Τρίτη 13 Μαρτίου 2018
Prescribing to save patients money: Ethical considerations
In offering treatment options to their patients, physicians should always consider safety and efficacy. However, it is also important for physicians to consider the cost of medications and the out-of-pocket expense to patients, regardless of whether prescribed for cosmetic, "lifestyle," or medical indications. The final cost for which patients are responsible is dependent on several factors, such as the manufacturer's wholesale price, drug formularies, tiers and contractual copays set by insurance companies, and individual pharmacy discounts.
http://ift.tt/2Gp8QC7
I pledge to prescribe ethically
Throughout its existence, the US Food and Drug Administration has had to cope with various unexpected side effects of medications. Some of the most serious and detrimental to society involve irreparable harm to unborn fetuses. The use of thalidomide, and later isotretinoin, led to the implementation of a series of pregnancy prevention programs. The goal of these programs is to prevent fetal exposure to these medications. In 2002 the System to Manage Accutane Related Teratogenicity (SMART) program requiring physician education, informed consent, rigorous pregnancy testing, and restrictive dispensing policies was put in place.
http://ift.tt/2tJrJNJ
Alopecia areata is a medical disease
Alopecia areata (AA) is a common autoimmune disease characterized by nonscarring hair loss that affects all ages, both sexes, and all skin types. Despite significant advances in understanding the pathomechanism of the disease, the autoimmune comorbidities, and how quality of life (QoL) is affected, treatment for AA is still not considered medically necessary by many insurers and even some physicians.
http://ift.tt/2Fz2m6E
Indentured servitude or junior faculty extension of a residency? An ethical evaluation of the 3 + 3 program structure
Despite a growing push by dermatology residencies for program graduates to pursue careers in academic dermatology, the vast majority of dermatology graduates work in private practice.1 In response to this, some programs have taken novel measures to increase the number of their graduates working in academics. Some of these programs involve combined internal medicine-dermatology residencies and extended research tracks and have been lauded for their ingenuity; others like the 3 + 3 program highlighted in this case scenario have caused concern amongst members of the dermatology community.
http://ift.tt/2DpHh8O
Recommendations for improving the patient experience in specialty encounters
The relationship between patient experience and health care quality has generated significant interest in the patient experience measure. However, it is challenging to find information on how to improve one's patient experience score because scientific data on this topic are weak or lacking, and suggestions provided by scoring vendors are often overgeneralized and not specialty-specific. This review will focus on the current state of evidence supporting factors influencing patient experience (both positive and negative) in outpatient specialist encounters that are applicable to general and surgical dermatology.
http://ift.tt/2DpHkS2
Simple solution to prevent postoperative bleeding from paramidline forehead flap
Patients who undergo a forehead flap reconstructive procedure often have postoperative bleeding from the flap's pedicle that necessitates physician intervention and causes significant patient distress. A safe, effective, low-cost, convenient, and reliable method to reduce this problem would be highly desired by reconstructive surgeons.
http://ift.tt/2FJ7O2E
Correction of “sandwiching phenomenon” following horizontal mattress suture
Closure of surgical and traumatic defects under high amounts of tension often involves use of horizontal mattress sutures. When a horizontal mattress suture is performed, a "sandwiching phenomenon," in which the epidermal edges fail to meet, is often observed (Fig 1). It is often found in situations in which a large bite size is used to close a wound under tension; it results from unbalanced tension in the closure, in which the entire load of the closure is in the reticular dermis (Fig 2, A). This results in apposition of the deep tissues, but not of the papillary dermis or epidermis (Fig 2, B), which in turn results in a wound edge profile with exposed dermal edges "sandwiched" by epidermal edges.
http://ift.tt/2FIqyzl
Billing of botulinum toxin for hyperhidrosis: Ethical considerations
Severe hyperhidrosis has significant effects on a patient's daily life. Billing of botulinum toxin injections for this condition varies among practices, despite most insurance covering its use in patients who fail first-line therapies. Although many dermatologists bill insurance for qualified patients, others charge according to the fee schedule for cosmetic botulinum toxin injections, even if patients have insurance that covers the service.1
http://ift.tt/2FznbPf
Multizentrische Analyse des Nutzerverhaltens von Cochlea-Implantat-Trägern
Laryngo-Rhino-Otol
DOI: 10.1055/a-0574-2569
Zusammenfassung Neuartige Cochlear-Implant-Sprachprozessoren bieten die Möglichkeit der Speicherung von Nutzungsdaten (Datalogging). Mit Hilfe dieser Informationen kann eine gezieltere individuelle Betreuung von Patienten ermöglicht werden. Allerdings fehlen bisher Normdaten in größerem Umfang zum individuellen Nutzungsverhalten. Material und Methoden Im Rahmen einer retrospektiven Studie wurden die Nutzungsdaten von 2687 Patienten ausgewertet. Alle Patienten waren mit dem Nucleus 6-System der Firma Cochlear Ltd. versorgt. Ergebnisse Die Daten ermöglichen für die Nutzungsdauer bzw. Tragedauern von Cochlear-Implant-Sprachprozessoren einen Normalbereich festzulegen. Ebenso ist die Identifikation von auffälligem Nutzungsverhalten möglich.
[...]
© Georg Thieme Verlag KG Stuttgart · New York
Article in Thieme eJournals:
Table of contents | Abstract | Full text
http://ift.tt/2FzWpqd
Effects of nasal septum perforation repair on nasal airflow: An analysis using computational fluid dynamics on preoperative and postoperative three-dimensional models
The purpose of this research is to examine the changes in nasal airflow dynamics before and after the nasal perforation repair.
http://ift.tt/2FIwmJn
Clinical features of nasal and sinonasal inverted papilloma associated with malignancy
Nasal and sinonasal inverted papilloma (IP) are rare benign tumors and have the potential to exhibit malignancy in approximately 10% of cases. This study aimed to analyze the clinical features of IP associated with malignancy. Furthermore, we reviewed our therapeutic strategy and the clinical course of malignant IP.
http://ift.tt/2FBFjs4
Cover Image
The cover image, by G. Haymerle et al., is based on the Correspondence The effect of adjuvant radiotherapy on radial forearm free flap volume after soft palate reconstruction in 13 patients, DOI 10.1111/coa.13042.
http://ift.tt/2DqgWYi
Prevalence of C-shaped canal system in mandibular first and second molars in a Saudi population assessed via cone beam computed tomography: a retrospective study
Abstract
Objectives
The purpose of this study was to determine the prevalence of the C-shaped root canal configuration, location of the longitudinal groove, sex differences, and unilateral/bilateral presence in mandibular first and second molars in a Saudi population using cone beam computed tomography (CBCT).
Materials and methods
CBCT images for the mandibular first and second molars of 487 patients (a total of 529 first molars and 681 s molars) were evaluated. The teeth were assessed for the presence of C-shaped root canals according to Fan criteria. Subdivisions were also made according to sex, direction of the longitudinal groove, and unilateral/bilateral presence.
Results
Only one C-shaped mandibular first molar was observed (0.19%), whereas 62 second molars (9.1%) exhibited C-shaped anatomy. Unilateral presence of the C-shaped root canal system was more common (53.85%). Female patients had a higher prevalence than males. Longitudinal grooves were most commonly found on the root lingual surface (58.1%).
