutaneous SCC with parotid and/or cervical nodal metastases was performed. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The minimal-P approach was used to investigate the optimal lymph node ratio threshold.

Results

Our data included 77 recurrences and 101 deaths. A lymph node ratio of 6% was a significant predictor of shorter DFS (hazard ratio [HR] 1.62; 95% confidence interval [CI] 1.11-2.38; P = .01) and OS (HR 1.63; 95% CI 1.03-2.58; P = 0.04) on multivariable analysis.

Conclusion

The lymph node ratio is an independent prognosticator of survival outcomes in patients presenting with metastatic head and neck cutaneous SCC. A lymph node ratio >6% is a significant threshold to categorize patients into low and high risk.

http://ift.tt/2DEhDRM

Study Testing The Safety and Efficacy of Adjuvant Temozolomide Plus TTFields (Optune®) Plus Pembrolizumab in Patients With Newly Diagnosed Glioblastoma (2-THE-TOP)

Conditions:   Glioblastoma;   Glioblastoma, WHO Grade IV
Interventions:   Drug: Temozolomide (TMZ);   Device: Optune System;   Drug: Pembrolizumab
Sponsors:   University of Florida;   NovoCure Ltd.
Not yet recruiting

http://ift.tt/2rxF8Y3

Immunotherapy in Head and Neck Squamous Cell Carcinoma : Phase 2 Trial Evaluating the Efficacy and the Toxicity of Nivolumab Alone, and of the Combination Nivolumab and Ipilimumab

Condition:   Head and Neck Squamous Cell Carcinoma
Interventions:   Drug: Nivolumab;   Drug: Ipilimumab
Sponsor:   Gustave Roussy, Cancer Campus, Grand Paris
Not yet recruiting

http://ift.tt/2G9t4iM

Biosimilars: what the dermatologist should know

Abstract

Biosimilars are highly similar versions of approved branded biologics. In contrast to generics, which are identical copies of the originator medicines, biosimilars are considered unique but related molecules that differ from the originator reference product as well as from each other. Owing to the complexity of biologic medicines, such as therapeutic monoclonal antibodies, minor differences between biosimilars and the reference products are acceptable provided these differences do not result in any clinically meaningful differences in safety or efficacy. In addition, minor changes in structure and function may occur over time in originator biologic products as a result of alterations in production materials (e.g., cell lines), processes, or conditions. The developmental process for biosimilars focuses on a 'totality of evidence' approach that emphasizes a stepwise investigational process, including comprehensive structural, functional, pharmacologic, and clinical assessment for similarity. The goal of the phase 3 clinical development program for a biosimilar is not to establish efficacy, per se, but to demonstrate that there are no clinically meaningful differences between the proposed biosimilar and the reference product. The requirement to show clinical similarity informs biosimilar study design, including the selection of the patient population, disease state (indication), study endpoints, and statistical methods. Based on the clinical trials results in a representative patient population, results may be extrapolated to other indications provided scientific justification is demonstrated based on, among other things, similar mechanism of action in the extrapolated indications. This review presents the current state of knowledge with respect to biosimilars. We aim to provide the practicing clinician with a working knowledge of biosimilars as well as provide some practical guidance on their use and potential benefits in treating dermatologic diseases.

This article is protected by copyright. All rights reserved.

http://ift.tt/2F7wnpv

Olfactory dysfunction and cognition among older adults in the United States

Background

In this work we assess the association between olfactory dysfunction and cognition in a nationally representative sample of older adults in the United States.

Methods

Participants aged ≥60 years (n = 1236) from the 2013–2014 National Health and Nutritional Examination Survey underwent both olfactory and cognitive testing. Olfaction was assessed by both objective test (8-odor Pocket Smell Test: smell impairment defined as score ≤2) and self-report. Cognitive assessment consisted of the Digit Symbol Substitution Test (DSST), the Animal Fluency Test, and the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Regression models were used to examine the association between olfaction and cognition while adjusting for demographics, cardiovascular factors, and associated medical history.

