Αρχειοθήκη ιστολογίου

Αλέξανδρος Γ. Σφακιανάκης
ΩτοΡινοΛαρυγγολόγος
Αναπαύσεως 5
Άγιος Νικόλαος Κρήτη 72100
2841026182
6032607174

Τετάρτη 30 Μαΐου 2018

Obturators versus flaps after maxillary oncological ablation: A systematic review and best evidence synthesis

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Publication date: July 2018
Source:Oral Oncology, Volume 82
Author(s): Yubin Cao, Changhao Yu, Wei Liu, Cheng Miao, Bo Han, Jianong Yang, Longjiang Li, Chunjie Li
Maxillary defects can be resolved by prosthetic obturation, autologous tissue reconstruction, or a combination of both. However, there is still controversy in the selection of the optimal approach. Therefore, the aim of this study was to systematically review evidences comparing the performance of obturators and flaps in patients after maxillary oncological ablation. Both electronic and manual searching approaches were conducted to identify eligible evidence. Two reviewers independently assessed the risk of bias. In addition, the same reviewers independently extracted the data. Meta-analyses were performed using Revman 5.3, and best evidence synthesis was performed. Sixteen studies were included and a total of 528 participants were analyzed. All studies were assessed at low quality. Results of this meta-analysis showed weak evidence in the difference between obturators and flaps on the outcome regarding word intelligibility (P = 0.004) and masticatory efficiency (P = 0.002). However, no differences were detected regarding speech intelligibility and nasalance. All studies were compiled into the best evidence synthesis. The sum of 31 evidences was considered. Twelve evidences were evaluated at a moderate level, such as speech, mastication, pain, salivation, taste sensations, and mouth opening. Except the outcomes of word intelligibility, masticatory efficiency, and mouth pain, other moderate evidences showed no difference between obturators and flaps. In conclusion, both obturators and flaps might be effective in patients' rehabilitation functions after maxillary ablation. However, some advantages were observed when using surgical reconstruction over prosthetic rehabilitation. Additional high-quality studies are needed to provide more solid evidence before applying these results into clinical practice.



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Unravelling the molecular signatures in HNSCC: Is the homogenous paradigm becoming obsolete?

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Publication date: Available online 30 May 2018
Source:Oral Oncology
Author(s): Divya Gopinath, Rohit Kunnath Menon




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Τα σημάδια στα νύχια μπορεί να υποδείξουν πρόβλημα υγείας. http://medicalnews.gr/grammes-nyxia-shmainoun/


Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480






Targeting myeloid-derived suppressor cells for cancer immunotherapy

Abstract

Myeloid-derived suppressor cells (MDSCs) are a heterogeneous population of immature myeloid cells with an immune suppressive phenotype. They represent a critical component of the immune suppressive niche described in cancer, where they support immune escape and tumor progression through direct effects on both the innate and adaptive immune responses, largely by contributing to maintenance of a high oxidative stress environment. The number of MDSCs positively correlates with protumoral activity, and often diminishes the effectiveness of immunotherapies, which is particularly problematic with the emergence of personalized medicine. Approaches targeting MDSCs showed promising results in preclinical studies and are under active investigation in clinical trials in combination with various immune checkpoint inhibitors. In this review, we discuss MDSC targets and therapeutic approaches targeting MDSC that have the aim of enhancing the existing tumor therapies.



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An independent relation of atopic dermatitis to exercise-induced wheezing in asthmatic children

Publication date: Available online 30 May 2018
Source:Allergology International
Author(s): Satoshi Honjo, Yoko Murakami, Hiroshi Odajima, Yuichi Adachi, Koichi Yoshida, Yukihiro Ohya, Akira Akasawa
BackgroundAtopic dermatitis (AD) and exercise-induced asthma (EIA) are common in asthmatic children, and exercise is the most common trigger other than infection for acute onset asthma attack in children. We examined whether AD is related to exercise-induced wheezing (EIW), some proxy for EIA.MethodsJapanese version of the International Study of Asthma and Allergies in Childhood questionnaires were used. For 12,405 asthmatic school children, AD was defined as itchy rash coming and going for at least 6 months at any time in the last 12 months with affecting places of flexural parts of body, and severity of AD was rated according to frequency of being kept awake at night with the itch as follows: never in the past 12 months, less than one night per week and one or more nights per week.ResultsAdjusted for frequency of asthma attack, odds ratios (OR) of children with current AD as compared to those without AD for having EIW were 1.32 (95% confidence interval = 1.15–1.52), 1.35 (1.14–1.68) and 1.10 (0.92–1.31) for primary school, junior high school and high school children, respectively. EIW was more likely observed in accordance with increasing severity of AD in the primary school children with ORs of 1.12, 1.59 and 1.54 (p for trend < 0.01), and in the junior high school ones with ORs of 1.18, 1.31, 2.03 (<0.01), respectively.ConclusionsAD may be possibly related to EIW. Further studies investigating effect of AD treatment on EIW may be required.



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Interleukin 17A exacerbates ER-stress-mediated inflammation of macrophages following ICH

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Publication date: September 2018
Source:Molecular Immunology, Volume 101
Author(s): Zhao Yang, Qingjun Liu, Hui Shi, Xuheng Jiang, Song Wang, Yuanlan Lu, Ji Zhang, Xiaofei Huang, Anyong Yu
IL-17A contributes to the initiation of inflammation following intracerebral hemorrhage (ICH). Endoplasmic reticulum (ER) stress acts on protein folding and contributes to inflammatory diseases. The role of IL-17A in the regulation of ER stress following ICH has not been well characterized. In this study, macrophages were stimulated with IL-17A, and then, ER stress and downstream pro-inflammatory factors were measured in vitro. In addition, brain edema and brain injury in ICH mice were assessed in vivo. We demonstrated that IL-17A induced ER stress in macrophages and thus promoted inflammation in vitro. Conversely, IL-17A inhibition attenuated ER stress and neuroinflammation. Furthermore, ERK 1/2 and p38 MAPK pathways mediated IL-17A-induced ER stress in macrophages. We also showed that IL-17A inhibition significantly attenuated ER stress and brain injury in ICH mice.In conclusion, our results demonstrate that IL 17A increases ER stress in macrophages and represents a novel mechanism in ICH.



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Seafood allergy: A comprehensive review of fish and shellfish allergens

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Publication date: Available online 30 May 2018
Source:Molecular Immunology
Author(s): Thimo Ruethers, Aya C. Taki, Elecia B. Johnston, Roni Nugraha, Thu T.K. Le, Tanja Kalic, Thomas R. McLean, Sandip D. Kamath, Andreas L. Lopata
Seafood refers to several distinct groups of edible aquatic animals including fish, crustacean, and mollusc. The two invertebrate groups of crustacean and mollusc are, for culinary reasons, often combined as shellfish but belong to two very different phyla. The evolutionary and taxonomic diversity of the various consumed seafood species poses a challenge in the identification and characterisation of the major and minor allergens critical for reliable diagnostics and therapeutic treatments. Many allergenic proteins are very different between these groups; however, some pan-allergens, including parvalbumin, tropomyosin and arginine kinase, seem to induce immunological and clinical cross-reactivity.This extensive review details the advances in the bio-molecular characterisation of 20 allergenic proteins within the three distinct seafood groups; fish, crustacean and molluscs. Furthermore, the structural and biochemical properties of the major allergens are described to highlight the immunological and subsequent clinical cross-reactivities. A comprehensive list of purified and recombinant allergens is provided, and the applications of component-resolved diagnostics and current therapeutic developments are discussed.



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Effects of different photobiomodulation dosimetries on temporomandibular dysfunction: a randomized, double-blind, placebo-controlled clinical trial

Abstract

Changes involving temporomandibular joint, masticatory musculature, and associated structures characterize temporomandibular dysfunction (TMD). The analgesic and anti-inflammatory effect produced by photobiomodulation has contributed to pain relief and functional improvement. However, the parameters to be used have not yet been well established. The aim of this study is to compare the efficacy of three different photobiomodulation dosimetries in the treatment of patients with TMD. A randomized, double-blind, placebo-controlled clinical trial with 44 subjects divided into the groups 8 J/cm2 (n = 11), 60 J/cm2 (n = 11), 105 J/cm2 (n = 11), and control (n = 11). Pain, symptom severity, and joint mobility were evaluated before and after a ten-session protocol of photobiomodulation with AlGaAs laser (830 nm), at a power density of 30 mW/cm2. The mouth opening increased in the 8-J/cm2 group from 10.49 ± 4.68 to 15.40 ± 6.43 degrees, and in the right protrusion from 9.80 ± 4.2 to 12.56 ± 5.40 degrees after the intervention protocol (p < 0.05). All groups significantly decreased pain (p < 0.05). 830-nm laser photobiomodulation was effective in reducing TMD pain and symptoms at all doses tested. Only the doses of 8 J/cm2 were effective regarding maximal opening and protrusion of the mandible.



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Evaluation of the effects of Er:YAG laser, Nd:YAG laser, and two different desensitizers on dentin permeability: in vitro study

Abstract

The purpose of this in vitro study was to evaluate and compare the efficacy of erbium-doped yttrium aluminum garnet (Er:YAG) laser, neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, PrevDent nano-hydroxyapatite toothpaste plus Repairing Serum Kit (PNH), and NUPRO Sensodyne Prophylaxis Paste with NovaMin (NPP) on dentin permeability reduction. Forty dentin discs obtained from bovine incisors were divided into four study groups: Er:YAG laser-treated (2940 nm; 0.2 W, 80 mJ/pulse, 3 Hz); Nd:YAG laser-treated (1064 nm; 1 W, 10 Hz); PNH-treated; and NPP-treated groups. The quantitative changes in permeability of each dentin disc were measured using a computerized fluid filtration method (CFFM) before and after desensitizer treatments. The data were analyzed using the Wilcoxon, paired-samples t, Kruskal-Wallis, and Mann-Whitney U tests. The dentin surfaces and tubules were also morphologically detected by scanning electron microscopy (SEM). In all groups, dentin permeability was significantly reduced after the desensitizer and laser treatments (p < 0.05). Among the groups, we detected a significant difference in only when comparing the Er:YAG laser- and NPP-treated groups (p = 0.034). SEM analysis revealed physical changes in the dentin surface in all groups. This in vitro study shows that all tested desensitizers and laser treatments reduced dentin permeability. Also, surface changes, such as complete or partial occlusion or shrinkage of dentin tubules, were observed in all groups. Although the laser groups performed best, the PNH protocol can be considered as an alternative therapeutic product. In addition, clinical and laboratory studies should be performed for this product, and their efficacy should be assessed by combined therapy with lasers.



