A Chronic Glottic Foreign Body Diagnosed by Radiograph after 9 Months of Symptoms

A six-year-old girl presented to an emergency room after describing choking on a rubber band. She was in no distress and was discharged. Over the course of the next 9 months, she had numerous outpatient and emergency room visits due to intermittent stridor, difficulty breathing, and hoarseness. Eventually, dedicated airway films revealed a laryngeal foreign body. During rigid bronchoscopy, a two-centimeter rubber band was discovered in the larynx. It extended from the supraglottis, through the glottis, and into the subglottis. It was successfully removed. The patient was asymptomatic 24 hours later. This case highlights the appropriate evaluation and management of a child with stridor.

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MRI as an Alternative to Second Look Mastoid Surgery

Abstract

The main goal of surgery of cholesteatoma is eradication of the disease and revision surgery is indicated when a dry and safe ear has not been achieved. Residual cholesteatoma usually occurs at the sites that are difficult to reach with an operating microscope, such as posterior tympanum and anterior epitympanic recess. Computed tomography can be performed to delineate the extent of disease. High-resolution computed tomography scanning is important for planning for surgery and is indicated for all revision mastoid operations. Magnetic resonance imaging is superior to computed tomography in tissue characterization for diagnosis of recurrent cholesteatoma. To evaluate the cases of recurrent cholesteatoma comparing the intraoperative surgical findings with the preoperative MRI radiological findings and if the preoperative MRI can replace the second look surgery for cholesteatoma. This study was applied on 60 patients that have a recurrent cholesteatoma after previous mastoid surgery. A preoperative radiological evaluation was done by Magnetic resonance, surgical management was done by canal wall up or canal wall down mastoidectomy to exclude residual disease. Then, radiological, and surgical findings correlation was done. Diffusion-weighted MRI successfully detected 42 cases out of the 45 cases of surgically proved cholesteatoma, it has accuracy 95%, sensitivity 93.33%, specificity 100%, PPV 100% and NPV 83.33%. MRI is better than CT in tissue characterization for diagnosis of recurrent cholesteatoma, and can replace the unnecessary second look surgery of cholesteatoma

https://ift.tt/2KLPS9P

Efficacy of Tinnitus Retraining Therapy, A Modish Management of Tinnitus: Our Experience

Abstract

Tinnitus retraining therapy involves masking of tinnitus at sound perception level in combination with structured counselling sessions. To assess efficacy of Tinnitus retraining therapy (TRT) in Patients of Tinnitus with Sensori Neural Hearing loss. Prospective study was carried out on patients who presented with Tinnitus in ENT OPD from December 2015 to December 2016. Severity of tinnitus was documented using Tinnitus handicap inventory scale. Response to tinnitus is evaluated at the end of 3 months. In our study 57 patients in age group 21–78 years were selected and Tinnitus retraining therapy was administered. Most of patients had moderate (75.43%) perception of tinnitus before initiation of therapy. After completion of therapy tinnitus completely disappeared in 34 (59.65%) patients. Improvement in Tinnitus perception was observed in total of 49 (85.96%) patients. There was no improvement in Tinnitus perception in 8 (14.03%) patients. TRT aims in reducing the tinnitus perception by inducing habituation of tinnitus-induced reactions allowing patients to achieve control over their tinnitus, live a normal life, and participate in everyday activities.

https://ift.tt/2s2hAbA

Post-operative Sensorineural Hearing Loss After Middle Ear Surgery

Abstract

Chronic suppurative otitis media is managed by tympanomastoid surgery often requires mastoid drilling. Sometimes patients develop sensorineural hearing loss after middle ear surgery. Objective of the study was to compare pre and post operative bone conduction thresholds after middle ear surgeries. The study was conducted on 90 patients who had undergone middle ear surgeries, 30 patients of tympanoplasty (group I), modified intact canal wall mastoidectomy and tympanoplasty type-I (group II) and modified radical mastoidectomy (group III) each ware included. Demographic and clinical data were reviewed. Duration of surgery, ossicular and middle ear status and drilling time noted. Pre operative and post operative (after 3–4 months) bone conduction thresholds were compared statistically. A value of p < 0.05 was considered statistical significant. The average pre-operative hearing loss of study group was 43.78 ± 14.22 dB. Though postoperatively mean air conduction threshold improved to 36.07 ± 13.05 dB, six patients presented with deterioration of hearing. Mastoidectomy has been performed in all six. Post-operative worsening of bone conduction was seen in three patients (13.75–21.5 dB), one patient of group II and two patients of group III developed postoperative worsening of bone conduction thresholds. Significant hearing losses may occur after tympanomastoid surgery in few patients. While we are evaluating the results besides reporting average results such individual patient should be identified.

https://ift.tt/2IGhvAz

MRI as an Alternative to Second Look Mastoid Surgery

Abstract

The main goal of surgery of cholesteatoma is eradication of the disease and revision surgery is indicated when a dry and safe ear has not been achieved. Residual cholesteatoma usually occurs at the sites that are difficult to reach with an operating microscope, such as posterior tympanum and anterior epitympanic recess. Computed tomography can be performed to delineate the extent of disease. High-resolution computed tomography scanning is important for planning for surgery and is indicated for all revision mastoid operations. Magnetic resonance imaging is superior to computed tomography in tissue characterization for diagnosis of recurrent cholesteatoma. To evaluate the cases of recurrent cholesteatoma comparing the intraoperative surgical findings with the preoperative MRI radiological findings and if the preoperative MRI can replace the second look surgery for cholesteatoma. This study was applied on 60 patients that have a recurrent cholesteatoma after previous mastoid surgery. A preoperative radiological evaluation was done by Magnetic resonance, surgical management was done by canal wall up or canal wall down mastoidectomy to exclude residual disease. Then, radiological, and surgical findings correlation was done. Diffusion-weighted MRI successfully detected 42 cases out of the 45 cases of surgically proved cholesteatoma, it has accuracy 95%, sensitivity 93.33%, specificity 100%, PPV 100% and NPV 83.33%. MRI is better than CT in tissue characterization for diagnosis of recurrent cholesteatoma, and can replace the unnecessary second look surgery of cholesteatoma

https://ift.tt/2KLPS9P

Efficacy of Tinnitus Retraining Therapy, A Modish Management of Tinnitus: Our Experience

Abstract

Tinnitus retraining therapy involves masking of tinnitus at sound perception level in combination with structured counselling sessions. To assess efficacy of Tinnitus retraining therapy (TRT) in Patients of Tinnitus with Sensori Neural Hearing loss. Prospective study was carried out on patients who presented with Tinnitus in ENT OPD from December 2015 to December 2016. Severity of tinnitus was documented using Tinnitus handicap inventory scale. Response to tinnitus is evaluated at the end of 3 months. In our study 57 patients in age group 21–78 years were selected and Tinnitus retraining therapy was administered. Most of patients had moderate (75.43%) perception of tinnitus before initiation of therapy. After completion of therapy tinnitus completely disappeared in 34 (59.65%) patients. Improvement in Tinnitus perception was observed in total of 49 (85.96%) patients. There was no improvement in Tinnitus perception in 8 (14.03%) patients. TRT aims in reducing the tinnitus perception by inducing habituation of tinnitus-induced reactions allowing patients to achieve control over their tinnitus, live a normal life, and participate in everyday activities.

https://ift.tt/2s2hAbA

Post-operative Sensorineural Hearing Loss After Middle Ear Surgery

Abstract

Chronic suppurative otitis media is managed by tympanomastoid surgery often requires mastoid drilling. Sometimes patients develop sensorineural hearing loss after middle ear surgery. Objective of the study was to compare pre and post operative bone conduction thresholds after middle ear surgeries. The study was conducted on 90 patients who had undergone middle ear surgeries, 30 patients of tympanoplasty (group I), modified intact canal wall mastoidectomy and tympanoplasty type-I (group II) and modified radical mastoidectomy (group III) each ware included. Demographic and clinical data were reviewed. Duration of surgery, ossicular and middle ear status and drilling time noted. Pre operative and post operative (after 3–4 months) bone conduction thresholds were compared statistically. A value of p < 0.05 was considered statistical significant. The average pre-operative hearing loss of study group was 43.78 ± 14.22 dB. Though postoperatively mean air conduction threshold improved to 36.07 ± 13.05 dB, six patients presented with deterioration of hearing. Mastoidectomy has been performed in all six. Post-operative worsening of bone conduction was seen in three patients (13.75–21.5 dB), one patient of group II and two patients of group III developed postoperative worsening of bone conduction thresholds. Significant hearing losses may occur after tympanomastoid surgery in few patients. While we are evaluating the results besides reporting average results such individual patient should be identified.

https://ift.tt/2IGhvAz

Correction to: The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients with Cervical Cancer

Two corrections were made to the above publication following its original online publication on 4th May 2018.

https://ift.tt/2x6uzhk

Effect of photobiomodulation (670 nm) associated with vitamin A on the inflammatory phase of wound healing