Results

The prevalence of smell impairment in US older adults was 18.0% (95% confidence interval [CI], 14.0-22.0%) and 22.0% (95% CI, 18.5-25.6%) based on objective smell test and self-report, respectively. In a multivariate model adjusted for relevant factors, low smell test scores were consistently associated with low scores on cognitive assessments, with a DSST score difference of −1.5 (95% CI, −2.2 to −0.8), Animal Fluency Test score difference of −0.4 (95% CI, −0.7 to −0.1), and CERAD Word List score difference of −0.4 (95% CI, −0.6 to −0.2) per 1-point decrease in smell test score. There was no association between self-reported smell impairment and cognition.

Conclusion

Objectively measured olfactory dysfunction is independently associated with cognitive impairment. These findings are consistent with previous studies and suggest the utility of objective olfactory tests as an indicator for cognitive impairment as compared with self-reported olfactory dysfunction, which is an uncertain indicator.

http://ift.tt/2rwhf2S

Concentration of filaggrin monomers, its metabolites and corneocyte surface texture in individuals with a history of atopic dermatitis and controls

Abstract

Background

Atopic dermatitis (AD) is characterized by skin barrier dysfunction. Notably, a high number of nano-scale protrusions on the surface of corneocytes, which can be expressed by the Dermal Texture Index (DTI), was recently associated with pediatric AD, loss-of-function mutations in filaggrin gene (FLG), and reduced levels of natural moisturizing factors (NMF). No study has so far examined the association between these parameters and monomeric filaggrin levels in adults.

Objective

To determine DTI, monomeric filaggrin and NMF in healthy controls and a group of patients with controlled dermatitis.

Methods

A total of 67 adults (20 healthy controls and 47 dermatitis patients) were included. In the patient population, a personal history of AD was diagnosed by the U.K. Working Party's Diagnostic Criteria. All participants were tested for FLG mutations (R501X, 2282del4, R2447X). Transepidermal water loss, monomeric filaggrin, DTI and NMF were measured.

Results

In the patient population, 78.7% (37/47) had a history of AD and 59.5% (28/47) had FLG mutations. Patients had significantly higher levels of DTI and significantly lower levels of monomeric filaggrin and NMF compared to the 20 healthy controls. Among patients, reduced level of monomeric filaggrin and NMF correlated with the presence of FLG mutations and clinical phenotypes such as xerosis, palmar hyperlinearity and AD. Among healthy controls, DTI was significantly higher in the oldest age group compared to the two younger age groups.

Conclusion

A significant difference in DTI, monomeric filaggrin and NMF levels was found when comparing dermatitis patients with healthy controls. These findings suggest that even mild dermatitis or non-visible inflammation has a significant and negative effect on the skin barrier as inflammation is known to reduce filaggrin levels. DTI was significantly increased in aged individuals in the healthy control group, suggesting a gradual change in corneocyte morphology with age.

This article is protected by copyright. All rights reserved.

http://ift.tt/2n57zH8

Intraoperative Brief Electrical Stimulation of the Spinal Accessory Nerve (BEST SPIN) for prevention of shoulder dysfunction after oncologic neck dissection: a double-blinded, randomized controlled trial

Abstract

Background

Shoulder dysfunction is common after neck dissection for head and neck cancer (HNC). Brief electrical stimulation (BES) is a novel technique that has been shown to enhance neuronal regeneration after nerve injury by modulating the brain-derived neurotrophic growth factor (BDNF) pathways. The objective of this study was to evaluate the effect of BES on postoperative shoulder function following oncologic neck dissection.

Methods

Adult participants with a new diagnosis of HNC undergoing Level IIb +/− V neck dissection were recruited. Those in the treatment group received intraoperative BES applied to the spinal accessory nerve (SAN) after completion of neck dissection for 60 min of continuous 20 Hz stimulation at 3-5 V of 0.1 msec balanced biphasic pulses, while those in the control group received no stimulation (NS). The primary outcome measured was the Constant-Murley Shoulder (CMS) Score, comparing changes from baseline to 12 months post-neck dissection. Secondary outcomes included the change in the Neck Dissection Impairment Index (ΔNDII) score and the change in compound muscle action potential amplitude (ΔCMAP) over the same period.