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Helminth-induced regulatory T cells and suppression of allergic responses

Jayden Logan | Severine Navarro | Alex Loukas | Paul Giacomin

https://ift.tt/2Jk7lcv

Dendritic cells, T cells and lymphatics: dialogues in migration and beyond

Marc Permanyer | Berislav Bošnjak | Reinhold Förster

https://ift.tt/2JjjSwJ

Pediatric Residents’ Assessment of Atopic Dermatitis Severity for Risk Assessment of Early Peanut Introduction,

Atopic dermatitis (AD), often referred to as eczema, is one of the most common skin disorders affecting the pediatric population.1 Although pediatricians diagnose eczema frequently, classification of severity can be challenging, as score-based indices (e.g., The Eczema and Area Severity Index (EASI), Scoring Atopic Dermatitis (SCORAD) index) are complicated and designed primarily for use in clinical trials. These instruments are used infrequently by general pediatricians and may be associated with discrepancies in AD classification between providers.

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Development of Food Protein-Induced Enterocolitis Syndrome (FPIES) to egg following Immunoglobulin E (IgE)-mediated egg allergy,

Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE)-mediated condition characterized by repetitive vomiting 1-4 hours after ingestion of the particular food accompanied by additional symptoms such as lethargy, pallor or diarrhea.1 Atypical FPIES characterizes patients who are noted to have IgE-mediated sensitization to the FPIES-inducing food,2 and has been associated with an increased likelihood of persistent FPIES.3 A clinical conversion from an FPIES phenotype to an IgE-mediated phenotype to the same food has been described.

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Pilot study of the CAPS (Clinical extent, Area, Pruritus, Sleep) measure for atopic dermatitis severity,,✯✯✯,✯✯✯✯

Eczema; Atopic dermatitis; Outcome measures; Severity; Symptoms; ItchAbbreviations: AD, atopic dermatitis; BSA, body surface area; CAPS, Clinical extent, Area, Pruritus, Sleep; DLQI, Dermatology Life Quality Index; EASI, Eczema Area and Severity Index; IGA, Investigator Global Assessment; POEM, Patient-Oriented Eczema Measure

https://ift.tt/2kAs5Pa

Different Treatments With the TRV Reposition Chair

Condition:   Benign Paroxysmal Positional Vertigo
Intervention:   Procedure: Type of repositional maneuvre
Sponsor:   Aalborg Universitetshospital
Recruiting

https://ift.tt/2skyW3H

Audit of the Spanish EURECCA Esophagogastric Cancer Registry

Conditions:   Cancer of Stomach;   Cancer of Esophagus
Intervention:  
Sponsor:   Parc de Salut Mar
Not yet recruiting

https://ift.tt/2xu0Lvo

Thykamine Safety and Efficacy Study in Mild-to-Moderate Atopic Dermatitis

Condition:   Atopic Dermatitis Eczema
Interventions:   Drug: Administration of Placebo;   Drug: Administration of PUR0110 (Thykamine) 0.05%;   Drug: Administration of PUR0110 (Thykamine) 0.1%;   Drug: Administration of PUR0110 (Thykamine) 0.25%
Sponsor:   PurGenesis Technologies Inc.
Recruiting

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ctDNA as a Biomarker for Treatment Response in HNSCC

Condition:   Carcinoma, Squamous Cell of Head and Neck
Intervention:   Other: Blood draw
Sponsor:   The Netherlands Cancer Institute
Not yet recruiting

https://ift.tt/2xsYW1J

Re: “High Thyroid Cancer Mortality Rate in Japan: A Result of Non-aggressive Treatment Strategy, or Just an Aging Population?” By Magner (Thyroid [Epub ahead of print]; DOI: 10.1089/thy.2018.0121)

Thyroid, Ahead of Print.


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No-Scar Transoral Thyroglossal Duct Cyst Excision in Children

Thyroid, Ahead of Print.


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The impact of cold on the respiratory tract and its consequences to respiratory health

The increasing use, and sometimes the abuse, particularly in industrialized countries of air conditioning at home, in car, hotel and shopping centres has highlighted new emerging public health issues, resultin...

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Volumetric comparison of autogenous bone and tissue-engineered bone replacement materials in alveolar cleft repair: a systematic review and meta-analysis

The goal of reconstruction of the alveolar cleft in patients with cleft lip and palate is to improve the quality of tissue, the structural stability, and increase the volume of bone. This study is a systematic review with meta-analysis of volumetric bony filling using autogenous bone and various tissue-engineered bone substitutes. We made an electronic search on MEDLINE, EMBASE, SCOPUS, WEB OF SCIENCE, "grey" publications (materials and research produced by organisations outside traditional channels for commercial or academic publishing and distribution), and relevant cross references according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

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Is there an ideal way to close the donor site of radial forearm free flaps?

Radial forearm free flaps (RFFF) are the "workhorse" of reconstructive head and neck surgery, but have considerable morbidity at the donor site. The aim of this study was to review current publications about the incidence and type of morbidity and the different techniques used for closure of the site. We screened the MEDLINE database to find relevant papers using the terms "RFFF head and neck" and "RFFF donor site". Abstracts were filtered, and the full texts studied carefully. We found 1056 publications during the period 1982–2017 of which 389 were studied in full, and 39 studies were finally included in the review.

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Could fetal reduction induce facial cleft? Report of a case

We describe a paramedian cleft of the lower lip that cannot be explained by embryological development in a child with only one predisposing factor, which was fetal reduction for a multiple pregnancy. To the best of our knowledge, there has been no report of a cleft that has been induced by the reduction of a multifetal pregnancy.

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Primary intestinal-type adenocarcinoma of the buccal mucosa: a case report and literature review

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Kentaro Kikuchi, Shuichi Fukunaga, Fumio Ide, Miyako Hoshino, Harumi Inoue, Yuji Miyazaki, Tie-Jun Li, Kaoru Kusama
Intestinal-type adenocarcinoma (ITAC) of the primary salivary glands is extremely rare. So far, only eleven cases of primary ITAC of the oral cavity and major salivary glands have been reported. Two of those tumors arose in the floor of mouth, seven in the tongue, and two in the major salivary glands. However, it has remained unclear whether these tumors are derived from mature salivary glands and primary ITAC of the buccal mucosa has not been reported previously. Here we present the first documented case of primary ITAC arising in a minor salivary gland of the buccal mucosa. Histopathologically, the tumor resembled a well differentiated or mucinous colonic adenocarcinoma. Immunohistochemically, the tumor cells were diffusely positive for AE1/AE3, CAM5.2, CK7, SATB2, β-catenin, p53, Ki-67, MUC2 and MUC5AC. CK14 and CK20 were positive in some of the tumor cells. CDX2, CA19-9, SP-A, TTF-1, PSA, SMA, p63 and cyclin D1 were negative in the tumor cells. The present case may have originated from salivary gland duct epithelium that underwent transformation to phenotypic intestinal-type epithelium. By reference to this very rare case of primary ITAC of the buccal mucosa, we consider diagnostic markers that could be indicative of mature salivary gland origin.



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A randomized controlled study to evaluate an experimental moisturizing mouthwash formulation in participants experiencing dry mouth symptoms

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Anto Jose, Mabi L. Singh, Britta Magnuson, Arwa Farag, Roshan Varghese, Athena Papas
ObjectiveTo evaluate efficacy and tolerability of an experimental moisturizing mouthwash versus water only in participants experiencing dry mouth symptoms including those with Sjögren's syndrome (SS; n=28).Study designParticipants were randomized to the experimental Mouthwash (n=53) or Water-only (n=47) groups. For 8 days, Mouthwash participants used 1–2 doses/day at home; both groups could sip water as needed. Supervised treatment occurred on Days 1, 3, and 8 where before/after administration participants completed the Product Performance and Attributes Questionnaire (PPAQ) parts 1–4.ResultsSignificant between-treatment differences on all PPAQ questions were shown at most time points. On Day 8, at 120 minutes, there was a significant difference on PPAQ3-Question 1 ('Relieves the discomfort of dry mouth'; the pre-defined primary efficacy variable) in favor of Mouthwash versus Water (0.63 [95% confidence intervals 0.17,1.10]; P = .0084). Sub-group analysis found a significant difference favored Mouthwash in participants without SS (0.67 [0.11,1.23]; P = .0203) but not with SS (0.52 [-0.35,1.38; P = .2272). Eight, non-serious, oral, treatment-related adverse events were reported by the Mouthwash group.ConclusionsThe findings of a subjective questionnaire showed that an experimental moisturizing mouthwash provided greater relief than water only from dry mouth symptoms over 8 days.Clinicaltrials.gov: NCT02641912



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Chronic myelogenous leukemia presenting with osteonecrosis of the jaw as a rare but debilitating toxicity of dasatinib: a case report and literature review.

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Alexander M. Won, Prajwal Boddu, Adegbenga O. Otun, Ruth Aponte-Wesson, Mark Chambers
This report describes a case of osteonecrosis of the jaw that developed following a routine dental extraction in a patient being treated with dasatinib, a tyrosine kinase inhibitor, for chronic myelogenous leukemia. As the role of tyrosine kinase inhibitors in cancer treatment expands, patterns of debilitating complications involving the osseous structures of the oral cavity have begun to emerge, and many long-term side effects of this promising therapy remain unknown. To limit the occurrence of known complications, health care providers and patients must be aware of the potential for serious complications of dasatinib and have appropriate protocols developed prior to their administration.



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Odontogenic carcinosarcoma: morphological and immunohistochemical description of one case.