Abstract

Wound healing is a complex biological process with specific phases. Photobiomodulation (PBM) decreases the inflammatory infiltrate, stimulating fibroblast proliferation and angiogenesis, and therefore, is indicated for wound healing. Vitamin A is used to reverse the inhibitory effects on wound healing and accelerate the healthy granulation tissue. The study aimed to evaluate the effect of topical vitamin A and PBM (GaAlAs) in inflammatory phase of cutaneous wounds. Forty Wistar male rats were separated into four groups: (1) control (CG); (2) laser group (LG) GaAlAs, 670 nm, 30 mW, energy per point of 0.9 J, radiating by 1 point in 30 s; (3) vitamin A group (VitAG); and (4) laser group plus vitamin A (LG + VitAG). Wounds were surgically made by a punch biopsy with 10 mm of diameter on the back of the animals and all treatments were started according to the experiment. The treatments were administered for four consecutive days and biopsy was performed on day 4. We performed both H&E and immunohistochemistry analysis. The results were compared between groups by one-way analysis of variance ANOVA test with post hoc Tukey (p < 0.05). Inflammatory infiltrate increased significantly in LG compared to CG and VitAG (p < 0.05). Regarding angiogenesis, VEGF expression was increased significantly in LG and LG + VitAG groups, p < 0.01. The results indicate that proposed treatments were effective on the healing process improved by LG and LG + VitAG. We show that laser plus vitamin A enhances healing by reducing the wound area and may have potential application for clinical management of cutaneous wounds.

https://ift.tt/2J3oDKY

Outcomes of Adoptive Cell Transfer With Tumor-infiltrating Lymphocytes for Metastatic Melanoma Patients With and Without Brain Metastases

Brain metastases cause significant morbidity and mortality in patients with metastatic melanoma. Although adoptive cell therapy (ACT) with tumor-infiltrating lymphocytes (TIL) can achieve complete and durable remission of advanced cutaneous melanoma, the efficacy of this therapy for brain metastases is unclear. Records of patients with M1c melanoma treated with ACT using TIL, including patients with treated and untreated brain metastases, were analyzed. Treatment consisted of preparative chemotherapy, autologous TIL infusion, and high-dose interleukin-2. Treatment outcomes, sites of initial tumor progression, and overall survival were analyzed. Among 144 total patients, 15 patients with treated and 18 patients with untreated brain metastases were identified. Intracranial objective responses (OR) occurred in 28% patients with untreated brain metastases. The systemic OR rates for patients with M1c disease without identified brain disease, treated brain disease, and untreated brain disease, and were 49%, 33% and 33%, respectively, of which 59%, 20% and 16% were durable at last follow-up. The site of untreated brain disease was the most likely site of initial tumor progression (61%) in patients with untreated brain metastases. Overall, we found that ACT with TIL can eliminate small melanoma brain metastases. However, following TIL therapy these patients frequently progress in the brain at a site of untreated brain disease. Patients with treated or untreated brain disease are less likely to achieve durable systemic ORs following TIL therapy compared with M1c disease and no history of brain disease. Melanoma brain metastases likely require local therapy despite the systemic effect of ACT.

https://ift.tt/2IFvczA

IL-21 Increases the Reactivity of Allogeneic Human Vγ9Vδ2 T Cells Against Primary Glioblastoma Tumors

Glioblastoma multiforme (GBM) remains the most frequent and deadliest primary brain tumor in adults despite aggressive treatments, because of the persistence of infiltrative and resistant tumor cells. Nonalloreactive human Vγ9Vδ2 T lymphocytes, the major peripheral γδ T-cell subset in adults, represent attractive effectors for designing immunotherapeutic strategies to track and eliminate brain tumor cells, with limited side effects. We analyzed the effects of ex vivo sensitizations of Vγ9Vδ2 T cells by IL-21, a modulating cytokine, on their cytolytic reactivity. We first showed that primary human GBM-1 cells were naturally eliminated by allogeneic Vγ9Vδ2 T lymphocytes, through a perforin/granzyme-mediated cytotoxicity. IL-21 increased both intracellular granzyme B levels and cytotoxicity of allogeneic human Vγ9Vδ2 T lymphocytes in vitro. Importantly, IL-21-enhanced cytotoxicity was rapid, which supports the development of sensitization(s) of γδ T lymphocytes before adoptive transfer, a process that avoids any deleterious effect associated with direct administrations of IL-21. Finally, we showed, for the first time, that IL-21-sensitized allogeneic Vγ9Vδ2 T cells significantly eliminated GBM tumor cells that developed in the brain after orthotopic administrations in vivo. Altogether our observations pave the way for novel efficient stereotaxic immunotherapies in GBM patients by using IL-21-sensitized allogeneic human Vγ9Vδ2 T cells.

https://ift.tt/2II6naE

Blockade of BAFF Receptor BR3 on T Cells Enhances Their Activation and Cytotoxicity

The BAFF receptor BR3 plays key roles in B-cell activation, maturation, and survival whereas the function of BR3 on T lymphocytes is less well characterized. Previous reports have demonstrated that BR3 costimulates human T-cell activation in vitro in the presence of high nonphysiological levels of plate-bound BAFF. Here, relying on the soluble and membrane-bound BAFF expressed by T cells themselves, we investigated the function of BR3 on activated primary CD4+ and CD8+ T lymphocytes using a BR3-specific neutralization antibody and shRNA gene down-modulation. Interestingly, the anti-BR3 blocking antibody resulted in significant augmentation of CD25 and IFN-γ expression by both subsets, as did shRNA-mediated down-modulation of BR3. In addition, granzyme B expression was substantially elevated in anti-BR3–treated and BR3-silenced T cells. Anti-BR3 blockade increased the expression of CD25 on cytolytic CRTAM+ T cells. Importantly, anti-BR3 significantly enhanced redirected killing of P-815 cells by both CD4+ and CD8+ cytotoxic T cells [cytotoxic T lymphocytes (CTLs)]. Furthermore, anti-BR3–augmented CD4+ T-cell–mediated killing of class II+ melanoma cell line A375 and cervical cancer cell line HeLa in vitro, increasing the level of granzyme B activity as measured by PARP-1 cleavage and active caspase 3. Together, our data indicate that BR3 neutralization increases the activation and cytolytic function of CD4+ and CD8+ cytotoxic T lymphocytes. Our findings provide a novel strategy for ex vivo T-cell activation applicable to T-cell immunotherapy platforms such as TIL or CAR-T cell therapeutics.

https://ift.tt/2IFVkdU

Diabetes and Blood Glucose Disorders Under Anti-PD1

Acute type 1 diabetes (AD1) is a rare but definitive immune-related adverse event associated with anti-PD1. Most of the reported cases are close to what has been described as "fulminant type 1 diabetes." We sought to determine whether anti-PD1 could impair glycoregulation and whether occurrence of AD1 could be anticipated by prior glycemic changes. Fasting glycemia collected before, under, and after treatment in melanoma patients treated with anti-PD1 over a period of 36 months were retrospectively analyzed. Glycemic trend analyses were performed using linear regression analysis. In total, 1470 glucose values were monitored in 163 patients treated for a mean duration of 5.96 months. Three patients developed an AD1 (1, 84%). Two other cases were observed in the same period in a still-blinded trial of anti-PD1 versus ipilimumab. All cases of AD1 occurred in patients with a normal pretreatment glycemia, and there was no detectable drift of glycemia before ketoacidosis onset. In 4 of 5 cases of AD1, the HLA subgroups were DRB01* 03 or 04, known to increase type 1 diabetes risk in the general population. In the 28 patients with preexisting type 2 diabetes, there was a slight trend for glycemia increase with anti-PD1 infusions (0.05 mmol/L/infusion P=0.004). In the 132 patients with normal pretreatment glycemia, there was a slight trend for a decrease of glycemia with anti-PD1 infusions (−0.012/mmol/L/infusion P=0.026). These data suggest that the monitoring of glycemia under anti-PD1 cannot help to anticipate AD1, and there is no general tendency to glycemic disorder. HLA genotyping before treatment may help to focus surveillance in patients with the HLA DRB1*03/04 group.

https://ift.tt/2LllpAB

Characterization of Postinfusion Phenotypic Differences in Fresh Versus Cryopreserved TCR Engineered Adoptive Cell Therapy Products

Adoptive cell therapy (ACT) consisting of genetically engineered T cells expressing tumor antigen-specific T-cell receptors displays robust initial antitumor activity, followed by loss of T-cell activity/persistence and frequent disease relapse. We characterized baseline and longitudinal T-cell phenotype variations resulting from different manufacturing and administration protocols in patients who received ACT. Patients with melanoma who enrolled in the F5-MART-1 clinical trial (NCT00910650) received infusions of MART-1 T-cell receptors transgenic T cells with MART-1 peptide-pulsed dendritic cell vaccination. Patients were divided into cohorts based on several manufacturing changes in the generation and administration of the transgenic T cells: decreasing ex vivo stimulation/expansion time, increased cell dose, and receiving fresh instead of cryopreserved cells. T-cell phenotypes were analyzed by flow cytometry at baseline and longitudinally in peripheral blood. Transgenic T cells with shorter ex vivo culture/expansion periods displayed significantly increased expression of markers associated with less differentiated naive/memory populations, as well as significantly decreased expression of the inhibitory receptor programmed death 1 (PD1). Patients receiving fresh infusions of transgenic cells demonstrated expansion of central memory T cells and delayed acquisition of PD1 expression compared with patients who received cryopreserved products. Freshly infused transgenic T cells showed persistence and expansion of naive and memory T-cell populations and delayed acquisition of PD1 expression, which correlated with this cohort's superior persistence of transgenic cells and response to dendritic cell vaccines. These results may be useful in designing future ACT protocols.

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Tonsillar cytokine expression between patients with tonsillar hypertrophy and recurrent tonsillitis

Tonsils provide an innovative in vivo model for investigating immune response to infections and allergens. However, data are scarce on the differences in tonsillar virus infections and immune responses between...