Results

Fifty-four patients were randomized to the treatment or control group with a 1:1 allocation scheme. No differences in demographics, tumor characteristics, or neck dissection types were found between groups. Significantly lower ΔCMS scores were observed in the BES group at 12 months, indicating better preservation of shoulder function (p = 0.007). Only four in the BES group compared to 17 patients in the NS groups saw decreases greater than the minimally important clinical difference (MICD) of the CMS (p = 0.023). However, NDII scores (p = 0.089) and CMAP amplitudes (p = 0.067) between the groups did not reach statistical significance at 12 months. BES participants with Level IIb + V neck dissections had significantly better ΔCMS and ΔCMAP scores at 12 months (p = 0.048 and p = 0.025, respectively).

Conclusions

Application of BES to the SAN may help reduce impaired shoulder function in patients undergoing oncologic neck dissection, and may be considered a viable adjunct to functional rehabilitation therapies.

Trial registration

Clinicaltrials.gov (NCT02268344, October 17, 2014).

http://ift.tt/2n4Zp1s

Postmenopausaler Lichen planopilaris alias fibrosierende frontotemporale Alopezie Kossard

Zusammenfassung

Der postmenopausale Lichen planopilaris (PLPP) alias fibrosierende frontotemporale Alopezie Kossard (FFAK) ist eine nicht seltene entzündliche Erkrankung der Kopfhaut und betrifft etwa 5 % der Patienten an spezialisierten Haarzentren. Die allgemeine Inzidenz des sporadischen Vorkommens liegt vermutlich bei knapp 1 % in der älteren, vorrangig weiblichen Allgemeinbevölkerung. Da die Erkrankung oft nicht diagnostiziert wird, ist sie statistisch wahrscheinlich unterrepräsentiert. Sie kommt speziell bei Frauen betont in der 6. und 7. Lebensdekade postmenopausal vor (um 90 %), etwa in 10 % aber auch prämenopausal. Bei Männern ist sie nur in Einzelfällen dokumentiert. Die Folge ist ein bleibender vernarbender Haarausfall, betont am vorderen Haaransatz mit Rückwärtsbewegung des Ansatzes, begleitet von einem regelhaften, typischen Verlust auch der Augenbrauen. Die Erkrankung führt daher bei Betroffenen oft zu erheblichen psychischen Belastungen und sozialen Ängsten. Hieraus leitet sich das zwingende Erfordernis ab, Therapiekonzepte evidenzbasiert zu entwickeln. Während zahlreiche retrospektive Fallserien die Phänomenologie der FFAK sehr gut charakterisiert haben, fehlen bis heute randomisierte kontrollierte Studien zur evidenzbasierten Therapie. Wir stellen hier den Homburger evidenzorientierten Therapiealgorithmus vor, der so weit an Fallserienevidenzen orientiert ist, dass er a) als Therapieanleitung für die Praxis dienen und b) als Arbeitsgrundlage herangezogen werden kann, um zukünftig belastbare, auf Studienevidenz basierte Daten zu erarbeiten. Der Beitrag enthält detaillierte praktische Hinweise zur Fotodokumentation, zur Biopsieentnahme und histologischen Aufarbeitung bis hin zur praktischen Durchführung etwa der intraläsionalen Steroidtherapie sowie Hinweise zu Auswahlkriterien geeigneter Systemtherapien.

http://ift.tt/2DsSiag

Risk Factors for Distant Metastasis in Patients with Oral Cavity Squamous Cell Carcinoma Undergoing Surgical Treatment