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Jean Nunes dos Santos, João Paulo Silva Servato, Sergio Vitorino Cardoso, Paulo Rogério de Faria, Bruno Cunha Pires, Adriano Mota Loyola
ObjectivesThe goal of this study was to describe an extremely rare case of odontogenic carcinosarcoma (OCS) and compare the findings with a literature review.Study DesignThe clinical and pathological data of an OCS affecting the posterior maxilla of a 42-year-old male patient was described. The lesion was immunostained for cell-cycle, cytokeratin (CK), and mesenchymal markers. A review of literature from 1960 to 2017 was conducted in a search for similar well-documented case reports. Descriptive statistics were calculated to compare clinical and pathological variables.ResultsIn the reported case, the percentage of Ki-67-positive epithelial and mesenchymal cells was estimated as 40% and 25%, respectively. Epithelial cells were focally positive for CKs 7, 8, 14, 18, and diffusely positive for CK19, p53, and p16. Mesenchymal cells were strongly positive for desmin, HHF-35, and vimentin. Our review showed that OCS is diagnosed mostly in advanced stage. All patients with relapsed tumors had died because of the disease.ConclusionsThe very few cases reported in the literature support that most OCSs develop in the posterior mandible in a wide age range, without gender and racial predilections. Only one other OCS case has been reported in the maxilla. Until today, the best treatment remains unknown.



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Spontaneous brain activity and connectivity in female patients with temporomandibular joint synovitis pain: a pilot functional magnetic resonance imaging study

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Juan Zhang, Xin Li, Zhen Jin, Meng Liang, Xuchen Ma
Objective.It has been proposed that mechanisms in the central nervous system contribute to the development and maintenance of pain in temporomandibular disorders. Here we tested whether spontaneous brain activity and functional connectivity (FC) were altered in patients with temporomandibular joint (TMJ) synovitis pain.Study design.A prospective, cross-sectional design was adopted. Each of 8 patients and 10 healthy controls (HCs) underwent two sessions of functional magnetic resonance imaging: mouth closed and mouth open (painful for patients). Regional Homogeneity (ReHo) was used to measure spontaneous brain activity in each participant. Brain areas with altered ReHo in patients compared to HCs were identified, and their FCs with the rest of the brain were examined and compared between groups.Results.Compared with the HCs, the patients showed decreased pain-related ReHo in the right anterior insula (rAI). The rAI showed a weaker positive FC with the left mid-cingulate cortex (MCC) and a weaker negative FC with the right precuneus in patients compared with HCs. Furthermore, the rAI-MCC FC showed a negative correlation with pain intensity in patients.Conclusions.These results provide evidence supporting altered pain-related spontaneous brain activity and functional connectivity in the central nervous system in patients with TMJ synovitis pain.



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Oral and maxillofacial metastasis of male breast cancer: report of a rare case and literature review

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Nathalia de Almeida Freire, Bruno Augusto Benevenuto de Andrade, Nathalie Henriques da Silva Canedo, Michelle Agostini, Mário José Romañach
Oral and maxillofacial metastatic tumors are uncommon, with the breast, prostate, lung and kidney representing the most common primary sites. Less than 1% of all breast cancers occur in male patients, and to date, only eight cases of metastatic breast adenocarcinoma to the oral and maxillofacial region in a male patient have been reported in the literature. An 88-year-old male with previous history of a successfully treated primary breast adenocarcinoma 12 years earlier was referred for evaluation of an oral swelling lasting 6 months. Intraoral examination revealed a 2 cm reddish, pedunculated nodule with a smooth surface located in the left retromolar region. Imaging revealed maxillary sinus involvement. The patient was submitted to incisional biopsy, and microscopic evaluation revealed invasive tumor islands compounded by malignant epithelial cells, sometimes exhibiting ductal arrangement, which were positive for the estrogen receptor and GCDFP-15. The final diagnosis was metastatic breast adenocarcinoma. Breast metastases are exceedingly rare in the oral and maxillofacial region of male patients; however, clinicians should consider breast metastasis when evaluating reddish oral nodules in older patients, including men, especially those with a history of malignancy.



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Lingual cyst with respiratory epithelium: report of two cases and review of the literature

Publication date: Available online 30 May 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Scott M. Peters, Mark Park, Michael A. Perrino, Molly Cohen
The lingual cyst with respiratory epithelium (LCRE) is a congenital cyst of the tongue or floor of mouth that is lined predominately by respiratory-type epithelium. The terminology for this lesion was first proposed by Manor et al. in 1999, who stated that a descriptive term is best for this cyst of debatable pathogenesis. Although it is a cyst of foregut origin, the LCRE is distinguished from the traditional enteric (foregut) duplication cyst in that the latter contains gastric and/or intestinal-type mucosa and has smooth muscle within the cyst wall. This article presents two new cases of this entity as well as reviews the nineteen cases in the literature that were found to fulfill the histologic criteria of a LCRE.



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Unravelling the molecular signatures in HNSCC: Is the homogenous paradigm becoming obsolete?

Dear Sirs,

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Upper airway morphologic changes after mandibular setback surgery in skeletal class III malocclusion patients measured using cone beam computed tomography superimposition

This study used the superimposition of cone beam computed tomography (CBCT) images to evaluate three-dimensional morphologic changes in the upper airway space of skeletal class III malocclusion patients with normally positioned maxilla who had undergone mandibular setback surgery.The upper airways of 18 subjects (10 males and eight females) who underwent mandibular setback surgery were assessed using CBCT superimposition at T0 (2weeks before surgery) and T1 (1year after surgery) according to the cervical vertebrae 1 (CV1), CV2, CV3 and CV4 reference planes on CBCT.

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Reconstrucción de defectos orofaríngeos tras cirugía transoral robótica. Revisión y recomendaciones de la Comisión de Cirugía de Cabeza y Cuello de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello

Publication date: Available online 30 May 2018
Source:Acta Otorrinolaringológica Española
Author(s): José Ángel González García, Carlos Pollán Guisasola, Carlos Miguel Chiesa Estomba, Constanza Viña Soria, David Virós Porcuna
La cirugía transoral de la orofaringe ha presentado una importante evolución en los últimos años, al ampliarse las opciones quirúrgicas disponibles (TORS, TOUSS, TOLS), la capacidad de resecar lesiones cada vez más extensas y el número de pacientes que se beneficia de ellas. Este hecho ha provocado una evolución en la reconstrucción de los defectos quirúrgicos tras cirugía transoral. Este artículo tiene como objetivo la revisión de las posibles técnicas reconstructivas, las indicaciones y factores que tener en cuenta previamente a la cirugía, además de proponer un protocolo para valorar la necesidad de reconstrucción transoral sobre la base de la profundidad del defecto, la estadificación y el tratamiento previamente recibido.Transoral surgery of the oropharynx has seen an important evolution in recent years, expanding the surgical options available (TORS, TOUSS, TOLS). The capacity to resect increasingly extensive lesions and the number of patients who benefit from them. This fact has led to an evolution in the reconstruction of surgical defects after transoral surgery. This article aims to review the possible reconstructive techniques, indications and factors to be taken into account prior to surgery, proposing a protocol to assess the need for transoral reconstruction based on the depth of the defect, the staging, and previous treatment.



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Monophasic Synovial Sarcoma of Tongue: A Rarest of Rare Case Scenario

Abstract

Synovial sarcoma is a rare tumour of head and neck. Primary synovial sarcoma of tongue is very uncommon. Based on morphology, it can be classified as classical biphasic variant, monophasic spindle cell variant, monophasic epithelial variant and poorly differentiated variant. The authors with an index case of 74 year old lady with monophasic spindle cell synovial sarcoma of oral tongue which is one of the rarest variants (our case is the 15th case reported of synovial sarcoma of the tongue and only the 3rd case in the world which had a monophasic histopathologic pattern) studied the morphology and described the disease entity in detail. She was treated with wide local excision of sarcoma followed by adjuvant radiotherapy.



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Robot Assisted Trans Axillary Thyroidectomy: A Subcontinent Experience



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Successful treatment of primary bone marrow Hodgkin lymphoma with brentuximab vedotin: a case report and review of the literature

Hodgkin lymphoma usually presents with sequential enlargement of peripheral lymph nodes, and bone marrow invasion rarely occurs (approximately 3–5%). However, several cases have been reported as "primary" bone...

https://ift.tt/2srgQMq

Trichophyton erinacei Transmitted to a Pregnant Woman From Her Pet Hedgehogs

This case report describes a pregnant woman who developed tinea manus from Trichophyton erinacei infection transmitted to her from her pet hedgehogs.

https://ift.tt/2IWzDdx

Lentigo Maligna—Challenges, Observations, Imiquimod, Confocal Microscopy, and Personalized Treatment

The word melanoma imparts considerable fear and concern in patients. Fortunately, for patients with the lentigo maligna (LM) subtype of melanoma in situ, there is overall good prognosis. The challenge of LM, however, is that it has the highest rate of local recurrence (approximately 20%) of all melanoma subtypes when treated by standard surgical excision alone, owing to frequent, unpredictable, subclinical extension. To reduce this risk, the use of Mohs surgery or staged excision has consistently demonstrated lower recurrence rates of 0.3% to 2.2% yet requires larger surgical margins for histological clearance than other in situ melanoma subtypes. Moyer et al also demonstrated that with increasing lesion size, both the surgical margin required to clear the lesion and the risk of local recurrence increased, suggesting increased subclinical spread with increasing lesion size. In addition, LM is typically located in the head and neck area, a complex zone with potential cosmetic and functional impairment owing to extensive surgery. Finally, differentiating LM from background atypical melanocytic hyperplasia can be challenging. Thus, treatments directed toward reducing the extent of surgery, minimizing morbidity, and providing a cure would enhance patient outcomes.