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A Survey Analysis on the Management of Moderately Dysplastic Nevi Among Academic Dermatologists Across the United States

https://ift.tt/2x1vRKk

The Potential of Narrow Band UVB to Induce Sustained Durable Complete Remission off-Therapy in Stage I Mycosis Fungoides

Narrow Band UVB (NB UVB) produces high rates of complete response (CR) for patients with stage I mycosis fungoides (MF). Data on long-term remission off therapy are lacking. NB UVB induced >5 years disease and therapy free survival in ∼ 60% of CR patients. NB UVB can be considered a disease modifying and potentially curative therapy for patients with stage I MF..

https://ift.tt/2ID2sf2

Financial burden of emergency department visits for atopic dermatitis in the United States

Patients with atopic dermatitis have multiple risk factors for utilizing the emergency department.; The prevalence and cost of emergency department visits for atopic dermatitis was high and increased between 2006 and 2012.; Interventions are needed to decrease ED visits for AD.

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Atopic dermatitis is associated with osteoporosis and osteopenia in older adults

https://ift.tt/2Lk1wtI

Head and Neck Cancer and the Elderly Patient

Management of head and neck cancer in the elderly patient is particularly challenging given the high morbidity associated with treatment. Surgery, radiotherapy, and chemotherapy have all been demonstrated as effective in older patients; however, older patients are more susceptible to treatment-induced toxicity, which can limit the survival benefits of certain interventions. This susceptibility is better associated with the presence of multiple comorbidities and decreasing functional status than with age alone. Screening tools allow for risk stratification, treatment deintensification, and even treatment avoidance in patients who are deemed at high-risk of being harmed by standard therapy.

https://ift.tt/2IDeYXT

Subjective perception of paraesthesia of the lower lip after bilateral sagittal split osteotomy at a district general hospital

Our aim was to assess patients' perception of paraesthesia of the lower lip after bilateral sagittal split osteotomy (BSSO) at a district general hospital. Patients who had BSSO between August 2013 and August 2014 (n=46) were asked to score their perception of numbness between 0–10 (0=normal sensation. 10=complete loss of sensation/total numbness) one day postoperatively and then weekly for seven weeks, and at three months, 6 months, and one year. Data was collected on score sheets and by regular contact by telephone.

https://ift.tt/2IZkZle

Sensitivity and specificity of sentinel lymph node biopsy in patients with oral squamous cell carcinomas using Indocyanine Green Fluorescence Imaging

The purpose of this clinical study was to evaluate the sensitivity and specificity of cervical sentinel lymph node biopsy after mapping with indocyanine green fluorescence (ICG) for imaging early-stage oral cancer.

https://ift.tt/2GHKuSD

A systematic review of different substance injection and dry needling for treatment of temporomandibular myofascial pain

Temporomandibular myofascial pain presents a major challenge in the diagnosis of temporomandibular disorders (TMD). Due to the characteristics of this condition, intramuscular injection procedures are often needed for adequate control of symptoms and treatment. Thus, the aim of this systematic review was to evaluate the effectiveness of dry needling and injection with different substances in temporomandibular myofascial pain. Electronic databases PubMed, EMBASE, CENTRAL/Cochrane, Lilacs, Scopus, Web of Science and CAPES Catalog of Dissertations and Theses were searched for randomized clinical trials until January 2018.

https://ift.tt/2x9PDUm

Extreme Diets: Fads and Facts

Radical diets have exploded in popularity since the 19th century. We dig into notable examples -- from Fletcherism to liquid diets to Beverly Hills -- reviewing their history, claims, and impact.
Medscape Internal Medicine

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Consumer Reports Ranks Top Sunscreens for 2018

Despite concerns about chemical sunscreens, they protect you better from the sun than "natural" sunscreens, Consumer Reports' latest sunscreen report finds.
WebMD Health News

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A Pilot Study of a Novel Automated Somatosensory Evoked Potential (SSEP) Monitoring Device for Detection and Prevention of Intraoperative Peripheral Nerve Injury in Total Shoulder Arthroplasty Surgery

Introduction: Peripheral nerve injury is a potentially devastating complication after total shoulder arthroplasty (TSA) surgery. This pilot study aimed to assess the feasibility of using an automated somatosensory evoked potential (SSEP) device to provide a timely alert/intervention to minimize intraoperative nerve insults during TSA surgery. Methods: A prospective, single-arm, observational study was conducted in a single university hospital. The attending anesthesiologist monitored the study participants using the EPAD automated SSEP device and an intervention was made if there was an alert during TSA surgery. The median, radial, and ulnar nerve SSEP on the operative arm, as well as the median nerve SSEP of the nonoperative arm were monitored for each patient. All patients were evaluated for postoperative neurological deficits 6 weeks postoperatively. Results: In total, 21 patients were consented and were successfully monitored. In total, 4 (19%) patients developed intraoperative abnormal SSEP signal changes in the operative arm, in which 3 were reversible and 1 was irreversible till the end of surgery. Median and radial nerves were mostly involved (3/4 patients). The mean cumulative duration of nerve insult (abnormal SSEP) was 21.7±26.2 minutes. Univariate analysis did not identify predictor of intraoperative nerve insults. No patients demonstrated postoperative peripheral neuropathy at 6 weeks. Conclusions: A high incidence (19%) of intraoperative nerve insult was observed in this study demonstrating the feasibility of using an automated SSEP device to provide a timely alert and enable an intervention in order to minimize peripheral nerve injury during TSA. Further randomized studies are warranted. The study (IRB #107438) was approved by Lawson Health Research Institute, Western University. Clinical trial registration #: NCT02237599 (www.clinicaltrials.gov). J.C. is the archival author. J.M.M. is member of Scientific Advisory Board of SafeOp Surgical, Hunt Valley, MD. J.C. and D.D. has no conflicts of interest to disclose. Address correspondence to: Jason Chui, MBChB, FANZCA, C3-106, University Hospital, 339 Windermere Road, London, ON, Canada N6A 5A5 (e-mail: Jason.chui@lhsc.on.ca). Received January 31, 2018 Accepted March 29, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Application of Standardised Yoga Protocols as the Basis of Physiotherapy Recommendation in Treatment of Sleep Apneas: Moving Beyond Pranayamas

Abstract

Yoga is an ancient Indian practice of mental and physical exercises (syn: asanas), postures (syn: mudras), movements and breathing techniques which sustain healthy living of the body and the mind. It incorporates various exercises of breathing, oropharyngeal structures and facial expressions, the physiology and effect of which are comparable to international physiotherapy recommendations in treatment of obstructive sleep apnea (OSA) i.e. to preserve upper airway patency by maintaining airway dilator muscle tone. Preliminary results show that yoga can be an effective and constructive alternative to physiotherapy for sleep apnea and snoring patients. To compare the physiotherapy recommendations in snoring patients with various yoga exercises postures. To determine the efficacy of yoga in treatment of sleep apnea. To formulate a standardized yoga protocol for universal usage in sleep apnea. We studied the available literature on physiotherapy recommendations for OSA and yoga asanas involving the nasal, oropharynx and facial structures and perceived a noteworthy similarity in physiological basis of both. A set of these yogasanas were put together and patients presenting with snoring and diagnosed with mild to moderate sleep apnea were presented and encouraged to perform the standardized set of yoga exercises for a period of 3 months. A total of 23 patients were recommended yoga protocols as initial form of treatment in snoring and mild to moderate sleep apnea. Clinical and statistically significant improvement gauzed by recommended score chart was discerned in majority of subjects. The results were comparable to the efficacy of existing physiotherapy regimen published in international literature. The benefits of yoga in sleep disorders go beyond the scope of measured outcomes. Standardizing the protocols for yoga in treatment for snoring and sleep apnea is the need of the hour. Further studies on efficacy of yoga need to be performed to understand its full realm of potential.

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Under the Knife: The History of Surgery in 28 Remarkable Operations

No abstract available

https://ift.tt/2KNX0mh

Identifying Barriers to Implementation of the National Partnership for Maternal Safety Obstetric Hemorrhage Bundle at a Tertiary Center: Utilization of the Delphi Method

BACKGROUND: In 2015, the National Partnership for Maternal Safety (NPMS) developed an obstetric hemorrhage consensus bundle to provide birthing facilities in the United States with consistent, validated practice guidelines for postpartum hemorrhage management. The process of implementing each bundle element at a large tertiary labor and delivery unit has not been described; we sought to identify practice deficiencies and perceived barriers to bundle implementation among multidisciplinary providers. METHODS: We conducted a prospective, cross-sectional, consensus-building study based on the Delphi method. A multidisciplinary expert panel comprised of anesthesiologists, obstetricians, nurses, and surgical technicians was assembled and participated in 4 sequential questionnaires. The first round identified bundle elements that experts determined as not currently adequate and perceived barriers to implementation. The second round established prioritization of elements within each professional group; and the third round ranked the elements with at least 60% agreement on feasibility of implementation and positive impact on patient care. The last round revealed responses across all 4 professional groups to derive a final consensus. Descriptive statistics were performed. RESULTS: A total of 38 experts completed the study (11 anesthesiologists, 11 obstetricians, 10 nurses, and 6 surgical technicians). While all 13 (100%) NPMS obstetric bundle elements were described as deficient in our labor and delivery unit by a provider in at least 1 discipline, consensus among at least 3 of the 4 disciplines was achieved for 6 element deficiencies. Barriers to implementation were determined. The initiatives that achieved consensus as possessing high patient impact and implementation feasibility were protocol-driven management, unit-based simulation drills, blood loss quantification, and team huddles and debriefings. CONCLUSIONS: The NPMS obstetric hemorrhage bundle was created to help guide practice and systems improvement for US birthing facilities. The Delphi method enabled identification of deficient elements and perceived barriers to element implementation, as well as group consensus on elements with highest patient impact and feasibility. Multidisciplinary group consensus can identify deficiencies and promote tangible, quality improvements in a large, tertiary-care labor and delivery unit. Institutions may utilize our described technique to guide implementation of future care bundles. Accepted for publication April 12, 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 (https://ift.tt/KegmMq). Institutional Research Ethics Board: Partners HealthCare Institutional Review Board, Partners Human Research Committee, 116 Huntington Ave, Suite 1002, Boston, MA 02116. Clinical trial number and registry URL: NCT03018119 https://ift.tt/2IIP98H. Reprints will not be available from the authors. Address correspondence to Annemaria De Tina, MD, FRCPC, Department of Anesthesiology, McMaster University, Third Floor, 237 Barton St E, Hamilton, ON L8L 2X2, Canada. Address e-mail to detinaa@mcmaster.ca. © 2018 International Anesthesia Research Society