Conclusions
The prevalence of the C-shaped canal configuration in a Saudi Arabian population was 0.19% in the mandibular first molar and 9.1% in the mandibular second molar. Longitudinal groove prevalence was highest on the lingual surface. Women had a significantly higher prevalence of the C-shaped canal configuration than men. Patients with unilateral presence of the C-shaped canal configuration were more common than those with bilateral presence.
Clinical relevance
Tooth type, patient sex, and ethnicity can help clinicians predict the prevalence of the C-shaped canal system in mandibular molars.
http://ift.tt/2Hx59tC
Thyroid Disease Around the World
Thyroid disease is one of the most common pathologies in the world, with two of the most clinically important subgroups being iodine deficiency and thyroid goiter, and thyroid cancer. This review looks at the current state of thyroid disease in the world and evaluates the future direction in terms of thyroid disease treatment and prevention. Several of the most impactful epidemiologic studies are presented and analyzed, as well as a brief overview of the current socioeconomic burden of disease.
http://ift.tt/2FTAuJN
A turning point in therapy for ameloblastomas
Ameloblastoma is a benign but locally aggressive odontogenic neoplasm in the jaw and maxilla [1,2]. If untreated, these lesions can reach enormous sizes and sometimes pose an airway risk. Although most are nonmetastasizing, they frequently recur if not adequately resected [3]. The current standard therapy for ameloblastoma is complete bone resection (radical intervention) with an adequate margin of safety, which is classified as marginal or segmental osteotomy for the mandible, and partial or total maxillectomy for the maxilla [1,4].
http://ift.tt/2p6ijak
Cervicofacial actinomycosis can obscure a malignancy: A case report
A 72-year-old male presented with a diffuse growth on his left lower jaw region. The lesion started 1 year back as a small ulcer on his left cheek and gradually progressed to a diffuse growth involving most of his left lower jaw. The patient had a 50-year history of tobacco chewing. Intraoral examination revealed an ulcero-proliferative growth in the left buccal mucosa extending into the gingivobuccal sulcus. Multiple pus discharging sinuses were noted on the surface of the extra-oral lesion. Provisional diagnosis was Cervicofacial Actinomycosis.
http://ift.tt/2HwV9Aq
Asthma-Related Mortality in the United States of America, 1999-2015: A Multiple Causes of Death Analysis
Asthma mortality based on the underlying cause of death (UCOD) underestimates disease burden.
http://ift.tt/2DqQj5h
Sunscreen sun protection factor (SPF): Is higher better?
The harmful properties of sunlight are well known. Actinic keratoses occur nearly exclusively in chronically sun exposed skin. Nonmelanoma skin cancer, especially squamous cell carcinoma, is strongly linked to sun exposure. The International Agency for Research on Cancer (IARC) of the World Health Organization classifies sunlight as a Group I carcinogen.1 Sun exposure is also strongly associated with photoaging. It is estimated that 80% or more of the changes in the skin that occur over time are due to the extrinsic effects of sunlight.
http://ift.tt/2HucaeQ
Ixekizumab treatment shows a neutral impact on cardiovascular parameters in patients with moderate-to-severe plaque psoriasis: results from UNCOVER-1, -2, and -3
The impact of ixekizumab treatment for psoriasis on cardiovascular-related parameters in patients is unknown., Ixekizumab maintenance dosing (12-60-weeks) had a neutral impact on cardiovascular-related parameters (including total cholesterol, LDL-cholesterol, HDL-cholesterol, LDL/HDL, triglycerides), Ixekizumab's neutral impact on cardiovascular-related parameters should not alter decisions to treat with other medications/interventions targeting cardiovascular-related parameters.
http://ift.tt/2p81Xh4
Unilateral Cleft Lip Rhinoplasty
Source:Operative Techniques in Otolaryngology-Head and Neck Surgery
Author(s): Phillip Montague, Mark Armeni
Cleft lip rhinoplasty is a challenging procedure both in terms of obtaining desirable appearance and function, but also in achieving consistency across one's patient population. Classically, formal nasal surgery was delayed until the patient had completed nasal and mid-facial growth, however, this paradigm is changing, and more rhinoplasty is being performed at the time of the lip repair which has revolutionized patient outcomes. The three options for repair in terms of timing are designated as primary, intermediate, and secondary (defined later in this text). At our institution, the majority of cases are either primary or secondary, with intermediate rhinoplasty reserved for only special circumstances. This article aims to describe the relevant anatomy and its aberrancy as well as discuss the surgical techniques to repair the cleft nasal deformity.
http://ift.tt/2p9q2Ey
Relation between globus pharyngeus and OSA in patients examined simultaneously by PSG and pH monitor: A cross sectional study
Publication date: Available online 12 March 2018
Source:Auris Nasus Larynx
Author(s): Ayako Fukui, Meiho Nakayama, Naoko Sakamoto, Sachie Arima, Shintaro Sato, Motohiko Suzuki, Shingo Murakami
ObjectiveThis was a first cross-sectional single-center study to research the relation between globus pharyngeus, OSA and GERD. Since previous clinical studies have demonstrated a relationship between globus phayrngeus and GERD, however, no reported study on the relation between globus pharyngeus, sleep disorders including OSA, and GERD.MethodsSeventeen patients underwent general and otorhinolaryngological examinations and responded to several questionnaires (ESS, PSQI, HADS, and Globus pharyngeus VAS score) at their first visit, and underwent a gastroesophageal test for 24-h pH monitoring and in-laboratory PSG one to two months later.ResultsNo significant differences were seen in ESS, PSQI, or HADS scores between the groups. The acid exposure time was not significantly different among the groups. The percentage of esophageal reflux time was higher than the percentage of laryngopharyngeal reflux time through the total time as well as the supine period. This indicated that GERD occurred more frequently than laryngopharyngeal reflux. The entire results showed concurrent OSA in 10 cases (59%) and concurrent GERD in 7 cases (41%). The cases with OSA were treated by CPAP or oral appliance, and those treatments were effective for globus pharyngeus.ConclusionAlthough the relation between OSA and globus phayngeus is still controversial, these findings suggest that OSA may be a previously undetected cause of globus pharyngeus. By improving OSA, it may offer an additional option of treatment for those globus pharyngeus cases combined with OSA.
http://ift.tt/2DoC9Sn
Acquired Non-malignant Cervical Trachea-Esophageal Fistula: A Case Series
Abstract
Acquired non-malignant trachea-esophageal fistula (TEF) of cervical oesophagus is rare. Surgical closure of fistula is the standard treatment of choice. Our experience in management of such cases is presented. Five cases of acquired cervical TEF of varying etiology were retrospectively analysed. Two patients had history of migrated endoluminal stent. All the patients were treated by trans-cervical repair with muscle interposition. Tracheal Stenosis in two patients was managed concurrently. Successful repair was achieved in four cases. One patient with chronic obstructive pulmonary disease and active leprosy has residual fistula. Of the two patients with tracheal stenosis correction one was decannulated 6 month later and second has stent in situ. Post-operative vocal cord palsy occurred in one patient. Transcervical repair with muscle interposition is treatment of choice in cases of acquired nonmalignant cervical tracheoesophageal fistulas. Endoluminal stents have high tendency to migrate and are not recommended.