Objective: The aim of this study is to investigate the clinical and pathological factors related to distant metastasis in patients with oral cavity squamous cell carcinoma (OCSCC) undergoing surgery. Study Design: A retrospective data review was conducted on patients who underwent primary surgery for OCSCC at the Instituto do Cancer do Estado de São Paulo (ICESP) between 2009 and 2015. Distant metastasis rates were calculated and predictive factors were determined by the Cox proportional-hazards model. Results: There was a total of 274 patients, including 210 (76.6%) men and 64 (23.4%) women, with a mean age of 59.9 ± 10.9 years. The incidence of distant metastasis was 9.6%, with the lung being the most common site. The mean time interval between surgical treatment and the diagnosis of distant metastasis was 12 months (range 2–40 months). In the multivariate analysis, angiolymphatic invasion (HR = 2,87; p = 0.023), contralateral cervical metastasis (HR = 3.3; p = 0,007), tumor thickness #x3e;25 mm (HR = 3.50; p = 0.009), and locoregional recurrence (HR = 6.59; p #x3c; 0.0001) were the only independent risk factors for distant metastasis. Conclusion: Patients with OCSCC who have contralateral lymph node metastasis, tumors with a thickness #x3e;25 mm, angiolymphatic invasion, or locoregional recurrence after surgical treatment have a greater risk of developing distant metastasis.
ORL 2017;79:347–355

http://ift.tt/2E1Ai85

Cervical left pulmonary artery

Abstract

We detail what we believe to be the first reported case of a congenital 'Cervical Left Pulmonary Artery' in which an aberrant left pulmonary artery courses cranially into the mid-cervical neck before descending back into the thorax to the left pulmonary hilum. Due to the location and course of the artery, we believe that this anomaly is likely due to a developmental error of the sixth pharyngeal arch. Ultimately, the use of a reconstructed 3D computed tomography image provided detailed characterization of the unique anatomical variant, aiding in a successful surgical repair of the defect.

http://ift.tt/2F6FB5b

Co-existing infantile hepatic hemangioma and mesenchymal hamartoma in a neonate

Abstract

Infantile hepatic hemangioma (IHH) and mesenchymal hamartoma (MH) form the first and second most common benign hepatic tumors in children. In this case report, we present a newborn child in whom a growing hepatic mass was discovered at the age of 7 days. She suffered also from anemia, respiratory and renal failure. No signs of heart disease or cutaneous lesions were detected. Alpha-fetoprotein was elevated for her age (3562.2 ng/ml). Imaging studies showed multifocal large cystic lesions associated with heterogeneous small solid lesions with arterial enhancement of the liver. Non-anatomical liver resection was performed initially and synchronous MH and IHH GLUT-1 positive were discovered in the pathological analysis. Segmental IV hepatic resection and later on selective cysts excision were done for persistent hepatic lesion despite medical treatment. After 14 months of beta-blockers treatment, clinical follow-up shows a healthy child with no residual cystic lesions.

http://ift.tt/2DEfl5q

Do all type 2 aortic dissection require emergency surgery?

Abstract

We represent a case of asymptomatic isolated chronic ascending aortic dissection that lasted for 15 years in which a patient was only followed up with medical therapy that saved him from early surgical intervention.

http://ift.tt/2F6YUv8

A novel safe approach to laparoscopic colorectal cancer resection in patients with ventriculoperitoneal shunt: report of two cases and literature review

Abstract

There is ongoing challenges regarding the safety of performing laparoscopic surgery with the presence of ventriculoperitoneal (VP) shunts, especially in patients treated for cancer disease. To date, only one case has been reported in the English literature. Herein, we report an additional two cases of patients with previous insertion of a VP shunt, diagnosed with colon cancer. Both our patients underwent successful laparoscopic colectomies, without clamping or removal of the VP shunt, with no reported perioperative complications or postoperative neurological deficits. Laparoscopic bowel resection for cancer, in patients with a pre-existing VP shunt, could be considered a potentially safe and feasible procedure. Furthermore, due to the increasing number of patients with VP shunts, additional case reports and investigations are warranted to further confirm safety of this procedure.

http://ift.tt/2DEf7eA

Cutaneous eruptions by new therapies against hepatitis C virus infection. Not as common as we presumed

http://ift.tt/2G7XMsT

Methazolamide-induced toxic epidermal necrolysis in a man carrying HLA-B*59:01: successful treatment with infliximab and glucocorticoid

http://ift.tt/2rzJMog

A rare cause of blanching red legs: cutaneous collagenous vasculopathy

http://ift.tt/2G7bnk9

Onkologie und Versorgung in Fach- und Publikumsmedien

http://ift.tt/2E1U1o2

Severe Drug-Induced Agranulocytosis Successfully Treated with Recombinant Human Granulocyte Colony-Stimulating Factor