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Organ Donation After Circulatory Death: Ethical Issues and International Practices

Donation after circulatory death (DCD) is an increasingly utilized practice that can contribute to reducing the difference between the supply of organs and the demand for organs for transplantation. As the number of transplanted organs from DCD donors continues to increase, there is an essential need to address the ethical aspects of DCD in institutional DCD protocols and clinical practice. Ethical issues of respecting the end-of-life wishes of a potential donor, respecting a recipient's wishes, and addressing potential conflicts of interest are important considerations in developing policies and procedures for DCD programs. Although there may be diversity among DCD programs in Europe, Australia, Israel, China, the United States, and Canada, addressing ethical considerations in these DCD programs is essential to respect donors and recipients during the altruistic and generous act of organ donation. Accepted for publication April 12, 2018. Funding: None. The author declares no conflicts of interest. Reprints will not be available from the author. Address correspondence to Barbara G. Jericho, MD, FASA, Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, 1740 W Taylor St, Suite 3200, M\C 515, Chicago, IL 60612. Address e-mail to jericho@uic.edu. © 2018 International Anesthesia Research Society

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“Modified Dynamic Needle Tip Positioning” Short-Axis, Out-of-Plane, Ultrasound-Guided Radial Artery Cannulation in Neonates: A Randomized Controlled Trial

BACKGROUND: Radial artery cannulation is extremely challenging in neonatal patients. Herein, we compared the success rate of the modified dynamic needle tip positioning short-axis, out-of-plane, ultrasound-guided technique with that of the traditional palpation technique in neonatal radial artery cannulation. METHODS: Sixty term neonates undergoing major abdominal surgery were randomized into the ultrasound or palpation group via the sealed-envelope method. The ultrasound group underwent radial artery cannulation using an ultrasonic apparatus, while traditional palpation of arterial pulsation was used in the palpation group. The arterial diameter and depth were measured on ultrasound before the puncture. We recorded age, weight, sex, and other background characteristics. The primary outcomes included the first-attempt, total success rates, and the total puncture procedure duration. Secondary outcomes included the incidence of complications (hematoma and thrombosis). Data were compared between the 2 groups. RESULTS: Sixty term neonates were enrolled in the study. The success rates of the first attempt in the ultrasound and palpation groups were 40% (n = 30) and 10% (n = 30), respectively (P = .007; relative risk, 4.0; 95% confidence interval, 1.3–12.8). The total success rate was 96.7% in the ultrasound group and 60.0% in the palpation group (P = .001; relative risk, 1.61; 95% confidence interval, 1.19–2.17). The average time to accomplish radial artery cannulation in the ultrasound and palpation groups was 91.4 ± 55.4 and 284.7 ± 153.6 seconds, respectively (P

https://ift.tt/2KLu0vb

The Effect of Dexmedetomidine on Propofol Requirements During Anesthesia Administered by Bispectral Index-Guided Closed-Loop Anesthesia Delivery System: A Randomized Controlled Study

BACKGROUND: Dexmedetomidine, a selective α2-adrenergic agonist currently approved for continuous intensive care unit sedation, is being widely evaluated for its role as a potential anesthetic. The closed-loop anesthesia delivery system (CLADS) is a method to automatically administer propofol total intravenous anesthesia using bi-spectral index (BIS) feedback and attain general anesthesia (GA) steady state with greater consistency. This study assessed whether dexmedetomidine is effective in further lowering the propofol requirements for total intravenous anesthesia facilitated by CLADS. METHODS: After ethics committee approval and written informed consent, 80 patients undergoing elective major laparoscopic/robotic surgery were randomly allocated to receive GA with propofol CLADS with or without the addition of dexmedetomidine. Quantitative reduction of propofol and quality of depth-of-anesthesia (primary objectives), intraoperative hemodynamics, incidence of postoperative adverse events (sedation, analgesia, nausea, and vomiting), and intraoperative awareness recall (secondary objectives) were analyzed. RESULTS: There was a statistically significant lowering of propofol requirement (by 15%) in the dexmedetomidine group for induction of anesthesia (dexmedetomidine group: mean ± standard deviation 0.91 ± 0.26 mg/kg; nondexmedetomidine group: 1.07 ± 0.23 mg/kg, mean difference: 0.163, 95% CI, 0.04–0.28; P = .01) and maintenance of GA (dexmedetomidine group: 3.25 ± 0.97 mg/kg/h; nondexmedetomidine group: 4.57 ± 1.21 mg/kg/h, mean difference: 1.32, 95% CI, 0.78–1.85; P

https://ift.tt/2rZKPvI

Interviewing in Social Science Research: A Relational Approach

No abstract available

https://ift.tt/2KO2GwG

Perianesthetic and Anesthesia-Related Mortality in a Southeastern United States Population: A Longitudinal Review of a Prospectively Collected Quality Assurance Data Base

BACKGROUND: Perianesthetic mortality (death occurring within 48 hours of an anesthetic) continues to vary widely depending on the study population examined. The authors study in a private practice physician group that covers multiple anesthetizing locations in the Southeastern United States. This group has in place a robust quality assurance (QA) database to follow all patients undergoing anesthesia. With this study, we estimate the incidence of anesthesia-related and perianesthetic mortality in this QA database. METHODS: Following institutional review board approval, data from 2011 to 2016 were obtained from the QA database of a large, community-based anesthesiology group practice. The physician practice covers 233 anesthetizing locations across 20 facilities in 2 US states. All detected cases of perianesthetic death were extracted from the database and compared to the patients' electronic medical record. These cases were further examined by a committee of 3 anesthesiologists to determine whether the death was anesthesia related (a perioperative death solely attributable to either the anesthesia provider or anesthetic technique), anesthetic contributory (a perioperative death in which anesthesia role could not be entirely excluded), or not due to anesthesia. RESULTS: A total of 785,467 anesthesia procedures were examined from the study period. A total of 592 cases of perianesthetic deaths were detected, giving an overall death rate of 75.37 in 100,000 cases (95% CI, 69.5–81.7). Mortality judged to be anesthesia related was found in 4 cases, giving a mortality rate of 0.509 in 100,000 (95% CI, 0.198–1.31). Mortality judged to be anesthesia contributory were found in 18 cases, giving a mortality of 2.29 in 100,000 patients (95% CI, 1.45–3.7). A total of 570 cases were judged to be nonanesthesia related, giving an incidence of 72.6 per 100,000 anesthetics (95% CI, 69.3–75.7). CONCLUSIONS: In a large, comprehensive database representing the full range of anesthesia practices and locations in the Southeastern United States, the rate of perianesthestic death was 0.509 in 100,000 (95% CI, 0.198–1.31). Future in-depth analysis of the epidemiology of perianesthetic deaths will be reported in later studies. Accepted for publication April 20, 2018. Funding: Departmental. The authors declare no conflicts of interest. This study was presented in part at the International Anesthesia Research Society Annual Meeting, Washington, DC, May 6, 2017. Reprints will not be available from the authors. Address correspondence to Richard Pollard, MD, FASA, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Address e-mail to rpollard@bidmc.harvard.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2s0Xmiv

Does Respiratory Variation in Inferior Vena Cava Diameter Predict Fluid Responsiveness in Mechanically Ventilated Patients? A Systematic Review and Meta-analysis

BACKGROUND: We performed a systematic review and meta-analysis of studies investigating the diagnostic accuracy of respiratory variation in inferior vena cava diameter (ΔIVC) for predicting fluid responsiveness in patients receiving mechanical ventilation. METHODS: MEDLINE, EMBASE, the Cochrane Library, and Web of Science were screened from inception to February 2017. The meta-analysis assessed the pooled sensitivity, specificity, diagnostic odds ratio, and area under the receiver operating characteristic curve. In addition, heterogeneity and subgroup analyses were performed. RESULTS: A total of 12 studies involving 753 patients were included. Significant heterogeneity existed among the studies, and meta-regression indicated that ventilator settings were the main sources of heterogeneity. Subgroup analysis indicated that ΔIVC exhibited better diagnostic performance in the group of patients ventilated with tidal volume (TV) ≥8 mL/kg and positive end-expiratory pressure (PEEP) ≤5 cm H2O than in the group ventilated with TV 5 cm H2O, as demonstrated by higher sensitivity (0.80 vs 0.66; P = .02), specificity (0.94 vs 0.68; P 5 cm H2O, this threshold was 14% ± 5%. CONCLUSIONS: ΔIVC shows limited ability for predicting fluid responsiveness in distinct ventilator settings. In patients with TV ≥8 mL/kg and PEEP ≤5 cm H2O, ΔIVC was an accurate predictor of fluid responsiveness, while in patients with TV 5 cm H2O, ΔIVC was a poor predictor. Thus, intensivists must be cautious when using ΔIVC. Accepted for publication April 16, 2018. Funding: This study was supported by the grants from Sun Yat-Sen University Clinical Research 5010 Program (2007015). 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 (https://ift.tt/KegmMq). X. Si and H. Xu contributed equally and share first authorship. Reprints will not be available from the authors. Address correspondence to Xiangdong Guan, PhD, MD, Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan No. 2 Rd, Guangzhou, People's Republic of China. Address e-mail to guanxiangdong1962@163.com. © 2018 International Anesthesia Research Society

https://ift.tt/2ICOpC6

Halving the Volume of AnaConDa: Evaluation of a New Small-Volume Anesthetic Reflector in a Test Lung Model