http://ift.tt/2tGKv8e
Validation conform ISO-15189 of assays in the field of autoimmunity: Joint efforts in The Netherlands
Source:Autoimmunity Reviews
Author(s): Leontine Mulder, Renate van der Molen, Carin Koelman, Ester van Leeuwen, Anja Roos, Jan Damoiseaux
ISO 15189:2012 requires validation of methods used in the medical laboratory, and lists a series of performance parameters for consideration to include. Although these performance parameters are feasible for clinical chemistry analytes, application in the validation of autoimmunity tests is a challenge. Lack of gold standards or reference methods in combination with the scarcity of well-defined diagnostic samples of patients with rare diseases make validation of new assays difficult. The present manuscript describes the initiative of Dutch medical immunology laboratory specialists to combine efforts and perform multi-center validation studies of new assays in the field of autoimmunity. Validation data and reports are made available to interested Dutch laboratory specialists.
http://ift.tt/2HxZXpr
Acquired Non-malignant Cervical Trachea-Esophageal Fistula: A Case Series
Abstract
Acquired non-malignant trachea-esophageal fistula (TEF) of cervical oesophagus is rare. Surgical closure of fistula is the standard treatment of choice. Our experience in management of such cases is presented. Five cases of acquired cervical TEF of varying etiology were retrospectively analysed. Two patients had history of migrated endoluminal stent. All the patients were treated by trans-cervical repair with muscle interposition. Tracheal Stenosis in two patients was managed concurrently. Successful repair was achieved in four cases. One patient with chronic obstructive pulmonary disease and active leprosy has residual fistula. Of the two patients with tracheal stenosis correction one was decannulated 6 month later and second has stent in situ. Post-operative vocal cord palsy occurred in one patient. Transcervical repair with muscle interposition is treatment of choice in cases of acquired nonmalignant cervical tracheoesophageal fistulas. Endoluminal stents have high tendency to migrate and are not recommended.
http://ift.tt/2tGKv8e
Effects of a protein-free oat plantlet extract on microinflammation and skin barrier function in atopic dermatitis patients
Abstract
Atopic dermatitis (AD) is a common, highly pruritic, chronic inflammatory skin disease. Dysfunction of the epidermal barrier is witnessed by an increased transepidermal water loss in lesional and non-lesional AD skin. The inflammation in lesional AD skin is well characterized. Non-lesional skin of AD patients shows histological signs of a subclinical inflammation and a pro-inflammatory cytokine milieu. This microinflammation is present even in seemingly healed skin and must be taken into account regarding treatment of AD. Emollients provide a safe and effective method of skin barrier improvement, because they provide the skin with a source of exogenous lipids, thus improving its barrier function. The use of emollients is recommended for all AD patients irrespective of overall disease severity. Patients with moderate to severe AD should combine the emollients with a proactive therapy regimen of topical calcineurin inhibitors or topical corticosteroids. Skin areas affected by active eczema in flare should receive daily anti-inflammatory therapy first before introducing emollients, to induce rapid relief of skin lesions and pruritus. The microinflammation persisting in seemingly healed AD lesions should be addressed by a proactive treatment approach, consisting of minimal anti-inflammatory therapy and liberal, daily use of emollients. An emollient containing an extract of Rhealba oat plantlet has shown anti-inflammatory and barrier repairing properties, and was clinically tested in studies targeting the microinflammation in AD. All emollients based on Rhealba oat plantlet extract are free of oat protein, as the Rhealba extract is derived from the aerial parts of the oat plantlet and is unrelated to oatmeal proteins. The Rhealba oat plantlet extract is produced in a specific process, allowing the extraction of high levels of active principles such as flavonoids and saponins, whilst being virtually free of oat proteins to minimize the risk for allergic reactions.
http://ift.tt/2HvQoqO
Sex-Specific Associations Between Complement Component 3 and Component 4 Levels and Metabolic Syndrome in an Adult Population
Metabolic Syndrome and Related Disorders, Ahead of Print.
http://ift.tt/2pbmFfw
The Effects of High-Protein and High-Monounsaturated Fat Meals on Postprandial Lipids, Lipoprotein Particle Numbers, Cytokines, and Leptin Responses in Overweight/Obese Subjects
Metabolic Syndrome and Related Disorders, Ahead of Print.
http://ift.tt/2InlCBH
Biologics in Pregnancy Safe, Pose No Preterm or SGA Risk
Previous studies finding a link between biologics exposure and preterm birth or SGA did not adequately account for potential confounders, researchers note.
Medscape Medical News
http://ift.tt/2GpQZLG
Comparison of peri-implant soft tissues in submerged versus transmucosal healing: A split mouth prospective immunohistochemical study
Source:Archives of Oral Biology
Author(s): José María Martínez-González, María Martín-Ares, Natalia Martínez-Rodríguez, Cristina Barona-Dorado, Javier Sanz-Alonso, Jorge Cortés-Bretón-Brinkmann, Javier Ata-Ali
ObjectiveThe present split-mouth prospective study involves an immunohistochemical evaluation of peri-implant soft tissue healing after the osseointegration period, comparing submerged and transmucosal approaches using two-piece implant systems. The null hypothesis was that both surgical procedures elicit a similar immune response of the peri-implant soft tissues.DesignThirty-one healthy patients were included in this study, in which two implants were placed in the right and left maxillary pre-molar regions. A total of 62 dental implants were analyzed, establishing a control side with 31 submerged implants, and a study side with 31 exposed implants bearing healing abutments. After a three-month healing period, a soft tissue biopsy was collected and prepared for immunohistochemical analysis of the proportions of different lymphocyte subpopulations.ResultsThe comparative analysis between the submerged and transmucosal approaches failed to identify statistically significant differences in CD19+ B cells, CD4+ T cells, CD8+ T cells, CD25+ T cells or γd T cells. However, significant differences in NK lymphocytes (p = 0.012) were recorded with the submerged surgical procedure.ConclusionsPeri-implant soft tissue immune response with submerged or transmucosal healing protocols demonstrated comparable outcomes after the osseointegration period. There is sufficient evidence that the null hypothesis of no difference cannot be rejected. To the best of our knowledge, this is the first study of its kind. Further research is therefore needed to further clarify the role of these lymphocyte subpopulations in peri-implant soft tissues.
http://ift.tt/2DmLPNe
Comparison of peri-implant soft tissues in submerged versus transmucosal healing: A split mouth prospective immunohistochemical study
Source:Archives of Oral Biology
Author(s): José María Martínez-González, María Martín-Ares, Natalia Martínez-Rodríguez, Cristina Barona-Dorado, Javier Sanz-Alonso, Jorge Cortés-Bretón-Brinkmann, Javier Ata-Ali
ObjectiveThe present split-mouth prospective study involves an immunohistochemical evaluation of peri-implant soft tissue healing after the osseointegration period, comparing submerged and transmucosal approaches using two-piece implant systems. The null hypothesis was that both surgical procedures elicit a similar immune response of the peri-implant soft tissues.DesignThirty-one healthy patients were included in this study, in which two implants were placed in the right and left maxillary pre-molar regions. A total of 62 dental implants were analyzed, establishing a control side with 31 submerged implants, and a study side with 31 exposed implants bearing healing abutments. After a three-month healing period, a soft tissue biopsy was collected and prepared for immunohistochemical analysis of the proportions of different lymphocyte subpopulations.ResultsThe comparative analysis between the submerged and transmucosal approaches failed to identify statistically significant differences in CD19+ B cells, CD4+ T cells, CD8+ T cells, CD25+ T cells or γd T cells. However, significant differences in NK lymphocytes (p = 0.012) were recorded with the submerged surgical procedure.ConclusionsPeri-implant soft tissue immune response with submerged or transmucosal healing protocols demonstrated comparable outcomes after the osseointegration period. There is sufficient evidence that the null hypothesis of no difference cannot be rejected. To the best of our knowledge, this is the first study of its kind. Further research is therefore needed to further clarify the role of these lymphocyte subpopulations in peri-implant soft tissues.