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Prevalence of Skin Cancer Examination Among Indoor Tanning Bed Users

This study uses weighted national survey data to examine the prevalence of skin cancer examinations among users of indoor tanning beds.

https://ift.tt/2IW6IGB

Lentigo Maligna Treated With Off-Label Neoadjuvant Imiquimod

This medical record review examines the rate of recurrence of lentigo maligna in patients treated with neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions.

https://ift.tt/2H3ShKP

Adolescents’ Perspectives on Atopic Dermatitis Treatment

This qualitative study examines the beliefs, experiences, and preferences of adolescents with atopic dermatitis toward their treatment via focus groups interviews.

https://ift.tt/2J0WQvu

Multidisciplinary management of oculo-auriculo-vertebral spectrum

Purpose of review Oculo-auriculo-vertebral spectrum (OAVS) is a complex disorder that is represented by wide variations in phenotypic presentation. Recent publications and systematic reviews of the available literature are presented here. Recent findings Treatment strategies vary among craniofacial centers across the country. Advances in presurgical planning, virtual surgical planning, and computer-aided manufacturing have been incorporated in the treatment of patients. The psychosocial effect of OAVS with longitudinal follow-up is now being studied. Summary Optimal evaluation and management of the OAVS patient requires an awareness of the phenotypic and genetic differences and involves a multidisciplinary team in order to effectively and appropriately diagnose and treat such patients. Correspondence to Jamie Funamura, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, 2521 Stockton Blvd, Ste 7200, Sacramento, CA 95817, USA. E-mail: jlfunamura@ucdavis.edu Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Deconstructive SCNT reveals novel Treg subsets

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Publication date: Available online 30 May 2018
Source:Journal of Allergy and Clinical Immunology
Author(s): Manching Ku, Eugene Ke, Mohsen Sabouri-Ghomi, Justin Abadejos, Brent Freeman, Amy Nham, Nathaniel Phillips, Kevin Y. Yang, Kathy O. Lui, Oktay Kirak

Teaser

Using single-cell transcriptomic and SCNT, we identify multiple distinct Treg subsets. We show that naturally occurring and agonist-induced Tregs are two of these subsets, which differ amongst in TCR strength, development, differentiation, and Ctla4 expression.


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Saturated fatty acids, obesity and the NLRP3 inflammasome in asthma

Publication date: Available online 30 May 2018
Source:Journal of Allergy and Clinical Immunology
Author(s): Lisa G. Wood, Qian Li, Hayley A. Scott, Sandra Rutting, Bronwyn S. Berthon, Peter G. Gibson, Phil M. Hansbro, Evan Williams, Jay Horvat, Jodie L. Simpson, Paul Young, Brian G. Oliver, Katherine J. Baines
BackgroundBoth obesity and high dietary fat intake activate the NLRP3 inflammasome.ObjectiveWe aimed to examine NLRP3 inflammasome activity in the airways of obese asthmatics, following macronutrient overload and in immune cells challenged by inflammasome triggers.MethodsStudy 1: Cross-sectional, observational study of non-obese (n=51) and obese (n=76) asthmatic adults. Study 2: Randomized, crossover, acute feeding study in 23 asthmatic adults (n=12 non-obese, n=11 obese). Subjects consumed 3 isocaloric meals on 3 separate occasions: saturated fatty acid (SFA), n-6 polyunsaturated (PUFA) and carbohydrate (CHO); and were assessed at 0 and 4 hours. For Study 1 and 2, airway inflammation was measured using sputum differential cell counts, IL-1β protein (ELISA) and sputum cell gene expression (Nanostring nCounter). Study 3: Peripheral blood neutrophils and monocytes were isolated using Ficoll density gradient and magnetic bead separation, and incubated with or without palmitic acid, LPS or TNFα for 24 hours and IL-1β release measured (ELISA).ResultsStudy 1: NLRP3 and NOD1 gene expression were upregulated, and sputum IL-1β protein levels higher, in obese versus non-obese asthmatics. Study 2: The SFA meal led to increases in sputum %neutrophils and sputum cell gene expression of TLR4 and NLRP3 at 4 hours, in non-obese asthmatics. Study 3: Neutrophils and monocytes released IL-1β when challenged with a combination of palmitic acid and LPS or TNFα.ConclusionThe NLRP3 inflammasome is a potential therapeutic target in asthma. Behavioural interventions that reduce fatty acid exposure, such as weight loss and dietary saturated fat restriction warrant further exploration.Clinical implicationsBoth obesity and saturated fat intake cause NLRP3 inflammasome-mediated airway inflammation in asthma. Hence weight loss and dietary fat restriction warrant further exploration as anti-inflammatory strategies in asthma.

Graphical abstract

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Teaser

The NLRP3 inflammasome is upregulated in obese asthmatics and following a high saturated fat meal in non-obese asthmatics. Both reversal of obesity and restriction of dietary saturated fat intake warrant further exploration as anti-inflammatory strategies in asthma.


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Ketamine Anesthesia Does Not Improve Depression Scores in Electroconvulsive Therapy: A Randomized Clinical Trial

Background: Although interest in ketamine use during electroconvulsive therapy (ECT) has increased, studies have been equivocal with regard to its efficacy. The aims of this clinical trial were to evaluate ketamine's antidepressive effects in ECT as a primary anesthetic, determine ketamine's tolerability when compared with standard anesthesia, and determine if plasma brain-derived neurotrophic factor (BDNF) is necessary for treatment response. Materials and Methods: Adults meeting criteria for treatment-resistant depression undergoing index course ECT received either methohexital (1 to 2 mg/kg) or ketamine (1 to 2 mg/kg) anesthesia in this dual-arm double-blinded randomized clinical trial (NCT02752724). The primary outcome of this study is change in depression questionnaire scores before and after ECT. Seizure data, depression severity using self-reported and clinician-assessed questionnaires, cognitive scoring, and plasma BDNF concentrations were obtained before and after completion of ECT. Results: There were no differences in seizure lengths, hemodynamics, or seizure stimuli between the ketamine (n=23;138 ECTs) and methohexital (n=27;159 ECTs) groups. Depression scores improved similarly after ECT in both groups. In the methohexital group, 15% of patients failed to achieve adequate seizures and were switched to ketamine and 26% were converted to bilateral ECT stimulus, whereas all ketamine patients achieved adequate seizures and only 4% required bilateral stimulus. Plasma BDNF increased after ECT only in the ketamine group. Conclusions: Our data show that ketamine does not significantly improve depression when compared with methohexital as a single induction agent for ECT, increases serum BDNF and does not increase rates of post-ECT agitation. Ketamine use in ECT may have some benefits for some patients that are not captured through standard depression assessment questionnaires alone. This work was supported in part by a Pilot Project Award #850 from the United States Department of Veterans Affairs. The content does not represent the views of the United States Department of Veterans Affairs or the United States Government. The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The authors have no conflicts of interest to disclose. Address correspondence to: Charles William Carspecken, MD, MSc, MBA, Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3620 Hamilton Walk, Philadelphia, PA 19104 (e-mail: charles.carspecken@uphs.upenn.edu). Received March 2, 2018 Accepted April 23, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Automated Assessment of Existing Patient’s Revised Cardiac Risk Index Using Algorithmic Software

BACKGROUND: Previous work in the field of medical informatics has shown that rules-based algorithms can be created to identify patients with various medical conditions; however, these techniques have not been compared to actual clinician notes nor has the ability to predict complications been tested. We hypothesize that a rules-based algorithm can successfully identify patients with the diseases in the Revised Cardiac Risk Index (RCRI). METHODS: Patients undergoing surgery at the University of California, Los Angeles Health System between April 1, 2013 and July 1, 2016 and who had at least 2 previous office visits were included. For each disease in the RCRI except renal failure—congestive heart failure, ischemic heart disease, cerebrovascular disease, and diabetes mellitus—diagnosis algorithms were created based on diagnostic and standard clinical treatment criteria. For each disease state, the prevalence of the disease as determined by the algorithm, International Classification of Disease (ICD) code, and anesthesiologist's preoperative note were determined. Additionally, 400 American Society of Anesthesiologists classes III and IV cases were randomly chosen for manual review by an anesthesiologist. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve were determined using the manual review as a gold standard. Last, the ability of the RCRI as calculated by each of the methods to predict in-hospital mortality was determined, and the time necessary to run the algorithms was calculated. RESULTS: A total of 64,151 patients met inclusion criteria for the study. In general, the incidence of definite or likely disease determined by the algorithms was higher than that detected by the anesthesiologist. Additionally, in all disease states, the prevalence of disease was always lowest for the ICD codes, followed by the preoperative note, followed by the algorithms. In the subset of patients for whom the records were manually reviewed, the algorithms were generally the most sensitive and the ICD codes the most specific. When computing the modified RCRI using each of the methods, the modified RCRI from the algorithms predicted in-hospital mortality with an area under the receiver operating characteristic curve of 0.70 (0.67–0.73), which compared to 0.70 (0.67–0.72) for ICD codes and 0.64 (0.61–0.67) for the preoperative note. On average, the algorithms took 12.64 ± 1.20 minutes to run on 1.4 million patients. CONCLUSIONS: Rules-based algorithms for disease in the RCRI can be created that perform with a similar discriminative ability as compared to physician notes and ICD codes but with significantly increased economies of scale. Accepted for publication March 5, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. I. S. Hofer and A. Mahajan are working with counsel to patent the algorithms for the diseases described in this article. Reprints will not be available from the authors. Address correspondence to Ira S. Hofer, MD, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095. Address e-mail to ihofer@mednet.ucla.edu. © 2018 International Anesthesia Research Society

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What Does a Red Meat Allergy Have to Do With Anesthesia? Perioperative Management of Alpha-Gal Syndrome

Over the past decade, there has been a growing awareness of a new allergic syndrome known as alpha-gal allergy or alpha-gal syndrome, commonly recognized as a red meat allergy. We performed a review of the literature to identify articles that provide both background on this syndrome in general and any reports of reactions to medications or medical devices related to alpha-gal syndrome. Alpha-gal syndrome results from IgE to the oligosaccharide galactose-α-1,3-galactose, expressed in the meat and tissues of noncatarrhine mammals. It is triggered by the bite of the lone star tick and has been implicated in immediate-onset hypersensitivity to the monoclonal antibody cetuximab and delayed-onset hypersensitivity reactions after the consumption of red meat. There is growing recognition of allergic reactions in these patients to other drugs and medical devices that contain alpha-gal. Many of these reactions result from inactive substances that are part of the manufacturing or preparation process such as gelatin or stearic acid. This allergy may be documented in a variety of ways or informally reported by the patient, requiring vigilance on the part of the anesthesiologist to detect this syndrome, given its serious implications. This allergy presents a number of unique challenges to the anesthesiologist, including proper identification of a patient with alpha-gal syndrome and selection of anesthetic and adjunctive medications that will not trigger this allergy. Accepted for publication April 16, 2018. Funding: Institutional and/or departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to W. Jonathan Dunkman, MD, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to william.dunkman@duke.edu. © 2018 International Anesthesia Research Society

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Pain Medicine Board Review

No abstract available

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Assessing the Association Between Blood Loss and Postoperative Hemoglobin After Cesarean Delivery: A Prospective Study of 4 Blood Loss Measurement Modalities