BACKGROUND: Volatile anesthetics are increasingly used for sedation in intensive care units. The most common administration system is AnaConDa-100 mL (ACD-100; Sedana Medical, Uppsala, Sweden), which reflects volatile anesthetics in open ventilation circuits. AnaConDa-50 mL (ACD-50) is a new device with half the volumetric dead space. Carbon dioxide (CO2) can be retained with both devices. We therefore compared the CO2 elimination and isoflurane reflection efficiency of both devices. METHODS: A test lung constantly insufflated with CO2 was ventilated with a tidal volume of 500 mL at 10 breaths/min. End-tidal CO2 (EtCO2) partial pressure was measured using 3 different devices: a heat-and-moisture exchanger (HME, 35 mL), ACD-100, and ACD-50 under 4 different experimental conditions: ambient temperature pressure (ATP), body temperature pressure saturated (BTPS) conditions, BTPS with 0.4 Vol% isoflurane (ISO-0.4), and BTPS with 1.2 Vol% isoflurane. Fifty breaths were recorded at 3 time points (n = 150) for each device and each condition. To determine device dead space, we adjusted the tidal volume to maintain normocapnia (n = 3), for each device. Thereafter, we determined reflection efficiency by measuring isoflurane concentrations at infusion rates varying from 0.5 to 20 mL/h (n = 3), for each device. RESULTS: EtCO2 was consistently greater with ACD-100 than with ACD-50 and HME (ISO-0.4, mean ± standard deviations: ACD-100, 52.4 ± 0.8; ACD-50, 44.4 ± 0.8; HME, 40.1 ± 0.4 mm Hg; differences of means of EtCO2 [respective 95% confidence intervals]: ACD-100 − ACD-50, 8.0 [7.9–8.1] mm Hg, P

https://ift.tt/2IFlOft

Perioperative Peripheral Nerve Injury After General Anesthesia: A Qualitative Systematic Review

Perioperative peripheral nerve injury (PNI) is a well-recognized complication of general anesthesia that continues to result in patient disability and malpractice claims. However, the multifactorial etiology of PNI is often not appreciated in malpractice claims given that most PNI is alleged to be due to errors in patient positioning. New advances in monitoring may aid anesthesiologists in the early detection of PNI. This article reviews recent studies of perioperative PNI after general anesthesia and discusses the epidemiology and potential mechanisms of injury and preventive measures. We performed a systematic literature search, reviewed the available evidence, and identified areas for further investigation. We also reviewed perioperative PNI in the Anesthesia Closed Claims Project database for adverse events from 1990 to 2013. The incidence of perioperative PNI after general anesthesia varies considerably depending on the type of surgical procedure, the age and risk factors of the patient population, and whether the detection was made retrospectively or prospectively. Taken together, studies suggest that the incidence in a general population of surgical patients undergoing all types of procedures is

https://ift.tt/2rZci0s

Anesthesia and Neurotoxicity

No abstract available

https://ift.tt/2KI4SFN

Beneficial Effects of Antioxidant Furfuryl Palmitate in Non-pharmacologic Treatments (Prescription Emollient Devices, PEDs) for Atopic Dermatitis and Related Skin Disorders

Abstract

Introduction

Atopic dermatitis (AD) is a common chronic inflammatory skin disease; it requires long-term treatments focused on symptomatic relief. Current first-line treatments include moisturizers and topical corticosteroids. Recently, topical antioxidants have been added to moisturizer formulations to alleviate mild-to-moderate AD. The aim of this review was to evaluate the efficacy and tolerability of furfuryl palmitate, a new antioxidant molecule, and furfuryl derivatives.

Methods

A PubMed/Google Scholar search was conducted using the term "furfuryl palmitate" (and its derivatives, including AR-GG27^®) combined with "skin," "atopic dermatitis," and "atopic eczema." Existing trials including adult and pediatric patients with AD and related skin disorders were evaluated. The treatment indication(s), number of subjects, treatment protocols, results, and side effects were recorded.

Results

Effective treatments with furfuryl palmitate and furfuryl derivatives have been reported for the following conditions: atopic, seborrheic, irritative, and allergic contact dermatitis, eczema, xerosis, and cutaneous inflammatory pathologies. All the products tested showed a good tolerability profile.

Conclusion

Studies performed up to now showed that furfuryl derivatives can efficaciously contrast signs and symptoms of mild-to-moderate AD, erythema, and widespread diffuse cutaneous pathologies in both adult and pediatric patients, representing a real alternative to steroids and a valid aid in the treatment of skin disorders, with no side effects and without requiring precautions in use.

Funding

Relife-Menarini Industrie Farmaceutiche.

Plain Language Summary

Plain language summary available for this article.

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Biomarkers for early identification of recurrences in HPV-driven oropharyngeal cancer

Publication date: July 2018
Source:Oral Oncology, Volume 82
Author(s): Haitham Mirghani, Krystle A. Lang Kuhs, Tim Waterboer
One of the major concerns in oncology lies in the ability to detect recurrences at their earliest stage to increase the likelihood of cure following second line, or salvage, therapy. Although human papillomavirus (HPV)-driven oropharyngeal cancers have a good prognosis, 20–25% of patients will recur within 5 years of treatment and a significant portion will die from their disease. In recent years, great effort has been put toward evaluating the potential clinical utility of HPV-related biomarkers for early diagnosis of recurrent disease. Indeed, following completion of treatment, detection of HPV-DNA in oral rinses or blood and serologic assays against HPV oncoproteins could be helpful to track residual disease or recurrence. Several recent studies have reported promising findings, thus potentially paving the way for the use of biomarkers in the management of HPV-OPC.In this review, we evaluate and discuss the current knowledge on this topic and provide some directions for future research.



https://ift.tt/2keBU50

An assessment of patient burdens from head and neck cancer survivorship care

Publication date: July 2018
Source:Oral Oncology, Volume 82
Author(s): Sean T. Massa, Rebecca L. Rohde, Carole Mckinstry, Malia Gresham, Nosayaba Osazuwa-Peters, Gregory M. Ward, Ronald J Walker
ObjectivesTo assess head and neck cancer (HNC) patients' perspectives on the value and burdens of routine cancer follow-up care.Materials and methodsData was obtained from HNC patients (n = 100) at an urban, tertiary head and neck cancer clinic. A novel 15-question survey tool evaluated the logistic, financial, and psychosocial burdens associated with clinic visits. The clinical characteristics and survey responses of demographic groups were analyzed with comparative statistics. Linear regression modeling was utilized to identify predictors of overall stress.ResultsA majority of study participants were male (74%), white (83%), and had histories of tobacco (77%) and alcohol (77%) use. Most participants were satisfied with the frequency of their office visits (75%). Patients with laryngeal cancer, advanced stage disease, or who underwent multimodality therapy more often desired increased appointment frequency. These patients also rated the burdens of travel cost and overall stress higher, compared to patients desiring visits less often (41.5% vs 28.4%, p = 0.047 and 46.6% vs 38.3%, p = 0.003, respectively). Travel stress was associated with highest overall stress (beta 0.6, CI: 0.4, 0.7).ConclusionThe HNC survivor population is uniquely disenfranchised in several social and economic ways. While most patients are satisfied with their follow-up care, a significant subset of patients – those with limited social support, high financial stress, functional deficits, and those with transportation burdens – desire more frequent care. Survivorship care plans should incorporate the perspectives of current survivors.



https://ift.tt/2GHi77c

The unique and valuable soft tissue free flap in head and neck reconstruction: Lateral arm

Publication date: July 2018
Source:Oral Oncology, Volume 82
Author(s): Stephen Y. Kang, Antoine Eskander, Krupal Patel, Theodoros N. Teknos, Matthew O. Old
While the lateral arm free flap has been well described, there is a relative paucity in its use compared to other free flaps and regional flaps. The lateral arm free flap is a unique soft tissue free flap that provides several reconstructive advantages in head and neck reconstruction: excellent contour and color match to facial skin, well compartmentalized fat, donor nerves for nerve grafting, and the ability to two-team harvest and close the donor site without a skin graft. A detailed anatomic and harvest technique is described, along with indications and advantages of using lateral free flap for head and neck reconstruction. A scoping literature review was also conducted to tabulate indications, overall success and complications of the flap. The lateral arm flap is a primary option for defects requiring soft tissue reconstruction in the head and neck.