http://ift.tt/2DmLPNe
Hydroxy-urea and Temozolomide in Patients With a Recurrent Malignant Brain Tumor (Glioblastoma)
Conditions: Glioma; Glioblastoma
Interventions: Drug: Hydroxyurea; Drug: Temozolomide
Sponsors: M.E. van Linde; Massachusetts General Hospital
Recruiting
http://ift.tt/2Io2Jij
Interventions: Drug: Hydroxyurea; Drug: Temozolomide
Sponsors: M.E. van Linde; Massachusetts General Hospital
Recruiting
http://ift.tt/2Io2Jij
Gallium-68 Prostate Specific Membrane Antigen PET in Diagnosing Patients With Thyroid Cancer
Condition: Thyroid Gland Carcinoma
Interventions: Radiation: Gallium Ga 68-labeled PSMA-11; Procedure: Magnetic Resonance Imaging; Procedure: Positron Emission Tomography
Sponsor: University of California, San Francisco
Recruiting
http://ift.tt/2peWsNd
Interventions: Radiation: Gallium Ga 68-labeled PSMA-11; Procedure: Magnetic Resonance Imaging; Procedure: Positron Emission Tomography
Sponsor: University of California, San Francisco
Recruiting
http://ift.tt/2peWsNd
Epacadostat and Pembrolizumab in Patients With Head and Neck Cancer That Have Failed Prior Immunotherapy
Conditions: Head and Neck Squamous Cell Carcinoma; Head and Neck Cancer
Interventions: Drug: Pembrolizumab; Drug: Epacadostat
Sponsor: University of Chicago
Not yet recruiting
http://ift.tt/2IkAXTA
Interventions: Drug: Pembrolizumab; Drug: Epacadostat
Sponsor: University of Chicago
Not yet recruiting
http://ift.tt/2IkAXTA
Endotracheal tube size to leakage ventilation and tracheal dilatation
Abstract
Purpose
This study analyzed the clinical factors with the aim to determine the relationship between endotracheal tube (ETT) size and leakage ventilation (LV) and tracheal dilatation.
Methods
All patients with ETT intubation and ventilator support for more than 6 months were retrospectively evaluated. The inner tracheal diameter (TD) was measured over image at the starting and 6 months after ventilator initiated. We compared the clinical factors, outcomes and complications between patients with and without LV, as well as with and without a TD enlarging more than 25% after 6 months (TDn). Logistic regression analyses of factors related to the LV and TDn were performed. The cut-off points of the ratio of outer diameter of ETT (OD) to TD were set and evaluated for their accuracy of predicting LV and TDn.
Results
689 patients were enrolled initially and eventually 199 patients were included, of which 52 and 66 patients were identified to have LV and TDn, respectively. Patients with LV had a higher peak inspiratory pressure (PIP), smaller initial ETT OD/TD and higher incidence of pneumonia. Patients with TDn had a higher PIP, larger initial OD/TD and higher incidence of pneumonia. A higher PIP and smaller initial OD/TD were significantly related to LV and a higher PIP and larger initial OD/TD were significantly related to TDn. The incidence of LV and TDn was higher in patients with an initial OD/TD less than 0.51 and more than 0.54, respectively.
Conclusion
The initial ETT OD/TD ratio is a predictor for LV and TDn.
http://ift.tt/2Gmu8jZ
Primary Leiomyosarcoma of the Buccal Mucosa: Report of a Case and Review of the Literature
Abstract
This clinicopathologic study of primary oral leiomyosarcoma of the buccal mucosa involves a literature review of 15 cases with the addition of our report of a case. The demographic details, tumor size, treatment and outcome are documented for all the cases. In addition, this review examines the histologic features of leiomyosarcoma while noting that differentiation from other spindle cell tumors can be challenging, underscoring the necessity of an immunohistochemical work up for an accurate diagnosis. The unpredictability of the clinical behavior of these aggressive tumors requires, at the very least, wide local surgical excision and prolonged follow up.
http://ift.tt/2pd41Vt
CD47 expression in Epstein-Barr virus-associated gastric carcinoma: coexistence with tumor immunity lowering the ratio of CD8 + /Foxp3 + T cells
Abstract
Epstein-Barr virus-associated gastric carcinoma (EBVaGC) frequently harbors dense lymphocytic infiltration, suggesting a specific microenvironment allowing coexistence with tumor immunity. CD47, which mediates the "do not eat me" signal in innate immunity, is also important in adaptive anti-tumor immunity. We investigated the significance of CD47 in EBVaGC compared with EBV-negative gastric cancer and the correlation with various immune cells. By immunohistochemistry of CD47, high, low, and negative expression was observed in 24, 63, and 12% of EBVaGC (n = 41), while 11, 49, and 39% of EBV-negative gastric cancer (n = 262), respectively, indicating that high expression of CD47 in cancer cells was significantly frequent and increased in EBVaGC (P = 0.043). In contrast to EBV-negative gastric carcinoma in which no significant correlation was observed between CD47 and survival, high expression of CD47 correlated significantly with worse disease-specific survival (P = 0.011) and overall survival (P = 0.013) in EBVaGC. To further clarify the role of CD47 expression in EBVaGC, digital image analysis of immune cell infiltration revealed that high CD47 expression was correlated with a lower ratio of CD8+/Foxp3+ T cells (P = 0.021), a sensitive indicator of tumor immunity. Thus, CD47 lowers anti-tumor immunity in EBVaGC by finely tuning profile of infiltrating T cells, suggesting that CD47 is an additional target for cancer immunotherapy against this virus-driven gastric cancer.
http://ift.tt/2FKhHkd
Primary Leiomyosarcoma of the Buccal Mucosa: Report of a Case and Review of the Literature
Abstract
This clinicopathologic study of primary oral leiomyosarcoma of the buccal mucosa involves a literature review of 15 cases with the addition of our report of a case. The demographic details, tumor size, treatment and outcome are documented for all the cases. In addition, this review examines the histologic features of leiomyosarcoma while noting that differentiation from other spindle cell tumors can be challenging, underscoring the necessity of an immunohistochemical work up for an accurate diagnosis. The unpredictability of the clinical behavior of these aggressive tumors requires, at the very least, wide local surgical excision and prolonged follow up.
http://ift.tt/2pd41Vt
Primary Leiomyosarcoma of the Buccal Mucosa: Report of a Case and Review of the Literature
Abstract
This clinicopathologic study of primary oral leiomyosarcoma of the buccal mucosa involves a literature review of 15 cases with the addition of our report of a case. The demographic details, tumor size, treatment and outcome are documented for all the cases. In addition, this review examines the histologic features of leiomyosarcoma while noting that differentiation from other spindle cell tumors can be challenging, underscoring the necessity of an immunohistochemical work up for an accurate diagnosis. The unpredictability of the clinical behavior of these aggressive tumors requires, at the very least, wide local surgical excision and prolonged follow up.