When elderly patients are prescribed many different medications, the risk for developing serious adverse events should be kept in mind. One of these adverse events is agranulocytosis, which, although rare, can be life-threatening if left untreated. The majority of agranulocytosis cases are caused by drugs, including antibiotics. Here, we report a case of severe agranulocytosis in a 96-year-old woman following antibiotic therapy which was successfully managed using recombinant human granulocyte colony-stimulating factor (rhG-CSF) and the appropriate choice of antibiotics to treat her concomitant infection.

http://ift.tt/2rzeNsm

Generic quality of life in persons with hearing loss: a systematic literature review

To the best of our knowledge, no empirically based consensus has been reached as to if, and to what extent, persons with hearing loss (HL) have reduced generic Quality of life (QoL). There seems to be limited ...

http://ift.tt/2DEPyd2

A Rare Cause of a Fluctuating Cystic Lesion in the External Auditory Canal

Temporomandibular joint (TMJ) ganglionic cyst is an uncommon entity and only a few have been reported in the literature. TMJ ganglion within the external auditory canal presenting clinically as a fluctuating cystic lesion has never been reported. Here, we present a unique case of such a lesion together with otoscopic and radiological images as well as provide a descriptive review of TMJ ganglionic cysts.

http://ift.tt/2DysJbS

Specific Donor HLA-DR Types Correlate with Altered Susceptibility to Development of Chronic Lung Allograft Dysfunction

AbstractBackgroundThe greatest challenge to long-term graft survival is the development of chronic lung allograft dysfunction (CLAD). Th17 responses to collagen type V (colV) predispose lung transplant patients to the severe obstructive form of CLAD, known as bronchiolitis obliterans syndrome (BOS). In a previous study cohort (n=54), pre-transplant colV responses were increased in recipients expressing HLA-DR15, consistent with the high binding avidity of colV(α1) peptides for HLA-DR15, while BOS incidence, which was known to be strongly associated with post-transplant autoimmunity to colV, was higher in patients who themselves lacked HLA-DR15, but whose lung donor expressed it.MethodsTo determine if this DR-restricted effect on BOS incidence could be validated in a larger cohort, we performed a retrospective analysis of outcomes for 351 lung transplant recipients transplanted between 1988 and 2008 at the University of Wisconsin. All subjects were followed until graft loss, death, loss to follow-up, or through 2014, with an average follow-up of 7 years. Comparisons were made between recipients who did or did not develop BOS. Grading of BOS followed the recommendations of the international society for heart and lung transplantation.ResultsDonor HLA-DR15 was indeed associated with increased susceptibility to severe BOS in this population. We also discovered that HLA-DR7 expression by the donor or HLA-DR17 expression by the recipient decreased susceptibility.ConclusionWe show in this retrospective study that specific donor HLA class II types are important in lung transplantation, as they are associated with either protection from or susceptibility to development of severe BOS. Background The greatest challenge to long-term graft survival is the development of chronic lung allograft dysfunction (CLAD). Th17 responses to collagen type V (colV) predispose lung transplant patients to the severe obstructive form of CLAD, known as bronchiolitis obliterans syndrome (BOS). In a previous study cohort (n=54), pre-transplant colV responses were increased in recipients expressing HLA-DR15, consistent with the high binding avidity of colV(α1) peptides for HLA-DR15, while BOS incidence, which was known to be strongly associated with post-transplant autoimmunity to colV, was higher in patients who themselves lacked HLA-DR15, but whose lung donor expressed it. Methods To determine if this DR-restricted effect on BOS incidence could be validated in a larger cohort, we performed a retrospective analysis of outcomes for 351 lung transplant recipients transplanted between 1988 and 2008 at the University of Wisconsin. All subjects were followed until graft loss, death, loss to follow-up, or through 2014, with an average follow-up of 7 years. Comparisons were made between recipients who did or did not develop BOS. Grading of BOS followed the recommendations of the international society for heart and lung transplantation. Results Donor HLA-DR15 was indeed associated with increased susceptibility to severe BOS in this population. We also discovered that HLA-DR7 expression by the donor or HLA-DR17 expression by the recipient decreased susceptibility. Conclusion We show in this retrospective study that specific donor HLA class II types are important in lung transplantation, as they are associated with either protection from or susceptibility to development of severe BOS. To whom correspondence should be addressed: William J. Burlingham, burlingham@surgery.wisc.edu, G4/701 CSC, 600 Highland Avenue, Madison, WI 53792-7375 Authorship: Participated in research design- LDH, WJ, JM, KCM, WJB Participated in the writing of the paper – LDH, WJB, GL, KCM Participated in the performance of the research LDH, WJ, GL Participated in data analysis LDH, GL Disclosures- the authors declare no conflicts of interest This work was supported by NIH grants RO1AI119140 and PPG AI084853. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Sweet-Syndrom bei rheumatoider Arthritis