BACKGROUND: Visual estimation and gravimetric methods are commonly used to quantify the volume of blood loss during cesarean delivery (CD). However, the correlation between blood loss and post-CD hemoglobin (Hb) is poorly studied, and it is unclear whether the correlation varies according to how blood loss is measured. METHODS: After obtaining Institutional Review Board approval, we performed a prospective study of 61 women undergoing CD to assess the relations between post-CD Hb and blood loss measured using 4 modalities: gravimetric blood loss measurement (gBL), visual blood loss estimation by a blinded obstetrician (oBL) and anesthesiologist (aBL), and the Triton System (tBL). Hb was measured preoperatively and within 10 minutes after CD. gBL was quantified as blood volume in a suction canister in addition to the weight of blood-soaked sponges. tBL was measured with the Triton System by photographing blood-soaked sponges and suction canister contents. To assess the relation between blood loss and post-CD Hb, we performed correlation analyses and compared the magnitude of the correlations across the 4 measurement modalities using William t test. A Bonferroni correction was set to identify a statistically significant correlation (P

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Phentolamine Reverses Epinephrine-Enhanced Skin Antinociception of Dibucaine in Rats

BACKGROUND: The objective of the experiment was to assess the antinociceptive effect of dibucaine, bupivacaine, and epinephrine. To assess the mechanism of action of the interaction between dibucaine and epinephrine, phentolamine, a nonselective α-adrenergic antagonist, was added to the mixture. METHODS: We assessed sensory blockade with these drugs by injecting 0.6 mL of drug-in-saline in the dorsal thoracolumbar area of rats; pinprick of the "wheal" formed by the injectate was the area targeted for stimulation to elicit a cutaneous trunci muscle reflex. The sensory block of dibucaine was compared with that of bupivacaine or epinephrine. Drug–drug interactions were analyzed by isobologram. Phentolamine was added to investigate the antinociceptive effect of dibucaine coinjected with epinephrine. RESULTS: We demonstrated that dibucaine, epinephrine, and bupivacaine produced dose-dependent skin antinociception. On the median effective dose (ED50) basis, the potency was higher for epinephrine (mean, 0.011 [95% confidence interval {CI}, 0.007–0.015] μmol) than for dibucaine (mean, 0.493 [95% CI, 0.435–0.560] μmol) (P

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Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study

BACKGROUND: Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better analgesia and reduces opioid use compared with conventional repeated dosing of short-duration opioids. This investigation tested the hypothesis that in same-day ambulatory surgery, intraoperative methadone, compared with short-duration opioids, reduces opioid consumption and pain, and determined an effective intraoperative induction dose of methadone for same-day ambulatory surgery. METHODS: A double-blind, dose-escalation protocol randomized 60 patients (2:1) to intraoperative single-dose intravenous methadone (initially 0.1 then 0.15 mg/kg ideal body weight) or conventional as-needed dosing of short-duration opioids (eg, fentanyl, hydromorphone; controls). Intraoperative and postoperative opioid consumption, pain, and opioid side effects were assessed before discharge. Patient home diaries recorded pain, opioid use, and opioid side effects daily for 30 days postoperatively. Primary outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30 days opioid consumption, pain intensity, and opioid side effects. RESULTS: Median (interquartile range) methadone doses were 6 (5–6) and 9 (8–9) mg in the 0.1 and 0.15 mg/kg methadone groups, respectively. Total opioid consumption (morphine equivalents) in the postanesthesia care unit was significantly less compared with controls (9.3 mg, 1.3–11.0) in subjects receiving 0.15 mg/kg methadone (0.1 mg, 0.1–3.3; P

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Mixing Studies in Patients With Prolonged Activated Partial Thromboplastin Time or Prothrombin Time

BACKGROUND: Patients presenting for surgery may have isolated or combined prolonged activated partial thromboplastin time (aPTT) and/or prothrombin time (PT). In patients not receiving anticoagulants or with no identifiable cause for abnormal clot formation, a mixing study is performed. The index of circulating anticoagulant (ICA) has been used to predict the presence of an inhibitor, usually a lupus anticoagulant. METHODS: We retrospectively reviewed the results of mixing studies performed at Northwestern Memorial Hospital, between January 1, 2010 and February 29, 2012. We determined the number of samples that normalized or remained prolonged, the clotting factors associated with prolonged test results, and the presence of coagulation inhibitors. We calculated the ICA in the samples with prolonged aPTT and PT to determine its ability to predict a lupus anticoagulant. The primary comparison of interest was the diagnostic utility of the ICA at cutoff values of 11% for predicting the presence of lupus anticoagulant. RESULTS: There were 269 mixing studies performed: 131 samples with prolonged aPTT; 95 with prolonged PT; and 43 with both prolonged aPTT and prolonged PT. Of the samples with a prolonged aPTT, 55 of 131 (42%) normalized, 36 of 131 (27%) partially corrected, and 40 of 131 (31%) remained prolonged. Thirty-three of 95 samples (35%) with prolonged PT normalized, while 62 of 95 (65%) remained prolonged. Eight of 43 (19%) mixing studies of patients with prolonged PT and aPTT normalized; the aPTT normalized, but the PT remained prolonged in 17 of 43 (39%); the PT normalized, but the aPTT remained prolonged in 7 of 43 (16%); and both tests remained prolonged in 11 of 43 (26%) samples. Prolongations in the aPTT were primarily associated with low activities of CF XII, while the majority of the prolongations in PT were secondary to low activities in CF VII. Combined prolongations were secondary to deficiencies in both the intrinsic and extrinsic as well as the common pathways. An ICA >11% had 100% (95% CI, 59%–100%) sensitivity, 53% (95% CI, 35%–70%) specificity, and 77% (95% CI, 62%–92%) accuracy in predicting the presence of lupus anticoagulant in patients with prolonged aPTT. CONCLUSIONS: Normalization of the aPTT and PT in a mixing study was associated with low clotting factor activity. The ICA may be helpful in predicting the presence of a lupus anticoagulant. As anesthesiologists take ownership of the perioperative surgical home, we need to understand the clinical implications of the results of mixing studies. Accepted for publication April 12, 2018. Funding: Departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Honorio T. Benzon, MD, Northwestern University Feinberg School of Medicine, 251 E Huron, Feinberg Pavilion, 5–704, Chicago, IL 60611. Address e-mail to h-benzon@northwestern.edu. © 2018 International Anesthesia Research Society

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Opening the Black Box: Understanding the Science Behind Big Data and Predictive Analytics

Big data, smart data, predictive analytics, and other similar terms are ubiquitous in the lay and scientific literature. However, despite the frequency of usage, these terms are often poorly understood, and evidence of their disruption to clinical care is hard to find. This article aims to address these issues by first defining and elucidating the term big data, exploring the ways in which modern medical data, both inside and outside the electronic medical record, meet the established definitions of big data. We then define the term smart data and discuss the transformations necessary to make big data into smart data. Finally, we examine the ways in which this transition from big to smart data will affect what we do in research, retrospective work, and ultimately patient care. Accepted for publication March 22, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Ira S. Hofer, MD, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095. Address e-mail to ihofer@mednet.ucla.edu. © 2018 International Anesthesia Research Society

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Reversing Cholinergic Bronchoconstriction by Common Inotropic Agents: A Randomized Experimental Trial on Isolated Perfused Rat Lungs

BACKGROUND: The ability of inotropic agents to alter airway reactivity and lung tissue mechanics has not been compared in a well-controlled experimental model. Therefore, we compared the potential to alter lung tissue viscoelasticity and bronchodilator effects of commonly used inotropic agents in an isolated perfused rat lung model. METHODS: After achieving steady state lung perfusion, sustained bronchoconstriction was induced by acetylcholine (ACh). Isolated rat lungs were then randomly allocated to 6 groups treated with either saline vehicle (n = 8) or incremental concentrations of inotropes (adrenaline, n = 8; dopamine, n = 7; dobutamine, n = 7; milrinone, n = 8; or levosimendan, n = 6) added to the whole-blood perfusate. Airway resistance (Raw), lung tissue damping (G), and elastance were measured under baseline conditions, during steady-state ACh-induced constriction and for each inotrope dose. RESULTS: No change in Raw was observed after addition of the saline vehicle. Raw was significantly lower after addition of dopamine (maximum difference [95% CI] of 29 [12–46]% relative to the saline control, P = .004), levosimendan (58 [39–77]%, P

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The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort

BACKGROUND: The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding. METHODS: In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ2 test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks. RESULTS: The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P

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Readiness for Discharge After Foot and Ankle Surgery Using Peripheral Nerve Blocks: A Randomized Controlled Trial Comparing Spinal and General Anesthesia as Supplements to Nerve Blocks

BACKGROUND: Neuraxial anesthesia is often viewed as superior to general anesthesia but may delay discharge. Comparisons do not typically use multimodal analgesics and nerve blockade. Combining nerve blockade with general anesthesia may reduce pain, opioid consumption, and nausea. We hypothesized that general anesthesia (with nerve blocks) would lead to earlier readiness for discharge, compared to spinal anesthesia (with nerve blocks). METHODS: All patients underwent ambulatory foot and ankle surgery, with a predicted case duration of 1–3 hours. All patients received popliteal and adductor canal nerve blocks using bupivacaine and dexamethasone. No intraoperative opioids were administered. All patients received ondansetron, dexamethasone, ketamine, and ketorolac. Patients, data collectors, and the data analyst were not informed of group assignment. Patients were randomized to spinal or general anesthesia with concealed allocation. Spinal anesthesia was performed with mepivacaine and accompanied with propofol sedation. After general anesthesia was induced with propofol, a laryngeal mask airway was inserted, followed by sevoflurane and propofol. Time until ready for discharge, the primary outcome, was compared between groups after adjusting for age and surgery time using multivariable unconditional quantile regression. Secondary outcomes compared at multiple timepoints were adjusted for multiple comparisons using the Holm–Bonferroni step-down procedure. RESULTS: General anesthesia patients were ready for discharge at a median of 39 minutes earlier (95% confidence interval, 2–75; P = .038) versus spinal anesthesia patients. Patients in both groups met readiness criteria for discharge substantially before actual discharge. Pain scores at rest were higher among general anesthesia patients 1 hour after leaving the operating room (adjusted difference in means, 2.1 [95% confidence interval, 1.0–3.2]; P