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Early TLR4 blockade attenuates sterile inflammation-mediated stress in islets during isolation and promotes successful transplant outcomes

Background During the isolation process, pancreatic islets are exposed to an environment of sterile inflammation resulting in an upregulated inflammatory state prior to transplantation. Toll-like receptor 4 (TLR4) has been identified as a major mediator of sterile inflammation. Therefore, we sought to determine whether early TLR4 blockade would be effective in reducing the inflammatory burden in islets pretransplant. Methods Islets from C57BL/6 mice were treated with a TLR4 antagonist during the pancreatic ductal perfusion and digestion steps of the isolation process. Islets were then analyzed for inflammation by RT-PCR and western blot, and for viability and function in vitro. A syngeneic transplant model using a marginal mass of islets transplanted intraportally into mice with streptozotocin-induced diabetes was used to study transplant outcomes after early TLR4 blockade. Results Diabetic mice receiving 150 islets treated with early TLR4 blockade achieved euglycemia at a higher rate than mice receiving untreated islets (75% vs 29%; p

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Survival and Metabolic Function of Syngeneic Mouse Islet Grafts Transplanted into the Hepatic Sinus-tract

Background Islet grafts are transplanted into the liver via a portal vein in 90% of the clinical islet transplantations. However, the portal vein is far from being the ideal infusion site due to its unique drawbacks. These issues necessitated the exploration of an alternatively optimized site for clinical islet transplantation. With the widespread clinical application of percutaneous transhepatic puncture technique, we envisioned the possibility of islet transplantation into the hepatic sinus-tract (HST). Methods The HST was created by temporarily placing a medically approved material into the hepatic parenchyma of C57BL/6 mice. The syngeneic islets were transplanted into the HST, following which, the nonfasting blood glucose, intraperitoneal glucose tolerance, and morphology were evaluated. Results A collagen-lined HST was formed by the 28-day implantation of a cylindrical nylon rod. Transplantation of ~300 syngeneic islets into the HST routinely reversed the hyperglycemia of the recipient mice and maintained normoglycemia for >100 days until the graft was removed. The islet grafts within the HST stained positively for insulin, glucagon, and abundant microvessels and achieved comparable results to the islet grafts under the kidney capsule (KC) with respect to glycemic control and glucose tolerance. Conclusions These results suggested that an HST can be constructed for islet transplantation by temporarily placing a nylon material in the liver parenchyma. The HST is a promising site for clinical islet transplantation, thereby providing a satisfactory environment for the survival and metabolic function of islet grafts. Corresponding author Jialin Zhang, MD, PhD, Hepatobiliary Surgery Department and Unit of Organ Transplantation, the First Hospital of China Medical University, Shenyang 110001, China. Tel: 86-24-83283310. Fax: 86-24-83282997. Email: jlz2000@yeah.net Contribution: F.L participated in the research design, performance of the research, data analysis and writing of the manuscript. A.J, X.L, C.Z and N.S participated in the performance of the research and writing of the manuscript. J.Z participated in research design and writing of the manuscript. Disclosure Statement The authors report no conflicts of interest and are solely responsible for the content and writing of this manuscript. Financial Support: This work was supported by the National Natural Science Foundation of China (NSFC) (no. 31370989). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2x6JBDS

Belatacept in Solid Organ Transplant: Review of Current Literature Across Transplant Types

Calcineurin inhibitors (CNIs) have been the backbone immunosuppressant for solid organ transplant recipients for decades. Long-term use of CNIs unfortunately is associated with multiple toxicities, with the biggest concern being CNI-induced nephrotoxicity. Belatacept is a novel agent approved for maintenance immunosuppression in renal transplant recipients. In the kidney transplant literature, it has shown promise as being an alternative agent by preserving renal function and having a minimal adverse effect profile. There are emerging studies of its use in other organ groups, particularly liver transplantation, as well as using with other alternative immunosuppressive strategies. The purpose of this review is to analyze the current literature of belatacept use in solid organ transplantation and discuss its use in current practice. Corresponding author: Caroline P. Perez, PharmD, BCPS, Clinical Pharmacy Specialist, Solid Organ Transplant, Medical University of South Carolina, 150 Ashley Avenue, MSC 584, Charleston, SC 29425. perezca@musc.edu Authorship contribution: All authors were involved with analyzing the literature, interpreting the data, and writing the manuscript. CP, NP, and NAP were involved with revising the manuscript. CP was involved with coordination and final editing of the manuscript. All authors agreed upon final approval of the version submitted. Disclosure: The authors declare no conflicts of interest. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Secondhand hypertrophy: a rare case of genetically-based pathology developing within a transplanted heart

No abstract available

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Critical Appraisal of International Clinical Practice Guidelines in Kidney Transplantation Using the Appraisal of Guidelines for Research and Education (AGREE) II Tool: A Systematic Review

Background Whilst Clinical Practice Guidelines (CPGs) are used for the development of local protocols in kidney transplantation (Ktx), the quality of their methodology is variable. This systematic review aimed to critically appraise international CPGs in all aspects of Ktx using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Methods CPGs in Ktx and donation published between 2010 and 2017 were identified from MEDLINE, Embase, National Guideline Clearinghouse, NHS and NICE Evidence Searches, and the websites of transplant societies. Using AGREE II, 3 appraisers assessed the quality of CPGs. Interrater reliability was measured using the intraclass correlation coefficient (ICC). Results Searches identified 3,168 records and 115 CPGs were included. The highest scoring AGREE II domain was 'Scope and Purpose' (80%; Range 30-100%), followed by 'Clarity of Presentation' (77%; Range 43-98%), 'Editorial independence' (52%; Range 0-94%), 'Rigour of Development' (47%; Range 6-97%) and 'Stakeholder Involvement' (41%; Range 11-85%). The poorest scoring domain was 'Applicability' (31%; Range 3-74%). Most CPGs were recommended for future use either with (63%) or without modifications (18%). A small number were not recommended for future use (14%) or reviewers did not agree on recommending the CPG (5%). The overall mean CPG quality score was 4 out of 7 (Range 2-7). The mean ICC of 0.74 indicated substantial agreement between reviewers. Conclusions The quality of international CPGs in Ktx was variable, and most CPGs lacked key aspects of methodological robustness and transparency. Improvements in methodology, patient involvement and strategies for implementation are required. Correspondence information: Corresponding Author: Katriona JM O'Donoghue, E-mail: kodonoghue@rcseng.ac.uk, Mailing address: Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons, 35-43 Lincoln's Inn Fields, London WC2A 3PE. Systematic review registration PROSPERO ID: CRD42015027356 AUTHORSHIP PAGE Authorship KO, RR, SK, JO, PM and LP were involved in the concept and design of the systematic review. KO and LP designed the search strategy. KO and RR screened search results for relevant full-texts and these were checked by LP. KO and RR performed the data extraction. All authors were involved in the critical appraisal of guidelines with AGREE II. KO wrote the initial drafts of the manuscript and these were revised by LP. All authors critically revised the final draft of the manuscript. KO had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. KO is guarantor. Disclosure All authors have completed the ICMJE uniform disclosure form at https://ift.tt/PN8RmS and the authors declare no conflicts of interest. Funding No funding received Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2khpl9q

Population Health, Ethnicity and Rate of Living Donor Kidney Transplantation

Background Living donor kidney transplantation has declined in the United States since 2004, but the relationship between population characteristics and rate of living donation is unknown. The goal of our study was to use data on general population health and socioeconomic status to investigate the association with living donation. Methods This cross-sectional, ecological study used population health and socioeconomic status data from the CDC Behavioral Risk Factor Surveillance System (BRFSS) to investigate the association with living donation. Transplant centers performing ≥ 10 kidney transplants reported to the Scientific Registry of Transplant Recipients in 2015 were included. Center rate of living donation was defined as the proportion of all kidney transplants performed at a center that were from living donors. Results In a linear mixed effects model, a composite index of health and socioeconomic status factors was negatively associated with living donation, with a rate of living donation that was on average 7.3 percentage points lower among centers in areas with more comorbid disease and poorer socioeconomic status (95% CI: -12.2 to -2.3, p=0.004). Transplant centers in areas with higher prevalence of minorities had a rate of living donation that was 7.1 percentage points lower than centers with fewer minorities (95% CI: -11.8 to -2.3, p=0.004). Conclusions Center level variation in living donation was associated with population characteristics and minority prevalence. Further examination of these factors in the context of patient and center-level barriers to living donation is warranted. Corresponding Author: Jayme E. Locke MD MPH (author from whom reprints will be available), University of Alabama at Birmingham, 701 19th Street South, LHRB 748, Birmingham, AL 35294. (205) 934-2131. Email: jlocke@uabmc.edu AUTHOR CONTRIBUTIONS Research idea and study design: RDR, DS, BAS, PAM, JEL; data acquisition: RDR; data analysis/interpretation: RDR, DS, BAS, PAM, CEL, JEL; statistical analysis: RDR, DL; supervision or mentorship: DS, PAM, MH, VK, DL, RG, MK, BJ, CEL, JEL. Each author contributed important intellectual content during manuscript drafting and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated or resolved. DISCLOSURES None FUNDING This research was supported in part by the National Institutes of Health grant numbers K23-DK103918 (PI: Locke) and R01-DK113980 (PI: Locke). The data reported here have been supplied by the Minneapolis Medical Research Foundation (MMRF) as the contractor for the Scientific Registry of Transplant Recipients (SRTR). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the SRTR or US Government. These data were presented in preliminary form at the 2017 American Transplant Congress in Chicago, IL. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Delayed presentation of severe rhabdomyolysis leading to acute kidney injury following atorvastatin-gemfibrozil combination therapy: a case report

Rhabdomyolysis is a rare but serious complication of lipid-lowering therapy. Statin and fibrate combination increases the risk of rhabdomyolysis possibly by pharmacodynamic interactions. Advanced age, diabetes...

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Successful resection of a slow-growing synchronous pulmonary metastasis from distal cholangiocarcinoma resected 3.5 years after initial surgery: a case report

A few reports have described the effectiveness of resection for recurrent cholangiocarcinoma. However, none have described resection of synchronous pulmonary metastasis from distal cholangiocarcinoma. We repor...