http://ift.tt/2pd41Vt
Risk Factors for Titanium Mesh Implant Exposure Following Cranioplasty
Purpose: Titanium mesh is used to reconstruct the neurocranium in cranioplasties. Though it is generally well-tolerated, erosion of the overlying soft tissue with exposure of the implant is a complication that adversely affects patient outcomes. The purpose of this study is to investigate potential risk factors for titanium mesh exposure. Methods: This study comprises all consecutive patients who underwent titanium mesh cranioplasty between January 2000 and July 2016. A retrospective chart review was conducted to extract demographics, details of management, and outcome. Latest postoperative computed tomography scans were reviewed to document the thickness of soft tissue coverage over the implant and the presence of significant extradural dead space deep to it. Results: Fifty patients were included. Implant exposure occurred in 7 (14%), while threatened exposure was observed in 1 additional patient, for a total complication count of 8 (16%). Four (50%) exposure and 3 (7.1%) nonexposure patients underwent preoperative radiotherapy (odds ratio [OR] = 19.67, P = 0.018). Similarly, 4 (50%) exposure and 5 (11.9%) nonexposure patients had a free flap tissue transfer for implant coverage (OR = 6.50, P = 0.046). Postoperative computed tomography scans revealed significant thinning of soft tissues over titanium mesh in 7 (87.5%) exposure and 15 (35.7%) nonexposure patients (OR = 10.71 P = 0.040). No significant association was found between transposition/rotation flap, postoperative radiotherapy, or the presence of significant extradural dead space, and exposure (P = 0.595, P = 0.999, P = 0.44). Conclusion: Preoperative radiotherapy, free flap coverage, and soft tissue atrophy resulted in greater odds of titanium mesh exposure. The findings of this study provide important considerations for reconstructive surgeons using titanium mesh for cranioplasty. Address correspondence and reprint requests to Dr Oleh M. Antonyshyn, MD, FRCS(C), Division of Plastic and Reconstructive Surgery, Department of Surgery, Rm M1-520, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5; E-mail: oleh.antonyshyn@sunnybrook.ca Received 11 September, 2017 Accepted 25 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.
http://ift.tt/2paA5bA
http://ift.tt/2paA5bA
Evaluation of the Efficacy of Different Concentrations of Dextrose Prolotherapy in Temporomandibular Joint Hypermobility Treatment
Purpose: The aim of this study was to compare and evaluate the efficacy of different concentrations of dextrose prolotherapy for the treatment of temporomandibular joint (TMJ) hypermobility. Patients and Methods: A prospective, randomized clinical trial including patients with subluxation or dislocation was performed. The study comprised 40 patients. Patients were randomly divided into 4 groups: control group, 10% dextrose, 20% dextrose, and 30% dextrose group. Patients in all groups received injections into 4 different areas of each TMJ in 4 sessions at monthly intervals. Visual analog scale of TMJ pain intensity, maximum mouth opening (MMO), joint sounds, and frequency of luxations were recorded preoperatively and postoperatively after 1 month of last injection. The collected data were then statistically analyzed. Results: Each group showed postoperatively significant improvement in TMJ pain, significant decrease in both MMO and joint sound. Besides that, TMJ locking was not observed in any patient during the follow-up period. There were no statistically significant differences throughout the study intervals between the groups. Conclusion: It was concluded that there was no significant difference between control group and dextrose groups and there is no superiority of any concentration of dextrose over the others in TMJ prolotherapy, and all treatment procedures were efficient in improvement of clinical symptoms related to TMJ hypermobility. If dextrose is used as a proliferant, it can be said that 10% dextrose can be sufficient in TMJ hypermobility treatment. Address correspondence and reprint requests to Metin Güngörmüş, Professor, Department of Maxillofacial Surgery, Faculty of Dentistry, Gaziantep University, Gaziantep 27310, Turkey; E-mail: gungormusm@yahoo.com Received 29 July, 2017 Accepted 27 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.
http://ift.tt/2ImRZAB
http://ift.tt/2ImRZAB
Schwannoma with chondroid metaplasia of the external auditory canal – a rare finding in a rare location: a case report
Schwannomas are uncommon tumors of the external auditory canal. In the English literature, very few cases of schwannomas originating in the external auditory canal were reported and none of them showed chondro...
http://ift.tt/2FC3q5F
LCAT deficiency as a cause of proteinuria and corneal opacification
Description
A 44-year-old woman was diagnosed with corneal dystrophy (figure 1) and anaemia. Analytically, she showed an altered lipid profile (cholesterol 172 mg/dL, triglycerides 173 mg/dL, high-density lipoprotein (HDL) cholesterol 6.6 mg/dL, low-density lipoprotein cholesterol 131 mg/dL, very low-density lipoprotein (VLDL) cholesterol 45 mg/dL, VLDL triglycerides 143 mg/dL, apo A 62 mg/dL, apo B 69.6 mg/dL, lipoprotein A <2.5 mg/dL) and proteinuria between 1 and 2 g/day. A renal biopsy was performed. Histology revealed the presence of segmental hyaline lesions and irregular mesangial enlargement. Glomerular capillary walls showed parietal thickening and subendothelial deposits, vacuolisation and frequent images of reduplication of the basement membrane (figure 2). Electron microscopy showed lipid deposition in many areas (figure 3). The evaluation of the plasma lecithin cholesterol acyltransferase (LCAT) enzymatic activity was 15.2 nmol/mL/hour (reference range, 81±12 mL/min/hour). A genetic study of LCAT deficiency disease was performed which showed a missense homozygosis in the LCAT gene c368G>Cp (R123p), not previously described in literature.
...
http://ift.tt/2p6uSSU
An unusual manifestation of olfactory neuroblastoma
A 62-year-old woman presented with an 11-month history of worsening nasal symptoms of rhinorrhoea, anosmia, nasal congestion and intermittent epistaxis. MRI revealed a large mass in the upper nasal vault. Biopsy of the mass revealed an olfactory neuroblastoma. While waiting resection, she acutely developed severe proximal muscle weakness, lethargy and lower extremity oedema. Blood glucose was elevated, and hypokalaemic metabolic alkalosis was noted. Elevated serum cortisol level of 95.7 µg/dL (8.7–22.4 µg/dL) and markedly elevated 24-hour urinary cortisol level of 6962.3 µg/24 hours (4.0–50.0 µg/24 hours) with concurrent adrenocorticotropic hormone (ACTH) level of 171 pg/mL (6–58 pg/mL) were suggestive of an ACTH-dependent source of hypercortisolism. A subsequent positive high-dose dexamethasone suppression test was consistent with ectopic ACTH production. She underwent near-total resection of the right nasal mass followed by radiotherapy, resulting in complete resolution of signs and symptoms of cortisol excess.