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In Response

No abstract available

https://ift.tt/2Jd4rWS

Opioid Use Disorders: Perioperative Management of a Special Population

Opioid-related overdose deaths have reached epidemic levels within the last decade. The efforts to prevent, identify, and treat opioid use disorders (OUDs) mostly focus on the outpatient setting. Despite their frequent overrepresentation, less is known about the inpatient management of patients with OUDs. Specifically, the perioperative phase is a very vulnerable time for patients with OUDs, and little has been studied on the optimal management of acute pain in these patients. The preoperative evaluation should aim to identify those with OUDs and assess factors that may interfere with OUD treatment and pain management. Efforts should be made to provide education and assistance to patients and their support systems. For those who are actively struggling with opioid use, the perioperative phase can be an opportunity for engagement and to initiate treatment. Buprenorphine, methadone, and naltrexone medication treatment for OUD and opioid tolerance complicate perioperative pain management. A multidisciplinary team approach is crucial to provide clinically balanced pain relief without jeopardizing the patient's recovery. This article reviews the existing literature on the perioperative management of patients with OUDs and provides clinical suggestions for the optimal care of this patient population. Accepted for publication March 22, 2018. Funding:None. 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). Reprints will not be available from the authors. Address correspondence to Emine Nalan Ward, MD, Department of Psychiatry, Massachusetts General Hospital, 16 Blossom St, Boston, MA 02114. Address e-mail to enward@partners.org. © 2018 International Anesthesia Research Society

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The Use of Hydroxyethyl Starch 130/0.4 in Surgery Patients

No abstract available

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Efficacy of Malignant Hyperthermia Association of the United States–Recommended Methods of Preparation for Malignant Hyperthermia-Susceptible Patients Using Dräger Zeus Anesthesia Workstations and Associated Costs

BACKGROUND: The objective of this study was to assess the efficacy and cost of Malignant Hyperthermia Association of the United States–recommended methods for preparing Dräger Zeus anesthesia workstations (AWSs) for the malignant hyperthermia-susceptible patient. METHODS: We studied washout profiles of sevoflurane, isoflurane, and desflurane in 3 Zeus AWS following 3 preparation methods. AWS was primed with 1.2 minimum alveolar concentration anesthetic for 2 hours using 2 L/min fresh gas flow, 500 mL tidal volume, and 12/min respiratory rate. Two phases of washout were performed: high flow (10 L/min) until anesthetic concentration was

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Supraglottoplasty surgery types 1–3: A practical classification system for laryngomalacia surgery

Publication date: August 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 111
Author(s): Michael Del Do, Sungjin A. Song, Nicholas B. Nesbitt, Mark C. Spaw, Edward T. Chang, Bryan J. Liming, Benjamin B. Cable, Macario Camacho
ObjectiveThe objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system.MethodsThree authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system.Results231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery.ConclusionThis descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.



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Is the evidence of local allergic rhinitis growing?

Purpose of review To examine the recent advances on epidemiological studies, diagnostic approach and clinical management of local allergic rhinitis (LAR) in adults and children. Recent findings Evidence about LAR is growing especially in pediatric and Asian populations. The prevalence of LAR is lower in Asian countries compared with western countries in both children and adults. LAR is considered a chronic condition and an independent rhinitis phenotype that affects up to 26.5% of nonatopic rhinitis patients. The disease rapidly progress toward the clinical worsening with associated onset of asthma and conjunctivitis, which further impairs patient's quality of life. Nasal Allergen Provocation Test is the diagnostic gold standard that can be complemented by basophil activation test and the detection of specific IgE in nasal secretions. Allergen immunotherapy induces a significant and early improvement in both clinical symptoms and quality of life in LAR patients. Summary LAR is a common entity, with different prevalence depending on geographical locations. LAR has to be considered in the process of differential diagnosis in children and adults with rhinitis. Diagnosis of LAR is crucial in order to start an etiologic treatment such as allergen immunotherapy, which has proven to be very effective in these patients. Correspondence to Carmen Rondón, MD, PhD, Laboratorio de Investigación, Hospital Civil, pabellón 5, sótano, Plaza del Hospital Civil, 29009 Malaga, Spain. Tel: +34 951290313; fax: +34 951290302; e-mail: carmenrs61@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Multidisciplinary management of oculo-auriculo-vertebral spectrum

Purpose of review Oculo-auriculo-vertebral spectrum (OAVS) is a complex disorder that is represented by wide variations in phenotypic presentation. Recent publications and systematic reviews of the available literature are presented here. Recent findings Treatment strategies vary among craniofacial centers across the country. Advances in presurgical planning, virtual surgical planning, and computer-aided manufacturing have been incorporated in the treatment of patients. The psychosocial effect of OAVS with longitudinal follow-up is now being studied. Summary Optimal evaluation and management of the OAVS patient requires an awareness of the phenotypic and genetic differences and involves a multidisciplinary team in order to effectively and appropriately diagnose and treat such patients. Correspondence to Jamie Funamura, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California Davis, 2521 Stockton Blvd, Ste 7200, Sacramento, CA 95817, USA. E-mail: jlfunamura@ucdavis.edu Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Development and Assessment of a Transoral Robotic Surgery Curriculum to Train Otolaryngology Residents

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Purpose of the Study: (1) To develop a multifaceted didactic and hands-on curriculum to prepare otolaryngology residents to perform transoral robotic surgery (TORS) and safely transition to the operating room. (2) To assess the effectiveness of the TORS curriculum. Procedures: Learning objectives were developed and a curriculum was formulated utilizing five unique modalities: focused didactic reading, online training modules, backpack console simulations, videos of TORS cases, and hands-on cadaveric dissections with the robotic surgical system in a simulated operating room. The trainees completed a nine-item self-assessment of their skill level using a Likert scale. Results: Five senior otolaryngology residents completed the TORS curriculum. Before and after the cadaveric dissections, there was improvement in each of the nine items assessed. Composite scores were calculated and there was significant improvement from predissection (15.2 ± 2.2) to postdissection (31.4 ± 1.9) (p = 0.002). Conclusions: The current study demonstrates the feasibility of implementing a multifaceted TORS curriculum which incorporates robotic cadaveric dissection for otolaryngology residents. Residents demonstrate marked improvement in skills with the TORS curriculum. A TORS curriculum which includes robotic cadaveric dissection can improve surgical skills and serve as a key component of residency TORS education.
ORL 2018;80:69–76

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Follicular dendritic cell sarcoma presenting as a painless lump in the parotid

Follicular dendritic cell sarcoma (FDCS) is a rare neoplasm of the antigen presenting cells of the immune system. The majority occur in lymph nodes but around 30% can occur extranodally including in the spleen, lungs, head and neck and liver. We present an unusual case of an FDCS of the parotid gland in a 51-year-old woman with a history of Hodgkin's lymphoma treated with combination chemotherapy and modified mantle radiotherapy. Only four cases of an intraparotid FDCS have been previously reported. The patient underwent a superficial parotidectomy and level 2/3 neck dissection. A diagnosis of an intraparotid FDCS (25 mm) with no nodal disease was made. Given this patient's history of radiotherapy 20 years previously, we speculate the possibility of postradiation sarcoma.



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Maxillary sinus schwannoma

Schwannoma (neurilemmoma) is a benign tumour that arises from the Schwann cells which cover the nerve sheaths of the peripheral or autonomic nervous system especially the sympathetic system. Reported cases of schwannoma arising from the sinonasal tract are rare. We report a case of a 28-year-old man who presented to otolaryngology—head and neck surgery clinic with left cheek swelling and left-sided nasal obstruction for 1-year period. Endoscopic examination and high-resolution CT scan revealed a homogenous expansile mass occupying the left maxillary antrum extending to the left orbit and left ethmoidal air cells. The mass was excised through endoscopic endonasal approach followed by Caldwell-Luc approach for the residual tumour. Postoperative histopathological examination revealed benign type Antoni A schwannoma.



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Unusual presentation of Henöch-Schonlein purpura

We present a rare case of a 4-year-old boy with newly diagnosed Henöch-Schonlein purpura (HSP) affecting the scrotum and penis. The patient presented to the emergency department with palpable purpura symmetrically distributed over the lower limbs. This was associated with arthritis of the right knee, abdominal pain and scrotal swelling. These symptoms were preceded by an upper respiratory tract infection (URTI). The patient was initially treated with empirical oral antibiotics for epididymitis and was discharged. He subsequently re-presented 12 days later with penile swelling, erythema and tenderness. An ultrasound scan of the penis revealed grossly oedematous subcutaneous tissue with normal penile architecture. His symptoms resolved spontaneously and the patient remains under close follow-up by the paediatric team for further sequelae of HSP.



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Toe walking after three: how serious could it be?

A 4-year-old girl with no significant medical or family history presented with toe walking, leg pain, unsteady gait and frequent falls for 2 months. Examination revealed upper motor neuron signs in the lower extremities. Laboratory tests were normal including creatinephosphokinase and lactate dehydrogenase. Brain and lumbar spine MRI were normal. MRI cervical and thoracic spine showed a large intradural and extradural mass arising from the right C7 nerve root, widening of the neural canal with evidence of cord compression. She underwent C6–C7 laminectomy with excision of the tumour. Pathology revealed spindle cell tumour with extensive expression of S100 protein and CD56, with Ki-67 proliferation index of 1%–2% consistent with benign schwannoma. She made an excellent recovery following surgery and physiotherapy sessions. Review of literature shows rare reported case of schwannoma prior to the third decade of life.



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A 3-month-old infant with atypical Kawasaki disease

We report a 3-month-old girl who presented with high-grade fever for 3 days. Her initial physical examination was normal. Investigation showed abnormal white cells in her urine. She was diagnosed with a urinary tract infection and received an antibiotic for 1 day. After that, she developed a generalised maculopapular rash over her body. An adverse drug reaction from the antibiotic was suspected, and the patient was referred to our hospital. On admission, she still had fever and was irritable. She was diagnosed with sepsis and given another broad-spectrum antibiotic for 2 days. However, her fever still persisted. An additional thorough physical examination showed redness of her BCG inoculation scar. Consequently, a diagnosis of Kawasaki disease (KD) was made. After she received intravenous immunoglobulin, her fever diminished straight away. This case highlights an unusual manifestation of KD in an uncommonly young age group.