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Application of Standardised Yoga Protocols as the Basis of Physiotherapy Recommendation in Treatment of Sleep Apneas: Moving Beyond Pranayamas

Abstract

Yoga is an ancient Indian practice of mental and physical exercises (syn: asanas), postures (syn: mudras), movements and breathing techniques which sustain healthy living of the body and the mind. It incorporates various exercises of breathing, oropharyngeal structures and facial expressions, the physiology and effect of which are comparable to international physiotherapy recommendations in treatment of obstructive sleep apnea (OSA) i.e. to preserve upper airway patency by maintaining airway dilator muscle tone. Preliminary results show that yoga can be an effective and constructive alternative to physiotherapy for sleep apnea and snoring patients. To compare the physiotherapy recommendations in snoring patients with various yoga exercises postures. To determine the efficacy of yoga in treatment of sleep apnea. To formulate a standardized yoga protocol for universal usage in sleep apnea. We studied the available literature on physiotherapy recommendations for OSA and yoga asanas involving the nasal, oropharynx and facial structures and perceived a noteworthy similarity in physiological basis of both. A set of these yogasanas were put together and patients presenting with snoring and diagnosed with mild to moderate sleep apnea were presented and encouraged to perform the standardized set of yoga exercises for a period of 3 months. A total of 23 patients were recommended yoga protocols as initial form of treatment in snoring and mild to moderate sleep apnea. Clinical and statistically significant improvement gauzed by recommended score chart was discerned in majority of subjects. The results were comparable to the efficacy of existing physiotherapy regimen published in international literature. The benefits of yoga in sleep disorders go beyond the scope of measured outcomes. Standardizing the protocols for yoga in treatment for snoring and sleep apnea is the need of the hour. Further studies on efficacy of yoga need to be performed to understand its full realm of potential.

https://ift.tt/2x1Uerr

Intricate relationships between naked viruses and extracellular vesicles in the crosstalk between pathogen and host

Abstract

It is a long-standing paradigm in the field of virology that naked viruses cause lysis of infected cells to release progeny virus. However, recent data indicate that naked virus types of the Picornaviridae and Hepeviridae families can also leave cells via an alternative route involving enclosure in fully host-derived lipid bilayers. The resulting particles resemble extracellular vesicles (EV), which are 50 nm–1 μm vesicles released by all cells. These EV contain lipids, proteins, and RNA, and generally serve as vehicles for intercellular communication in various (patho)physiological processes. EV can act as carriers of naked viruses and as invisibility cloaks to evade immune attacks. However, the exact combination of virions and host-derived molecules determines how these virus-containing EV affect spread of infection and/or triggering of antiviral immune responses. An underexposed aspect in this research area is that infected cells likely release multiple types of virus-induced and constitutively released EV with unique molecular composition and function. In this review, we identify virus-, cell-, and environment-specific factors that shape the EV population released by naked virus-infected cells. In addition, current findings on the formation and molecular composition of EV induced by different virus types will be compared and placed in the context of the widely proven heterogeneity of EV populations and biases caused by different EV isolation methodologies. Close interactions between the fields of EV biology and virology will help to further delineate the intricate relationship between EV and naked viruses and its relevance for viral life cycles and outcomes of viral infections.

https://ift.tt/2IZkM1i

Activating and inhibitory receptors expressed on innate lymphoid cells

Abstract

Innate lymphoid cells (ILCs) are innate immune cells located in lymphoid and non-lymphoid tissues. They are particularly abundant at mucosal and barrier surfaces. Three major ILC subsets are present in humans and mice: group 1 ILCs (comprising natural killer (NK) cells and ILC1s), ILC2s, and ILC3s. ILCs are involved in the maintenance of homeostasis and the regulation of immunity. This review focuses on the extensive array of activating and inhibitory receptors expressed by ILCs for communication with other cell types and their environment in health and disease.

https://ift.tt/2s5cNFp

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations

Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the "fourth generation" in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2–3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient's body habitus (BMI #x3c; 30 kg/m²) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.
ORL

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Neuroimaging findings in Menkes disease: a rare neurodegenerative disorder

Menkes disease is a rare neurodegenerative metabolic disease with a reported incidence of 1 per 300 000 live births. It occurs due to mutations in ATP7A gene located on X-chromosome leading to deficiency of several copper-containing enzymes. The patient presents with history of neuroregression with characteristic kinky hair. MRI is the imaging modality of choice. Characteristic imaging findings are: bilateral subdural hygromas, cerebral and cerebellar atrophy, white matter changes and tortuous intracranial vessels on angiography. The rarity of this condition prompted us to report this case of Menkes disease along with the characteristic neuroimaging findings and brief review of literature.

https://ift.tt/2GEb2UR

Ro-positive interstitial lung disease treated with cyclophosphamide

Interstitial lung disease (ILD) comprises a spectrum of conditions involving inflammation and/or fibrosis of the alveolar wall causing limitation in gaseous exchange. Treatment varies depending on the underlying ILD. We describe the case of a woman presenting with a productive cough who was diagnosed with community-acquired pneumonia. While on the ward she developed type-1 respiratory failure requiring continuous positive airway pressure and intensive care unit admission. Failing to respond to targeted antimicrobials she was investigated by chest high-resolution CT and autoantibody screen to identify non-infective causes of her respiratory signs and symptoms. These demonstrated diffuse ground-glass change with peripheral honeycombing in keeping with fibrosis and alveolitis alongside high titres of anti-SS-A/Ro antibodies. She was managed with reducing course of steroids and immunosuppression with cyclophosphamide. The rational of long-term immunosuppression was based on a presumed diagnosis of lung-dominant connective tissue disease, a disease concept proposed in contemporary medical literature.

https://ift.tt/2khIxnq

Chronic Madura foot: mycetoma and/or Actinomyces spp or actinomycosis

A 58-year-old agricultural worker from a remote Western province farming community in Saudi Arabia presented with a 2-year history of right plantar foot soft tissue mass. According to the patient, the swelling had gradually increased in size over a few years, but it was painless and thus had not restricted him from continuing to farm until the lesion started to affect mobility. An MRI, microbiology and histopathology reported a rare infectious agent—Actinomyces spp, otherwise referred to as Madura foot. Three-dimensional CT aided in a preoperative surgical plan which included mass excision/debulking for this challenging lesion. Full eradication was not possible, and the patient required prolonged anti-infective therapy (>6 months) along with close surveillance to map resolution of infective symptoms.

https://ift.tt/2s1ApuF

Interaction Between Body Posture and Nocturnal Sleeping Disorders in Dysgnathic Patients

Conditions:   Dentofacial Deformities;   Sleep Disorder;   Posture
Intervention:   Other: polysomnography
Sponsor:   Laboratoire de Biomécanique Georges Charpak
Recruiting

https://ift.tt/2IAIkds

Concomitant Immune Check Point Inhibitor With Radiochemotherapy in Head And Neck Cancer

Condition:   Locally Advanced Head and Neck Cancer
Intervention:   Drug: Pembrolizumab
Sponsor:   Kuwait Cancer Control Center
Not yet recruiting

https://ift.tt/2s9vqIz

The Relationship Between Dizziness and Neck Pain

Conditions:   Dizziness;   Vertigo;   Neck Pain
Intervention:  
Sponsor:   Haukeland University Hospital
Recruiting

https://ift.tt/2ID6Iv5

Subjective perception of paraesthesia of the lower lip after bilateral sagittal split osteotomy at a district general hospital

Publication date: Available online 22 May 2018
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): E. Mackinnon, K. Bajaj, D. Tighe, M. Williams
Our aim was to assess patients' perception of paraesthesia of the lower lip after bilateral sagittal split osteotomy (BSSO) at a district general hospital. Patients who had BSSO between August 2013 and August 2014 (n=46) were asked to score their perception of numbness between 0–10 (0=normal sensation. 10=complete loss of sensation/total numbness) one day postoperatively and then weekly for seven weeks, and at three months, 6 months, and one year. Data was collected on score sheets and by regular contact by telephone. Of the 46 operated on, 31 were female and 15 male. Data were available one year postoperatively for 43 patients. Ten of the 92 sides were reported as feeling normal on day 1 postoperatively, three-quarters as feeling normal at six months, and 79 at one year. On multivariate analysis there was no significant difference in postoperative sensation at one year between sides operated on by the registrar (left) and consultant (right) operated (p=0.76). Our results compared favourably with the limited data available in similarly designed studies.



https://ift.tt/2rYkqye

Robotic Thyroid Surgery: Current Perspectives and Future Considerations

Robotic transaxillary thyroidectomy, pioneered in South Korea, is firmly established throughout the Far East but remains controversial in Western practice. This relates to important population differences (anthropometry and culture) compounded by the smaller mean size of thyroid nodules operated on in South Korea due to a national thyroid cancer screening programme. There is now level 2 evidence (including from Western World centres) to support the safety, feasibility, and equivalence of the robotic approach to its open counterpart in terms of recurrent laryngeal nerve injury, hypoparathyroidism, haemorrhage, and oncological outcomes for differentiated thyroid cancer. Moreover, robotic thyroidectomy has been shown to be superior to open surgery for certain patient-reported outcome measures, namely scar cosmesis and pain. Downsides include its high cost, longer operative time, and risk of complications not encountered in open thyroidectomy (brachial plexus neurapraxia). Careful patient selection is paramount as this procedure is not for every patient, surgeon, or hospital. It should only be undertaken by high-volume surgeons operating as part of a multidisciplinary robotic team in specialised centres. Novel robotic approaches utilising the retroauricular and transoral routes for thyroidectomy have recently been described but further studies are required to establish their respective role in modern thyroid surgery.
ORL

https://ift.tt/2GEk9oR

A multifaceted approach towards interpreting early life experience and infant feeding practices in the ancient Atacama Desert, Northern Chile