http://ift.tt/2HvKk1H
A case of tricuspid valve non-bacterial thrombotic endocarditis presenting as pulmonary embolism in a patient with antiphospholipid antibody syndrome
A 47-year-old woman with a medical history of Raynaud's phenomenon presented with fever, cough and shortness of breath. She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia. During the hospital course, her respiratory status worsened, and she was intubated on the third hospital day. To investigate the high A–a gradient, a Computerized Tomographic Pulmonary Embolism (CTPE) study was done which identified a large left lower pulmonary artery embolism. She was also found to have a new murmur, and an echocardiogram demonstrated a large lesion on tricuspid valve. However, multiple sets of her blood cultures came back consistently negative. Alternative diagnoses for culture-negative endocarditis were considered, and a full set of rheumatological workup was done. Laboratory tests were suggestive of antiphospholipid syndrome, hence the diagnosis of tricuspid valve Libman-Sacks endocarditis was made.
http://ift.tt/2p9WCG4
Coccidioides immitis septic knee arthritis
A 78-year-old man developed right knee pain and swelling without other systemic symptoms. He had travelled frequently to the Central Valley of California. He was diagnosed with coccidioidomycosis based on joint fluid culture. Coccidioidal complement fixation antibody titres were extremely elevated. Arthroscopic debridement and fluconazole therapy did not lead to satisfactory improvement. Subsequent open debridement and change to itraconazole was followed by resolution of clinical signs of infection.
http://ift.tt/2HuzNDO
Ovarian teratoma associated with anti-NMDA (N-methyl D-aspartate) receptor encephalitis
Anti-N-methyl D-aspartate receptor (NMDAR) encephalitis is a paraneoplastic, immune-mediated encephalopathy with a known association with ovarian teratomas. We present the first case in the UK of a 7-year-old patient presenting with this condition. Having been previously fit and healthy, the patient presented with an acute onset of cognitive disturbances. The initial suspicion was that of an infective encephalopathy; however, the lumbar puncture results were negative. Electroencephalography reported diffuse background slowing, supporting a diagnosis of encephalopathy. Extensive autoimmune screening was done and found to be positive for anti-NMDAR antibodies. A whole body MRI found a right adnexal lesion consistent with ovarian teratoma. At laparoscopy, the right ovary was excised and histology confirmed a mature cystic teratoma with neural tissue. There were no postoperative complications with the patient's neurology recovering progressively at follow-up.
http://ift.tt/2p4lPBZ
Case of Segmental Arterial Mediolysis
Segmental arterial mediolysis (SAM) is a rare, non-inflammatory, vascular condition that predominantly affects medium-sized to large-sized abdominal arteries and can present with haemorrhage into the abdominal cavity. We report the case of a patient with SAM of the coeliac, splenic, renal and gastroduodenal arteries in whom endovascular coil embolisation was successfully used to treat a bleeding gastroduodenal artery pseudoaneurysm.
http://ift.tt/2DoWOWe
Resolution of osseous sarcoidosis with steroids
Description
A 56-year-old man with a 10-pack-year history of smoking presented to the clinic with left hip pain. He was treated symptomatically with pain medications. With persistence of symptoms and normal preliminary laboratory results, he underwent MRI of the pelvis which showed lytic lesions suggestive of metastatic disease (figure 1A). Further imaging including CT of the chest revealed bilateral hilar and mediastinal adenopathy along with splenomegaly but no parenchymal lung involvement. Mediastinoscopy with lymph node biopsy showed non-caseating granuloma, and left pubic area biopsy revealed benign bone with epithelioid granuloma, both consistent with sarcoidosis. His pulmonary function tests revealed normal spirometry, lung volume and diffusion. Without any organ dysfunction, he was started on prednisone 40 mg once daily for his hip pain. After 6 months of steroid use, he had significant clinical and radiological improvement (figure 1B). Sarcoidosis is a multisystem disease characterised by the...
http://ift.tt/2p7mGBZ
Middle mediastinal schwannoma concealed by asthma and GORD
Neurogenic tumours of the mediastinum in adults occur most often at the posterior mediastinum, majority of which are benign of nerve sheath in origin. A 72-year-old woman, known asthmatic, presented with chronic symptoms of hoarseness, dysphagia, chest heaviness, easy fatigability, cough, epigastric pain, feeling of abdominal fullness and choking with food intake and at a supine position. Treated for other disorders, routine chest X-ray incidentally found a homogenous convex radiodensity at the right paratracheal area; mass which was also observed with CT and 18F-fludeoxyglucose-positron emission tomography/CT scan studies. Mediastinoscopy with biopsy showed spindle to plump cells with strong S100 positivity. Thoracoscopic surgery done to completely excise the mass found it to be benign schwannoma.
http://ift.tt/2Dp3XG1
Spontaneous thrombosis in an ectatic right coronary artery
Description
A 73-year-old man presented to our cardiology service with intense central chest pain as an ST-segment elevation myocardial infarction (STEMI) call. His ECG showed inferior ST-segment elevation with reciprocal anterior ST-segment depression. We proceeded directly to coronary angiography which showed an ectatic aneurysmal right coronary artery (RCA) with heavy thrombotic burden (figure 1) but trombolysis in myocardial infarction 3 flow.
Figure 1
Coronary angiogram of the right coronary artery showing an ectatic vessel with a heavy thrombotic burden.
At this point during the procedure, the patient was pain free, and his ST-segment elevation had resolved. As such, we elected to manage him acutely with intravenous unfractionated heparin. Abciximab was considered but given the patient's age, abnormal renal function, normalised ST segments and absence of pain, we elected not to use this therapy acutely. Atrial fibrillation was searched for in...
http://ift.tt/2p4lTSk
Ultrasonographic differentiation of the peripheral choroidal detachment from the circumferential scleral buckle
Description
A 40-year-old male patient presented with a history of surgery in the left eye for retinal detachment 1 year ago. His history of medical and surgical interventions was incomplete as the patient lost all his previous records. On examination, visual acuity was 20/20 in the right eye and hand movement close to face with accurate projection of rays in the left eye. Both eye corneas were clear with normal anterior chambers. The right eye had a clear lens, and the fundus was within normal limits. Whereas in the left eye, a total cataract was present. This hindered the retinal evaluation. Intraocular pressures were 18 mm Hg in the right eye and 14 mm Hg in the left eye. To assess the posterior segment, a B scan ultrasonography was performed which revealed a thick convex mount towards the vitreous cavity giving an appearance of shallow choroidal detachment.
To differentiate choroidal detachment from other misleading conditions,...
http://ift.tt/2DriQYM
Clinical evaluation of two dexamethasone regimens in the extractions of impacted third molars—a randomized clinical trial
Abstract
Purpose
The aim of the present study was to compare two therapeutic protocols of dexamethasone for the prevention of postoperative swelling, pain, and other complications after the extraction of impacted third molars, in a prospective, randomized, crossover, double-blinded clinical trial.
Methods
Fifty patients with symmetrical impaction of third molars were randomly assigned to two different protocols of dexamethasone for each side. Patients underwent two sessions performed at a 21-day interval. In group 1, patients took 8 mg of dexamethasone orally 1 h before the procedure, and in group 2, 4 mg dexamethasone orally 1 h before and 24 h after the procedure. Surgery duration, volume of local anesthetics, surgical technique, and rescue medication were standardized. Postoperative pain was evaluated using a visual analog scale (VAS) at predefined times: before operation; immediately after; 1, 2, 4, and 12 h; and 1, 2, 3, and 7 days after operation. The patients were also instructed to take notes of the number of rescue medication tablets taken. Edema and mouth opening were clinically evaluated before surgery and in the postoperative period (second and seventh postoperative days).