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Digitale Hautkrebserkennung — bald Realität?

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Hautkrebsscreening: Schulung bringt Dermatologen nur wenig

Dermatologen können ihre bereits guten Kenntnisse zu Hauttumoren durch die Schulung zum Hautkrebsscreening kaum noch verbessern. Lediglich beim Allgemeinwissen zum Screening haben sie in einer Studie noch zugelegt.

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Nur wenige Moisturizer sind allergenfrei

Wer ein feuchtigkeitsspendendes Hautpflegeprodukt sucht, hat es angesichts der unüberschaubaren Fülle frei verkäuflicher Produkte nicht leicht. US-amerikanische Dermatologen versuchen, Orientierungshilfe zu geben.

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Bei Alopecia areata Zink und Selen substituieren?

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Milbenrhinitis: SLIT bei Jugendlichen effektiv

Was bringt die sublinguale spezifische Immuntherapie gegen Hausstaubmilben bei Jugendlichen mit einer entsprechenden allergischen Rhinitis? Die gepoolte Auswertung zweier großer Phase-III-Studien gibt Antworten.

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Laserscanmikroskopie erleichtert Diagnostik bei Verdacht auf ein Basalzellkarzinom

In der Hand eines damit vertrauten Dermatologen lässt sich mit der konfokalen Laserscanmikroskopie das Basalzellkarzinom so gut wie durch die Beurteilung nach einer Stanzbiopsie diagnostizieren. Das gilt auch für die Subtypisierung.

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Ärzte sollten Arztsitz gegen MVZ-Pleite absichern

In einem medizinischen Versorgungszentrum tätige Ärzte sollten überlegen, eine Klausel zur Insolvenz ihrer Einrichtung in den Arbeitsvertrag einzubringen. Im Ernstfall hat das Vorteile für den Erhalt des Arztsitzes, wie ein neues BSG-Urteil nahelegt.

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Atopische Dermatitis: ab wann systemisch behandeln?

Nur ein kleiner Teil der Patienten mit atopischer Dermatitis benötigt eine systemische Therapie. Da die Umstände, die für die Umstellung auf eine systemische Therapie sprechen, aus den Leitlinien nicht klar hervorgehen, hat ein internationales Expertengremium entsprechende Empfehlungen verfasst, die behandelnde Dermatologen und Patienten bei der Entscheidung unterstützen sollen.

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Haben Sie auch eine fachliche Frage?

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Stressfaktor Nummer eins: die Bürokratie

Die Bürokratie begleitet Ärzte im Alltag auf Schritt und Tritt. Fast die Hälfte sowohl der leitenden Klinikärzte wie auch der Praxischefsidentifiziert die Dokumentationsanforderungen als Hauptursache für Stress im Versorgungsalltag.

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Hautpflege bei AD: Was gelangt in den Körper?

Kinder mit atopischer Dermatitis brauchen eine intensive Hautpflege. Doch was da alles durch die Epidermis in den Körper gelangt, ist bisher kaum untersucht. Eine Studie quantifizierte Emollenzienverbrauch sowie Phthalat- und Paraben-Systembelastung bei Kindern mit und ohne Neurodermitis.