International Journal of Osteoarchaeology, EarlyView.


https://ift.tt/2rYEh0m

The Role of Mannose-Binding Lectin Serum Level in Tubotympanic Chronic Suppurative Otitis Media

Background. Chronic suppurative otitis media (CSOM) is a common public health problem worldwide and a major cause of hearing impairment especially in developing countries. The role of Mannose-Binding Lectin (MBL), a component of innate immunity, in CSOM has not been studied. The aim of the study was to examine whether MBL deficiency was more frequently present in cases group of tubotympanic CSOM patients rather than healthy subjects. Material and Methods. This was an analytic observational study. Subjects were enrolled in the Otorhinolaryngology Clinic at Margono Soekarjo Hospital, Purwokerto, Indonesia. An independent -test was used to compare the mean of MBL serum concentration between tubotympanic CSOM subjects and control. Results. From 36 tubotympanic CSOM patients, there were 8 (22.22%) patients with MBL deficiency (MBL level

https://ift.tt/2GEA9XU

Randomized Clinical Trial Comparing Bucket Handle and Cartilage Tympanoplasty Techniques for the Reconstruction of Subtotal or Anterior Tympanic Membrane Perforation

Objective. The purpose of the study is to compare the clinical outcome of the two techniques of Bucket Handle Tympanoplasty and Cartilage Tympanoplasty in achieving success in graft survival as well as acceptable auditory results. 60 patients who suffered chronic otitis media with anterior perforation of the tympanic membrane were chosen. The patients were randomly assigned using Block Randomization Method of two groups including patients who underwent Bucket Handle Tympanoplasty () or those that underwent Cartilage Tympanoplasty (). The patients were followed up for 1, 3, 6, and 12 months postoperatively. Results. The mean PTA was lower in Bucket Handle Tympanoplasty group as case group compared to Cartilage Tympanoplasty group as the control (). No significant statistical differences had identified passing through the time, in terms of PTA outcome ( Value = 0.547) and SRT outcome ( Value = 0.352), between Bucket Handle Tympanoplasty group and the Cartilage Tympanoplasty group. In total, postoperative tympanic membrane perforation was found in 10.0% of patients in Cartilage Tympanoplasty group and 13.3% in Bucket Handle Tympanoplasty group with no difference (). Conclusions. Hearing improvements in both methods were similar. Registration Number. The trial is registered with IRCT2016022626773N1.

https://ift.tt/2KMlWdT

Awareness of and phobias about topical corticosteroids in parents of infants with eczema in Hangzhou, China

Pediatric Dermatology, EarlyView.


https://ift.tt/2GEtQU4

Dexamethasone Implant as Sole Therapy in Sympathetic Ophthalmia

We present the case of a 46-year-old woman with sympathetic ophthalmia occurring 27 years after complicated juvenile cataract surgeries. The patient declined systemic immunosuppressive therapy. Dexamethasone implant in the sympathizing eye allowed good visual recovery up to 18 months of follow-up with a total of 6 implants. Intraocular pressure rise was controlled medically. This is a unique report of sympathetic ophthalmia treated solely with slow-release dexamethasone implant without systemic therapies.
Case Rep Ophthalmol 2018;9:256–262

https://ift.tt/2IAIX6J

Evaluation of a nanocomposite of PEG-curcumin-gold nanoparticles as a near-infrared photothermal agent: an in vitro and animal model investigation

Abstract

Hyperthermia is a promising alternative modality for the conventional cancer treatments. Nanoparticle-mediated photothermal therapy (PTT) has been widely applied for hyperthermia cancer therapy by a near-infrared light irradiation. Some special nanoparticles can convert light energy into heat and destroy the tumor cells. Inspired from the photothermal efficacy of the gold nanoparticles, here we synthesized, characterized, and applied novel photothermal polyethylene glycol-curcumin-gold nanoparticles (PEG-Cur-Au NPs) in cancer PTT. The effect of PEG-Cur-Au NPs upon irradiation by an 808-nm laser on C540 (B16/F10) cell line as well as implanted (bearing) melanoma tumor in inbred C57 mice was investigated. In vitro temperature increment, cell viability evaluation, and histological analyses were performed. The results showed a dose-dependent cytotoxicity of PEG-Cur-Au NPs toward C540 (B16/F10) cell line at concentrations ≥ 25 μg mL⁻¹ with an IC₅₀ value of 42.7 μg mL⁻¹ in dark (and with no toxicity for 10 μg mL⁻¹). On the other hand, 808-nm laser irradiation alone (without using PEG-Cur-Au NPs) for 10 min induced killing effect on the C540 (B16/F10) cell line in a laser power-dependent manner at power density > 0.5 W cm⁻² (no toxicity for 0.5 W cm⁻²). However, PPT using PEG-Cur-Au NPs was tremendously observed after laser illumination. Even under laser irradiation at a power density of 0.5 W cm⁻² of PEG-Cur-Au NPs of concentrations < 10 μg mL⁻¹, PTT of the cells was substantial. Histological analyses and volume measurements of the induced tumors in the mice revealed an appropriate control of the tumors upon PTT by PEG-Cur-Au NPs. Combination of PEG-Cur-Au NP administration and 808-nm diode laser irradiation destroyed the melanoma cancer cells in the animal model.

https://ift.tt/2KMiyj3

Immuntherapie des Melanoms

Zusammenfassung

Hintergrund

Die Prognose für Patienten mit fernmetastasiertem Melanom war bis zur Zulassung des Anti-CTLA-4-Antikörpers Ipilimumab 2011 mit einem medianen Gesamtüberleben von 6 bis 10 Monaten infaust. Die Zulassung der Immuncheckpointinhibitoren, die für Patienten mit metastasiertem Melanom ein Langzeitüberleben erwirken können, stellt einen Durchbruch dar.

Ziel, Material und Methoden

Die aktuellen zugelassenen Systemtherapien des Melanoms unter Berücksichtigung der Studiendaten, die auf der Jahrestagung 2017 der American Society of Clinical Oncology (ASCO) sowie der European Society for Medical Oncology (ESMO) vorgestellt wurden, werden in dieser Übersichtsarbeit zusammengefasst.

Ergebnisse und Diskussion

Verglichen mit Ipilimumab konnten die beiden zugelassenen Anti-PD-1-Antikörper Pembrolizumab und Nivolumab eine höhere Wirksamkeit bei niedrigerer Toxizität erzielen. Die 2016 zugelassene Immunkombinationstherapie mit Nivolumab und Ipilimumab erzielte eine Ansprechrate von 58 % und eine Dreijahresüberlebensrate von 58 %. Schwere Grad-3/4-Nebenwirkungen traten bei 55 % der Patienten auf. Die frühzeitige Diagnose immunvermittelter Nebenwirkungen unter Immuncheckpointinhibitor-Therapie und ihre adäquate Behandlung ggf. unter Einsatz von systemischen Glukokortikosteroiden und weiteren Immunsuppressiva ist unabdingbare Voraussetzung für den Therapieerfolg. Die Immunkombinationstherapie mit Nivolumab und Ipilimumab erzielte bei Patienten mit metastasiertem Melanom und Hirnmetastasen intrakranielle Ansprechraten von 42–55 %, wobei die Toxizität im Vergleich zu Patienten ohne Hirnmetastasen nicht erhöht war. Aufgrund des erfolgreichen Einsatzes von Immuncheckpointinhibitoren für die Therapie des metastasierten Melanoms werden aktuell mehrere Studien durchgeführt, die insbesondere Anti-PD-1-Antikörper im adjuvanten Setting evaluieren. In aktuellen und zukünftigen Studien werden zunehmend innovative Immunkombinationstherapien, z. B. Anti-PD-1-Antikörper in Kombination mit IDO-Inhibitoren (IDO Indoleamine-pyrrole 2,3-dioxygenase) untersucht. Bisher vorliegende Daten sprechen für eine hohe Wirksamkeit und eine niedrige Toxizität.

https://ift.tt/2IFVFgK

Introduction of a modified double-lumen tube

https://ift.tt/2IB4yfn

Relationship between fresh frozen plasma to packed red blood cell transfusion ratio and mortality in cardiovascular surgery

Abstract

Purpose

The aim of this study was to examine the relationship between FFP (fresh frozen plasma)/pRBC (packed red blood cell) transfusion ratio and outcomes in patients undergoing cardiovascular surgery.

Methods

This is a single center retrospective cohort study performed in a cardiovascular center. Patients undergoing cardiovascular surgery between January 2012 and October 2016 with or without massive transfusion (n = 1453). Patients' outcomes were compared based on FFP/pRBC transfusion ratio (FFP/pRBC > 1 or FFP/pRBC ≤ 1).

Results

In hospital mortality and rate of stroke and myocardial infarction was significantly higher in patients with less than 1 of FFP/pRBC transfusion ratio only in patients with massive transfusion (3.0 vs 8.8%, p = 0.001; 0.7 vs 6.4%, p < 0.001; 1.0 vs 3.2%, p = 0.047, respectively).

Conclusions

Higher FFP/RBC ratio was associated with reduced risk of death, stroke and myocardial infarction only in patients with cardiovascular surgery receiving massive transfusion. Clinicians should be aware that judicious FFP replacement plays a critical role in the successful management of massive transfusion in cardiac surgery.

https://ift.tt/2IBbcOG