Results
There were no significant differences between groups for VAS scales (p = 0.5048), but the use of rescue medication was significantly lower in group 1 (p = 0.006). None statistically significant differences (p > 0.05) were observed between groups in any of the time points for all measurements of edema. However, the mouth opening limitation (DIINC) was bigger (p = 0.0069) for group 1 at 2 days.
Conclusion
Pre-emptive use of different dexamethasone regimens had a beneficial effect against pain, edema, and mouth opening limitation, especially when administered at an 8 mg concentration, which suggests that this protocol may also be efficient for more invasive surgery.
http://ift.tt/2DoV5Ak
Staging von Oropharynxkarzinomen
Zusammenfassung
Hintergrund
Die TNM-Klassifikation (TNM: Tumor, Nodus, Metastasen) wird regelmäßig entsprechend der Literatur sowie international abgestimmter Empfehlungen aktualisiert. Ausgeprägte Änderungen haben sich im Rahmen der 8. Auflage v. a. für Oropharynxkarzinome ergeben.
Material und Methoden
Die Änderungen sowie die praktische Anwendung der Klassifikation für das Staging von Oropharynxkarzinomen werden anhand von Fällen aus der Tumordatenbank dargestellt.
Ergebnisse
Die aktuelle Auflage der TNM-Klassifikation setzt Forderungen um, durch humane Papillomaviren (HPV) induzierte von HPV-negativen Tumoren im Rahmen des Stagings zu unterscheiden. Auch die prognostische Bedeutung der extranodalen Ausbreitung von Lymphknotenmetastasen wurde integriert. Während für p16-positive Tumoren in vielen Fällen ein Downstaging hinsichtlich der N‑Kategorie und der Stadien gemäß Union Internationale Contre le Cancer (UICC) stattfindet, führt extranodales Wachstum bei p16-negativen Tumoren zumeist zu einem deutlichen Upstaging. Bei einer begrenzten Spezifität der p16-Immunhistochemie muss die Bedeutung falsch-positiver Ergebnisse beachtet werden. Fehlende Integration des Rauchverhaltens, eine eingeschränkte Standardisierung der Untersuchungstechnik der extranodalen Ausbreitung sowie hohe Anforderungen an die Dokumentationsqualität sollten berücksichtigt werden.
Schlussfolgerung
Inwiefern die Änderungen Überlegungen einer Therapiedeeskalation für p16-positive Karzinome unterstützen, werden laufende Studien zeigen müssen. Im Rahmen einer prospektiven multizentrischen Datenerhebung sollte die universelle Anwendbarkeit, die Angemessenheit für alle Sublokalisationen sowie der prognostische Einfluss der neuen TNM-Auflage ausführlich untersucht werden.
http://ift.tt/2tIgqW2
Renovascular Mistaken as Essential Hypertension due to Giant Hepatic Hydatid: A Rare Treatable Entity
Renovascular hypertension is an unusual but treatable cause of refractory hypertension that is infrequently caused by external compression of the renal vasculature by a giant hydatid cyst, a parasitic infection, caused by Echinococcus granulosus in its larval stage which is endemic in many parts of the world including Saudi Arabia. The disease can produce a cyst in almost every part of the body with the liver and lungs being the most frequently targeted organs producing a variety of symptoms depending upon the site and size of the cyst. We report a case of giant hepatic hydatid cyst with the possibility of renovascular hypertension due to mass effect as evident by dramatic drop of the blood pressure to its normotensive state postoperatively.
http://ift.tt/2p8JhNy
The landscape of genetic alterations in ameloblastomas relates to clinical features
Abstract
Ameloblastoma is a mostly benign, but locally invasive odontogenic tumor eliciting frequent relapses and significant morbidity. Recently, mutually exclusive mutations in BRAF and SMO were identified causing constitutive activation of MAPK and hedgehog signaling pathways. To explore further such clinically relevant genotype-phenotype correlations, we here comprehensively analyzed a large series of ameloblastomas (98 paraffin block of 76 patients) with respect to genomic alterations, clinical presentation, and histological features collected from the archives of three different pathology centers in France, Germany, and Turkey. In good agreement with previously published data, we observed BRAF mutations almost exclusively in mandibular tumors, SMO mutations predominantly in maxillary tumors, and single mutations in EGFR, KRAS, and NRAS. KRAS, NRAS, PIK3CA, PTEN, CDKN2A, FGFR, and CTNNB1 mutations co-occurred in the background of either BRAF or SMO mutations. Strikingly, multiple mutations were exclusively observed in European patients, in solid ameloblastomas and were associated with a very high risk for recurrence. In contrast, tumors with a single BRAF mutation revealed a lower risk for relapse. We here establish a comprehensive landscape of mutations in the MAPK and hedgehog signaling pathways relating to clinical features of ameloblastoma. Our data suggest that ameloblastomas harboring single BRAF mutations are excellent candidates for neo-adjuvant therapies with combined BRAF/MEK inhibitors and that the risk of recurrence maybe stratified based on the mutational spectrum.
http://ift.tt/2Hr1Vba
Clinical evaluation of two dexamethasone regimens in the extractions of impacted third molars—a randomized clinical trial
Abstract
Purpose
The aim of the present study was to compare two therapeutic protocols of dexamethasone for the prevention of postoperative swelling, pain, and other complications after the extraction of impacted third molars, in a prospective, randomized, crossover, double-blinded clinical trial.
Methods
Fifty patients with symmetrical impaction of third molars were randomly assigned to two different protocols of dexamethasone for each side. Patients underwent two sessions performed at a 21-day interval. In group 1, patients took 8 mg of dexamethasone orally 1 h before the procedure, and in group 2, 4 mg dexamethasone orally 1 h before and 24 h after the procedure. Surgery duration, volume of local anesthetics, surgical technique, and rescue medication were standardized. Postoperative pain was evaluated using a visual analog scale (VAS) at predefined times: before operation; immediately after; 1, 2, 4, and 12 h; and 1, 2, 3, and 7 days after operation. The patients were also instructed to take notes of the number of rescue medication tablets taken. Edema and mouth opening were clinically evaluated before surgery and in the postoperative period (second and seventh postoperative days).
Results
There were no significant differences between groups for VAS scales (p = 0.5048), but the use of rescue medication was significantly lower in group 1 (p = 0.006). None statistically significant differences (p > 0.05) were observed between groups in any of the time points for all measurements of edema. However, the mouth opening limitation (DIINC) was bigger (p = 0.0069) for group 1 at 2 days.