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Morsicatio mucosae oris

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Neue Perspektiven in der Onkologie

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Schützt Atopie vor Basalzellkarzinomen?

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Patienten mit atopischer Dermatitis denken oft daran, sich umzubringen

Suizidgedanken sind unter erwachsenen Patienten mit atopischer Dermatitis keine Seltenheit. In einer deutschen Studie äußerte gut jeder fünfte von der Hautkrankheit Betroffene, sich mit Selbsttötungsfantasien zu plagen.

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Inhaltsverzeichnis

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Aktuelle Forschung kompakt

Veranstaltet in Wiesbaden und Berlin zählte das Derma Update 2017 mehr als 2.000 Teilnehmer. Wie gewohnt konnte das kompakte Fortbildungskonzept überzeugen: Das zweitägige Programm bot wieder einen aktuellen Überblick über wichtige Forschungsergebnisse, wie etwa zur Therapie bei Burning Mouth Syndrome oder kutanem Lupus erythematodes sowie zur digitalen Hautkrebserkennung.

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Antimalariamittel bei CLE erste Wahl

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Schneewittchen in Indien

Die südafrikanische Sprache isiXhosa bezeichnet die Hautaufhellung als „ukutsheyisa", übersetzt „nach Schönheit jagen". In Afrika wie in Indien, Gebieten mit den vielfältigsten Hautschattierungen, gilt: Je heller die Haut, desto größer das soziale Ansehen, wahrscheinlicher ein erfolgreicher Lebensweg, attraktiver die Person als möglicher (Ehe-)Partner. Menschen dunklerer Hautfarbe hingegen sind oft sozialer Abwertung und Schikanen ausgesetzt.

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The marginal fit of lithium disilicate crowns: Press vs. CAD/CAM

Abstract: This study aimed to compare the vertical marginal gap of teeth restored with lithium disilicate crowns fabricated using CAD/CAM or by pressed ceramic approach. Twenty mandibular third molar teeth were collected after surgical extractions and prepared to receive full veneer crowns. Teeth were optically scanned and lithium disilicate blocks were used to fabricate crowns using CAD/CAM technique. Polyvinyl siloxane impressions of the prepared teeth were made and monolithic pressed lithium disilicate crowns were fabricated. The marginal gap was measured using optical microscope at 200× magnification (Keyence VHX-5000, Japan). Statistical analysis was performed using Wilcoxon test. The lithium disilicate pressed crowns had significantly smaller (p = 0.006) marginal gaps (38 ± 12 μm) than the lithium disilicate CAD/CAM crowns (45 ± 12 μm). This research indicates that lithium disilicate crowns fabricated with the press technique have measurably smaller marginal gaps compared with those fabricated with CAD/CAM technique within in vitro environments. The marginal gaps achieved by the crowns across all groups were within a clinically acceptable range.

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Oral health related quality of life among pregnant women: a randomized controlled trial

Abstract: The aim of the present study was to compare negative impacts of oral conditions in Oral Heath Related Quality of Life (OHRQoL) assessed by the Oral Health Impact Profile-14 (OHIP-14) scores in pregnant women receiving or not comprehensive periodontal treatment. This randomized controlled clinical trial included pregnant women aged between 18 and 35 years old. Participants were randomized in a test group with 96 and a control group with 114 women. Patients in the test group received comprehensive periodontal treatment, supra and subgingival scaling and root-planning and periodontal maintenance appointments. The OHIP-14 was applied before and after treatment. The primary outcome was changes in OHIP-14 scores after follow-up period. The impact of having received or not comprehensive periodontal treatment on the change of the OHIP-14 scores was also investigated. Both groups showed significant reduction in OHIP-14 scores and effect size for the test group was 0.60 and 0.36 for the control group. Multinomial logistic regression analysis showed that participants of the control group had 5.9-fold odds (CI 95% 1.88-18.52) of worsening in OHIP-14 scores and their perception of oral conditions in relation to test group. Comprehensive periodontal treatment during pregnancy can reduce the negative impacts in OHRQoL.

http://ift.tt/2DoYq39