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Denosumab causing severe, refractory hypocalcaemia in a patient with chronic kidney disease

Denosumab is a fully human monoclonal antibody that is being increasingly used for the treatment of osteoporosis and prevention of skeletal-related events (SREs) in bone metastases from primary tumours. It has improved efficacy, better tolerability and convenient administration via subcutaneous route, in comparison with bisphosphonates; however, it has been reported to cause severe hypocalcaemia in certain high-risk individuals. We report the case of a 71-year-old man with a history of haemodialysis-dependent end-stage renal disease who developed severe hypocalcaemia with electrocardiographic changes after being started on denosumab for prevention of SREs from a recently diagnosed metastatic prostate cancer. He was admitted to the hospital for close monitoring and received multiple doses of intravenous calcium gluconate, along with haemodialysis with high calcium bath. We aim to highlight the risk of severe, life-threatening hypocalcaemia associated with denosumab and to recognise patients at risk of developing this serious adverse effect, so that prompt treatment and preventive strategies can be implemented.



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Subcutaneous oedema of upper limbs heralding an aggressive form of dermatomyositis

Subcutaneous oedema is a rare presenting clinical manifestation of dermatomyositis. In this case, we report a 44-year-old man presenting with bilateral upper extremity predominant swelling and weakness. The proximal muscle weakness, dysphagia and presence of Gottron's papules as well poikiloderma like skin changes led to the clinical diagnosis of dermatomyositis. He received aggressive treatment with high-dose glucocorticoids and required intravenous immunoglobulin with improvement in his symptoms.



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Lactation ketoacidosis: case presentation and literature review

A 35-year-old woman presented to the emergency department with a 2 days history of malaise and headache. She was breastfeeding her 5-month old infant and had recently started an altered diet based on reducing carbohydrate amount. Moreover, she had also started exercising 2 weeks prior to her illness. Initial blood tests revealed high anion gap metabolic acidosis and hypoglycaemia (pH 7.13 (normal 7.30–7.40), bicarbonate 9.4 mmol/L (normal 21.0–28.0), anion gap 22.6 mmol/L (normal 8–12), glucose 2.9 mmol/L (normal fasting 3.9–5.8) and ketones 6.4 mmol/L (normal <0.6)). The patient was treated with intravenous dextrose and showed complete resolution of ketoacidosis and hypoglycaemia within 48 hours. She was discharged home and remained well with a balanced diet. After excluding all other the causes of hypoglycaemia and ketoacidosis, the diagnosis of lactation ketoacidosis was made and it was considered triggered by altered diet, exercise and skipping meals. All 11 cases of lactation ketoacidosis which has previously been published are reviewed as well.



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Myeloid sarcoma of the small intestine in a patient without overt acute myeloid leukaemia: a challenging diagnosis of a rare condition

Myeloid sarcoma (MS) is a rare condition that most commonly occurs in the setting of acute myeloidleukaemia (AML) or other chronic myeloproliferative disorders. It presents as an abnormal growth that can develop anywhere in the human body, and its clinical manifestations are often non-specific.

We present the case of a patient admitted to the emergency room with bowel obstruction. After careful clinical assessment, she underwent a right hemicolectomy. After a thorough examination of the surgical pathology specimen, including testing a wide array of immunohistochemical markers, the patient was timely diagnosed with MS, allowing for the implementation of the appropriate treatment to achieve complete remission. This is crucial, since non-leukaemic patients with untreated MS always progress to AML, and have a better prognosis if adequate therapy is implemented early. Our patient is now in the second postoperative year and shows no signs of relapse.



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Left ventricular mural thrombus despite treatment with dabigatran and clopidogrel

We describe a case with severe heart failure and moderate aortic stenosis. Due to previous atrial fibrillation and ischaemic heart disease, this patient was treated with both dabigatran and clopidogrel. Despite this, a large mural thrombus was found on echocardiography. The treatment was altered to warfarin, but the thrombus did not resolve during the next eight months.

Guidelines for the use of anticoagulant treatment in left ventricular thrombus are needed. Previously, a few cases presenting resistance to novel oral anticoagulants have been published and cases with thrombus formation due to dabigatran have been described. Our patient showed resistance to both dabigatran and warfarin, and there was no thrombus resolution when changing the treatment to warfarin.



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Facilitated subcutaneous immunoglobulin treatment in pemphigus vulgaris

A novel administration strategy of immunoglobulin treatment is represented by injection of recombinant human hyaluronidase (rHUPH20) with subcutaneous immunoglobulins. The use of facilitated subcutaneous immunoglobulin treatment (fSCIG) for the treatment of autoimmune conditions is yet to be investigated. We present the case of a 56-year-old female patient with pemphigus vulgaris predominantly of the oral mucous membranes, previously treated for 24 months with azathioprine and medium doses of steroids, with only partial remission. When she came to our attention, a concomitant newly diagnosed infiltrating ductal breast cancer limited the use of immunosuppressive agents. She was started with fSCIG (25 g/monthly). After 18 months of follow-up, her breast cancer has been successfully treated and a substantial decrease of the rate of bullous mucous lesions and improvement of time to lesion healing and resolution was observed. fSCIG might represent a steroid-sparing tool for the treatment of selected cases of pemphigus vulgaris.



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Congenital limb deficiency requiring transfemoral amputation

A healthy female infant was born from a twin pregnancy with an isolated congenital lower extremity malformation. Aside from prenatally diagnosed polyhydramnios, the infant had normal prenatal and postnatal diagnostic workup. She underwent transfemoral amputation and healed uneventfully. Congenital limb anomalies may be the result of an unidentified amniotic band, thromboembolic event or twin–twin transfusion syndrome, though in this case, prenatal screening did not indicate any evidence of a limb anomaly and postnatal workup was negative.



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Renal cell carcinoma with sarcomatoid transformation, presenting as skin rashes

A 68-year-old man presented to our outpatient department, with chief complaints of rashes all over the body. On physical examination, purpuric rashes were present over all four limbs and a lump was palpable in right flank. Contrast-enhanced CT scan showed enhancing large right renal mass. He underwent right radical nephrectomy, and histopathological analysis showed features of renal cell carcinoma. Skin lesions disappeared after surgery.



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Giant cell lesion of the jaw as a presenting feature of Noonan syndrome

This is a case of a 20-year-old woman who presented with a left jaw mass which was resected and found to be a giant cell granuloma of the mandible. Her history and physical examination were suggestive for Noonan syndrome which was confirmed with genetic testing and the finding of a PTPN11 gene mutation which has rarely been associated with giant cell lesions of the jaw. Given her particular genetic mutation and the presence of a giant cell lesion, we present a case of Noonan-like/multiple giant cell lesion syndrome.



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Endometrial metastasis of primary malignant melanoma of the brain

Endometrial metastatic malignant melanoma is a rare occurrence from any primary site. A literature search has revealed only 15 reported cases in existing literature, majority of which originated from a primary cutaneous lesion. This is a case of endometrial metastasis of primary malignant melanoma of the brain, the first reported case of its kind. The rarity of endometrial metastatic melanoma may incline clinicians to neglect the importance of malignant melanoma in a patient's history when they present with abnormal uterine bleeding. However, with increasing rates of primary malignant melanoma, it is likely that the incidence of metastasis to rare sites, such as the endometrium, is also likely to increase. For those women with metastatic disease confined to the uterus, total abdominal hysterectomy +/-bilateral salpingo-oophorectomy improved prognosis considerably. Newer BRAF molecular testing and targeted adjuvant therapy may also significantly improve prognosis in addition to surgical resection and should be considered.



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Superior sagittal sinus thrombosis in a case of Mixed Connective Tissue Disease

Description 

A 21-year-old man presented with fever and left-sided chest pain since 4 days. His medical and family history were insignificant, with no history of rheumatological disease.

On examination, he was tachypnoeic (with a respiratory rate of 28/min), tachycardic (with a pulse of 120/min), febrile (with a temperature of 101°F) and had a stony dull note on percussing the left side of the chest, with decreased vesicular breath sounds on auscultation on the same side.

X-ray of the chest revealed bilateral pleural effusion (figure 1) which was aspirated and was found to be exudative in character, and there were 2100 cells, of which 65% were neutrophils; pleural fluid Adenosine Deaminase, Gene Xpert, culture, staining and cytology were negative. Blood culture was negative, and his complete blood count showed leucocytosis. Erythrocyte sedimentation rate was 65 mm/hour, Antinuclear Antibodies(ANA) was 4+ (speckled pattern) and C3, C4 levels were low, anti-U1RNP antibody was positive,...



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A chronic alcoholic man with high fever, neck rigidity and loss of consciousness: remember the Austrian syndrome a commonly unrecognised invasive pneumococcus triad

Austrian syndrome is a rare medical condition characterised by the triad of pneumonia, meningitis and endocarditis due to Streptococcus pneumoniae. Native aortic valve insufficiency is the most common cause of cardiac failure in these patients, requiring valve replacement. We report a 52-year-old chronic alcoholic man who presented with fever, neck rigidity and loss of consciousness. Lumbar puncture revealed central nervous system infection while chest X-ray showed pneumonia. Blood and cerebrospinal fluid cultures revealed S. pneumonia. Transoesophageal echocardiography revealed aortic endocarditis with severe valve insufficiency. The patient underwent aortic valve replacement and was finally discharged after completion of 6 weeks intravenous antibiotic treatment. Nowadays, Austrian syndrome is seen infrequently in the antibiotic era. However, clinicians should be aware of this syndrome as its early recognition and prompt combined medical and surgical treatment could reduce morbidity and mortality due to this potentially catastrophic clinical entity.



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Unusual case of cerebral demyelination and bilateral optic neuritis in an infant with suppurative BCG lymphadenitis

Cerebral demyelination and optic neuritis are often seen in children with acute disseminated encephalomyelitis following various infections and immunisations. An eight month old girl presented with a left axillary lymph node swelling and an erythematous lace-like rash over her cheeks and trunk. She then developed acute encephalopathy, bilateral nystagmus, right hemiparesis and left facial nerve palsy. Her electroencephalogram showed an encephalopathic process and visual evoked response study were grossly abnormal. Her MRI brain showed hyperintensities in the midbrain, pons and bilateral cerebellar peduncles. She was treated as postinfectious cerebral demyelination with intravenous antibiotics, methylprednisolone and immunoglobulin. Left axillary lymph node excision biopsy and GeneXpert test detected Mycobacterium tuberculosis complex that prompted initiation of antituberculous therapy. Her chest X-ray and cerebrospinal fluid examinations for tuberculosis were normal. She showed significant recovery after 2 weeks. This case illustrates a rare presentation of cerebral demyelination and bilateral optic neuritis following suppurative BCG lymphadenitis.