Conclusion
Pre-emptive use of different dexamethasone regimens had a beneficial effect against pain, edema, and mouth opening limitation, especially when administered at an 8 mg concentration, which suggests that this protocol may also be efficient for more invasive surgery.
http://ift.tt/2DoV5Ak
Patients at High Risk for Obstructive Sleep Apnea Are at Increased Risk for Atrial Fibrillation After Cardiac Surgery: A Cohort Analysis
BACKGROUND: Patients with obstructive sleep apnea (OSA) experience intermittent hypoxia, hypercarbia, and sympathetic activation during sleep, which increases risk for paroxysmal atrial fibrillation and other cardiac arrhythmias. Whether patients with OSA experience increased episodes of atrial fibrillation after cardiac surgery is unclear. We examined whether patients at increased risk for OSA, assessed by the STOP-BANG (snoring, tired during the day, observed stop breathing during sleep, high blood pressure, body mass index more than 35 kg/m2, age more than 50 years, neck circumference more than 40 cm, and male gender) questionnaire, had a higher incidence of new-onset postoperative atrial fibrillation after cardiac surgery. Because both postoperative atrial fibrillation and OSA increase resource utilization, we secondarily examined whether patients at increased OSA risk had longer duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay. METHODS: With institutional review board approval, this retrospective observational study evaluated adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass between 2014 and 2015 with preoperative assessment of OSA risk using the STOP-BANG questionnaire. Patients with a history of atrial fibrillation were excluded. The association between the STOP-BANG score and postoperative atrial fibrillation was examined using a multivariable logistic regression model. Secondarily, we estimated the association between the STOP-BANG score and duration of initial intubation using multivariable linear regression and ICU length of stay using Cox proportional hazards regression. We also descriptively summarized the percentage of patients requiring tracheal reintubation for mechanical ventilation. RESULTS: Of 4228 cardiac surgery patients, 1593 met inclusion and exclusion criteria. An increased STOP-BANG score was associated with higher odds of postoperative atrial fibrillation (odds ratio [95% confidence interval {CI}], 1.16 [1.09–1.23] per-point increase in the STOP-BANG score; P
http://ift.tt/2GmGTLt
http://ift.tt/2GmGTLt
Use of Survey and Delphi Process to Understand Trauma Anesthesia Care Practices
BACKGROUND: Few trauma guidelines evaluate and recommend anesthesiology practices and there are no trauma anesthesia-specific guidelines. There is no information on how anesthesiologists perceive clinical practice patterns. Our objective was to understand the perceptions of anesthesiologists regarding trauma anesthesia practices. METHODS: A survey assessing anesthesia management of trauma patients was distributed to 21,491 anesthesiologists. A subset of 10 of these questions was subsequently reviewed by a trauma anesthesiology focus group through a 3-round web-based Delphi process. A question was deemed to have respondent consensus if the response with the highest percentage of agreement was unchanged between rounds 1 and 2. RESULTS: A total of 2360 anesthesiologists (11% response rate) responded to the survey. Results demonstrated that the practitioners' answers conflicted with existing surgical trauma society recommendations (ie, when to transfuse component therapy), and several areas that lacked any guidelines, resulted in response variability among anesthesiologists where not 1 answer achieved >75% agreement (ie, intubation technique of choice for patients with uncleared cervical spine). Thirteen trauma anesthesiologists participated in round 1 (response rate 100%), and 12 responded in rounds 2 and 3 (response rate 92%) of the Delphi process. None of the questions received 100% agreement. Consensus was achieved on 9 of 10 statements pertaining to trauma anesthesia care. Consensus was not reached on the intubating technique in a hemodynamically unstable patient with an uncleared cervical spine with deficits. Delphi participant opinion conflicted with existing guidelines on 2 statements: the use of cricoid pressure, and when to begin blood component therapy. CONCLUSIONS: There are several important areas of trauma anesthesia practice where guidelines do not exist and several where existing guidelines are not endorsed by the majority of practitioners who completed our survey. The lack of consensus on trauma anesthesia management and the variation in survey responses demonstrate a need to develop evidence-based trauma anesthesia guidelines. Accepted for publication December 20, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Catherine M. Kuza, MD, Department of Anesthesiology, Keck School of Medicine of USC, 1520 San Pablo St, Suite 3451, Los Angeles, CA 90033. Address e-mail to catherine.kuza@med.usc.edu. © 2018 International Anesthesia Research Society
http://ift.tt/2Fw9wJ0
http://ift.tt/2Fw9wJ0
The Effectiveness of Applying Soft Tissue Bonding Adhesive Composed of 2-Ethyl Cyanoacrylate to Epidural Catheter Fixations Using Film Dressings: An Open-Label, Randomized, Parallel-Group Comparative Study
BACKGROUND: Insufficient fixation of an epidural catheter may result in migration of the catheter and eventual catheter failure. However, the best fixation method remains to be established. Aron Alpha A (2-ethyl cyanoacrylate) adhesive is approved for clinical use and can be used for surgical adhesion to both skin and blood vessels. We hypothesized that the addition of Aron Alpha A adhesive to film dressing would result in consistent and dependable catheter fixation. METHODS: In this study, 58 women who were scheduled for cesarean delivery under spinal and epidural anesthesia were recruited. Patients were randomly assigned to a control or treatment group. In the control group, the catheter was fixed solely by film dressing. In the treatment group, a small amount of Aron Alpha A was applied at 2 sites along the catheter. The fixation area was then covered by film dressing. The catheter insertion length was recorded after fixation (T0), immediately postoperatively (T1), on postoperative day 1 (T2), and when the catheter was removed (T3). The change in insertion length from T0 to T3 between the 2 groups was the primary outcome measure. The incidence of catheter failure was also recorded. For all comparisons, P
http://ift.tt/2DlQ8IH
http://ift.tt/2DlQ8IH
The Anesthesiologist-Informatician: A Survey of Physicians Board-Certified in Both Anesthesiology and Clinical Informatics
All 36 physicians board-certified in both anesthesiology and clinical informatics as of January 1, 2016, were surveyed via e-mail, with 26 responding. Although most (25/26) generally expressed satisfaction with the clinical informatics boards, and view informatics expertise as important to anesthesiology, most (24/26) thought it unlikely or highly unlikely that substantial numbers of anesthesiology residents would pursue clinical informatics fellowships. Anesthesiologists wishing to qualify for the clinical informatics board examination under the practice pathway need to devote a substantive amount of worktime to informatics. There currently are options outside of formal fellowship training to acquire the knowledge to pass. Accepted for publication January 29, 2018. Funding: Departmental. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). This study was presented in part at the Annual Meeting of the American Society of Anesthesiologists, Chicago, IL, October 22–26, 2016 (Abstract 16A3714ASAHQ). Reprints will not be available from the authors. Address correspondence to Richard H. Epstein, MD, Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami, 1400 NW 12th Ave, Suite 3075, Miami, FL 33136. Address e-mail to repstein@med.Miami.edu. © 2018 International Anesthesia Research Society
http://ift.tt/2GntmDk
http://ift.tt/2GntmDk
Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial
BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55–4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26–3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89–6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability. Accepted for publication December 22, 2017. Funding: This study was supported by the Australian National Health and Medical Research Council; Australian and New Zealand College of Anaesthetists; Heart and Stroke Foundation of Quebec; Heart and Stroke Foundation of Ontario, Canada; and General Research Fund of the Research Grant Council, Hong Kong Special Administrative Region, China. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Trial Registration: ClinicalTrials.gov (NCT00430989). ANZCA Clinical Trials Network for the ENIGMA-II investigators is listed in Appendix. Reprints will not be available from the authors. Address correspondence to W. Scott Beattie, MD, PhD, FRCPC, Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada; and Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada, 200 Elizabeth St, Eaton 3-402, Toronto, Ontario M5G 2C4. Address e-mail to scott.beattie@uhn.ca. © 2018 International Anesthesia Research Society
http://ift.tt/2FEfFib
http://ift.tt/2FEfFib
Εγγραφή σε:
Αναρτήσεις (Atom)