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Scleral dellen following strabismus surgery

Description 

A 28-year-old male patient underwent uneventful surgery for right sensory esotropia. On postoperative day 1, there was still residual esotropia, and the forced duction test (FDT) revealed a residual tightness of the medial rectus muscle. The patient underwent exploration under local anaesthesia; intraoperatively there were still residual adhesions, which were released to achieve a free FDT for the medial rectus without any residual deviation. Postoperatively, on day 1, the patient was orthophoric with absence of additional complications. However, on day 7, the patient presented with medial-sided conjunctival recession with bare sclera, along with dryness and thinning of the underlying sclera with uveal tissue exposure (figure 1A).

Figure 1

(A) On postoperative day 7, there were conjunctival recession, scleral thinning and underlying uveal show. (B) Seven days following conjunctival advancement, there was again minimal conjunctival recession but without any further scleral thinning or uveal exposure. (C) At the end of 3 weeks, there...



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Severe Babesia microti infection presenting as multiorgan failure in an immunocompetent host

A previously healthy 67-year-old farmer presented to an outside hospital after a 2-week history of non-specific respiratory symptoms. A certain diagnosis was not initially apparent, and the patient was discharged home on a regimen for presumed chronic obstructive pulmonary disease exacerbation. He re-presented to the emergency department with shock and hypoxaemic respiratory failure requiring prompt intubation and fluid resuscitation. He was then transferred to our institution due to multiorgan failure. On arrival, the patient demonstrated refractory shock and worsening acute kidney injury, severe anaemia and thrombocytopaenia. The peripheral smear revealed absence of microangiopathic haemolytic anaemia. A closer review of the smear displayed red blood cell inclusion bodies consistent with babesiosis. The patient was started on clindamycin and loaded with intravenous quinidine, and subsequently transitioned to oral quinine. A red cell exchange transfusion was pursued with improvement of the parasite load. The patient was discharged home on clindamycin/quinine and scheduled for outpatient intermittent haemodialysis.



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Acute Kidney Injury after Liver Transplantation

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Since the implementation of the MELD score-based allocation system, the number of transplant candidates with impaired renal function has increased. The aims of this review are to present new insights in the definitions and predisposing factors that result in acute kidney injury (AKI), and to propose guidelines for the prevention and treatment of post liver transplantation (LT) AKI. This review is based on both systematic review of relevant literature and expert opinion. Pretransplant AKI is associated with posttransplant morbidity, including prolonged post LT AKI which then predisposes to posttransplant chronic kidney disease (CKD). Prevention of posttransplant AKI is essential in the improvement of long term outcomes. Accurate assessment of baseline kidney function at evaluation is necessary, taking into account that serum creatinine overestimates glomerular filtration rate (GFR). New diagnostic criteria for AKI have been integrated with traditional approaches in patients with cirrhosis to potentially identify AKI earlier and improve outcomes. Delayed introduction or complete elimination of calcineurin inhibitors during the first weeks post LT in patients with early posttransplant AKI may improve GFR in high risk patients but with higher rates of rejection and more adverse events. Biomarkers may in the future provide diagnostic information such as etiology of AKI, and prognostic information on renal recovery post-LT, and potentially impact the decision for simultaneous liver-kidney transplantation. Overall, more attention should be paid to pretransplant and early posttransplant AKI to reduce the burden of late CKD. Corresponding Author Mitra K. Nadim, MD, FASN, Professor of Clinical Medicine, Division of Nephrology & Hypertension, Department of Medicine, University of Southern California, 1520 San Pablo St., Suite 4300, Los Angeles, CA 90033 AUTHORSHIP All authors participated in writing of the article DISCLOSURE The authors declare no conflicts of interest Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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OPTICAL OR TRANSBRONCHIAL BIOPSY TO DIAGNOSE ACUTE CELLULAR REJECTION

No abstract available

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Donating Another Person’s Kidney: Avoiding the Discard of Organs by Retransplantation

Background Procurement and retransplantation of a previously transplanted kidney reclaims a functioning organ that would otherwise have been discarded. Methods Case series of 3 retransplantation cases within the course of 1 calendar year. Results These cases illustrate how to overcome the immunological, logistical, and technical barriers that have thus far limited the potential of this approach. Within this series we report kidney reuse weeks and years following the original transplantation, as well as the previously undescribed 'living donation of a deceased donor kidney'. Conclusions Retransplantation of previously transplanted kidneys can be performed successfully and should be considered in the face of the current organ shortage. CORRESPONDING AUTHOR INFORMATION, Jeffrey Veale, MD AUTHORSHIP PAGE Jeffrey Veale, MD – participated in the writing of the paper and figures Erik L. Lum, MD – participated in the writing of the paper Nick G. Cowan, MD – participated in the writing of the paper and figures Melissa Wong, MD – participated in the writing of the paper Kelly Skovira – participated in the writing of the paper Mauri Armijo – participated in the writing of the paper Gabriel Danovitch, MD– participated in the writing of the paper Tom Mone – participated in the writing of the paper DISCLOSURES: The authors declare no conflicts of interest. FUNDING: The authors report no funding received for this work. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Diagnosis of Acute Cellular Rejection Using Probe-Based Confocal Laser Endomicroscopy in Lung Transplant Recipients: a Prospective, Multicenter Trial

Background Acute cellular rejection (ACR) in lung transplant recipients requires demonstration of perivascular lymphocytic infiltration in alveolar tissue samples from transbronchial biopsies (TBBs). Probe-based confocal laser endomicroscopy (pCLE) allows in vivo observation of alveolar, vascular, and cellular microstructures in the lung with potential to identify ACR. The objective of our prospective, blinded, multicenter observational study was to identify pCLE findings in patients with ACR diagnosed histopathologically by TBB. Methods Lung transplant recipients undergoing diagnostic bronchoscopies within 1 year posttransplant for suspected ACR had pCLE video imaging obtained immediately prior to tissue sampling via TBB. Findings of 2 pCLE criteria, abundant alveolar cellularity and perivascular cellularity (PVC), were assessed by 4 investigators familiar with pCLE and compared to histopathologic criteria of ACR to derive sensitivity, specificity, area under the receiver operating characteristic curve, and accuracy. Interobserver agreement was assessed by calculating intraclass coefficient and Fleiss κ. Findings were analyzed before and after a consensus meeting of investigators on interpreting images. Results Thirty pCLE procedures were performed on 24 patients, 8 showing ACR in TBB. Diagnostic performance and interobserver agreement using pCLE to identify PVC were significantly higher than those of abundant alveolar cellularity (P<.01 the number of blood vessels identified with pvc on pcle was significantly correlated histopathologic activity grading acr agreement among investigators improved after consensus meeting conclusions when found is a feasible and reproducible criterion for assessment in vivo but there learning curve image interpretation. reprints: cesar a. keller md lung transplant program mayo clinic san pablo rd jacksonville fl phone: fax: presented at american thoracic society international conference may washington dc. portions this manuscript have been published abstract form: c arenberg da smith m islam s. probe-based confocal laser endomicroscopy diagnosis acute rejection: results prospective multicenter trial. am j respir crit care med. authorship author contributions: dr. contributed to conception design experiments collection analysis interpretation data generation figures tables writing critical revision article. khoor images disclosures: none authors disclosures pertaining study. unrelated study serves as vats lobectomy course instructor ethicon endosurgery which they contribute norton institute. funding: mauna kea technologies paris france copyright wolters kluwer health inc. all rights reserved.>

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Invited author's reply to "Optimal culture methods and microbial contamination during kidney ex vivo normothermic perfusion"

No abstract available

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Optimal culture methods and microbial contamination during kidney ex vivo normothermic perfusion

No abstract available

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Domino Liver Transplant in Maple Syrup Urine Disease: Technical Details of Cases in which the First Surgery Involved a Living Donor

Background Data describing the technical aspects of living donor domino liver transplantation (LD-DLT) in maple syrup urine disease (MSUD) are limited. The largest published series includes only 3 cases. One great challenge of this procedure is to ensure adequate vascular stumps for the living donor, the MSUD patient, and the recipient of the domino graft. Here, we describe our experience in 11 cases of LD-DLT in MSUD, highlighting the technical aspects of LD-DLT. Methods From September 2012 to September 2017, 11 patients with MSUD underwent LDLT at our institution, and MSUD livers were used as domino grafts in 11 children. Results:1- MSUD patients Ten patients received a left lateral segment. The donor's left hepatic vein was anastomosed to the confluence of the recipient's 3 hepatic veins (HV). No venous grafts (VG) were required for portal vein (PV) anastomosis. Single arterial anastomosis was performed with microsurgery in 10 out of 11 patients. 2- MSUD graft recipients In 8 cases, HV reconstruction was performed between the graft's HV confluence and the recipient's HV confluence, and in 3 cases, a vena cava triangulation was necessary; 6 MSUD grafts required HV venoplasty. No VG were needed for HV reconstruction. VG were used for PV reconstruction in 3 cases due to sclerotic PV. In 2 cases, double arterial anastomoses were performed in the MSUD liver. All patients remain alive and well. Conclusion LDLT followed by DLT for MSUD is a complex procedure and demands technical refinement. Special attention must be paid to vascular reconstruction. Corresponding author: Joao Seda Neto, MD, PhD, Hospital Sirio-Libanes/Hospital A. C. Camargo, Rua Barata Ribeiro, 414, cj 65, Bela Vista, 01308-000, Sao Paulo, Brazil. Phone number: 55-11-32310800 Fax number: 55-11-32310900. E-mail: joaoseda@gmail.com Authorship Statements Concept/design: Roda KMO, Vincenzi R, Seda-Neto J Drafting of the article: Roda KMO, Vincenzi R, Seda-Neto J Critical revision of the article: Seda-Neto J, Vincenzi R, Fonseca EA, Chapchap P Data analysis/Data collection: Pugliese R, Miura IK, Benavides MR, Turine P, Afonso RC Schwartz I, Tonon T, Porta G Final approval: Seda-Neto J Disclosure No conflicts of interest exist. Funding No financial support was received. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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