Perioperative management of patients with cancer pain treated with opioids: a retrospective study

Abstract

Purpose

We retrospectively studied perioperative management of patients receiving opioid treatment for cancer pain to facilitate establishing a standard policy for our institute.

Methods

Subjects were patients who had been administered strong opioids for cancer pain and had undergone surgery with general anesthesia. We divided the patients into groups C and D. Group C was comprised of patients who had been administered their baseline opioids continuously during the perioperative period, and group D of those who had discontinued baseline opioid use during this period.

Results

We identified 70 evaluable patients, 36 in group C and 34 in group D. The intraoperative anesthesia courses were similar, being uneventful, in all cases. With respect to postoperative adverse effects within 24 h after awakening from anesthesia, severe adverse effects (additional administration of more than four analgesics and intense agitation) were significantly more frequent in group D than in group C (12 vs 1, respectively. p = 0.004). Univariate analysis revealed that baseline opioid discontinuation was the only factor associated with severe adverse effects [odds ratio 12.6, 95% confidence interval (1.49–105.8), p = 0.01].

Conclusion

Discontinuation of baseline opioid increased adverse effects in the early postoperative period, which were attributed to exacerbation of early postoperative pain.

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Olfactory bulbus volume and olfactory sulcus depth in migraine patients: an MRI evaluation

Abstract

Objectives

To compare the measurements of olfactory bulb volume and olfactory sulcus depth in patients with migraine and a control group.

Methods

The study included the cranial MRI (1.5 T) images of 200 adults diagnosed with migraine and a control group of 100 subjects without migraine. The control group mainly consisted of the patients with non-migraneous headache. The measurements were obtained from coronal T2-weighted images for standard olfactory bulb (OB) volume and olfactory sulcus (OS) depth.

Results

The OB volume and OS depth values were lower in the migraine group than in the control group. In the migraine group, left OB volume of the males was significantly lower than those of the females. In both the migraine and control groups separately, the left-side OB volume values and the right side OS depth values were significantly greater than those of the contralateral side. There were positive correlations between right and left OB volume, and right and left OS depth values. No change was seen in OB volume and OS depth values according to gender. In older patients, a decrease was determined in the right and left OB volume, and the left-side OS depth values. There was a negative correlation between osmophobia and OB volume values. In migraine patients with osmophobia, the OB volume values were significantly decreased.

Conclusion

OB volume values were lower in migraine patients. When osmophobia was present, the OB volume was lower than that of the non-osmophobia migraine patients. Olfactory function monitoring with olfactory tests and olfactory volume monitoring on MRI can be recommended for all migraine patients to diagnose olfactory dysfunction earlier, especially those with osmophobia. Because their OB volume values were detected as lower than those of the migraine patients without osmophobia, it may be thought that blood flow changes and osmophobia may affect the olfactory bulb volume shrinkage in migraine patients.

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Assessment modalities of non-ionizing three-dimensional images for the quantification of facial morphology, symmetry, and appearance in cleft lip and palate: a systematic review

Publication date: Available online 5 June 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): L.A.M. Thierens, N.M.C. De Roo, G.A.M. De Pauw, N. Brusselaers
The use non-ionizing three-dimensional (3D) imaging in cleft lip and palate is an emerging field, but properly designed methods for the assessment of these images are not well established. Therefore, the aim of this study was to review the current literature on the modalities of assessment of non-ionizing 3D images for the quantification of facial morphology, symmetry, and appearance in cleft lip and palate, and to assess the method error of these modalities. A systematic literature search was conducted using MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, Web of Science, and Embase. Cross-sectional studies with prospective or retrospective data collection, using non-ionizing 3D imaging, with a subjective or objective outcome assessment and including at least 10 cleft lip and/or palate patients were considered eligible. Overall, 1767 unique studies were identified and 33 met the inclusion criteria. The images were objectively assessed using elementary measurements and comprehensive statistical methods for superimposition, shape description, and structuring. Subjective assessment was performed using a Likert-type scale or visual analogue scale. It can be concluded that non-ionizing 3D images are widely used in cleft research, but 3D analysis of the images is often methodologically suboptimal. Researchers must fully utilize the content of 3D images to quantify morphology, symmetry, and appearance.



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Miriam’s Journey to Sound

"It was one of the best days of my life," says Miriam Green in an emotionally charged voice. "I wish...

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Save the Date: Dr. Steven Zeitels to Speak at ORL Frontiers Next Month

Steven Marc Zeitels, MD, is the invited speaker for ORL Frontiers 2018, which will be held Saturday, June 23, at...

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Amber Luong, MD, PhD Recognized as Trailblazer

Amber Luong, MD, PhD, associate professor of otorhinolaryngology, has been recognized with the 2017 Helen F. Krause, MD Memorial Trailblazer...

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A Novel Missense Mutation in SLC5A5 Gene in a Sudanese Family with Congenital Hypothyroidism

Thyroid, Ahead of Print.


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Dendritic cells in inflammatory angiogenesis and lymphangiogenesis

Daniela Bosisio | Roberto Ronca | Valentina Salvi | Marco Presta | Silvano Sozzani

https://ift.tt/2sEUqY4

ECT: a new look at an old friend

Purpose of review Electroconvulsive therapy (ECT) as a treatment option in psychiatry is advancing day by day. This review discusses new advancements in ECT with regards to anesthetic variables, stimulus, and response variables along with their impact on clinical outcomes. Recent findings Anesthetic variables influence clinical efficacy and patient tolerance of ECT. Although etomidate or a ketamine–propofol combination may be the first choice for many clinicians, the search for ideal induction agent continues. Dexmedetomidine, remifentanil, or ketamine may aid in augmentation of ECT; however, they are not recommended routinely. A systematic procedure for hyperventilation of the patient has been shown to have clinical repercussions. Optimizing anesthesia-ECT time interval (ASTI) has a significant impact on the success of the procedure. BIS monitoring alone cannot be relied upon for timing stimulus. High-dose brief pulse right unilateral ECT represents an acceptable first-line form of treatment, though there is currently no 'gold standard'. Other stimulus variations such as focal electrically administered seizure therapy, individualized low-amplitude seizure therapy, magnetic seizure therapy, left unilateral and left anterior right temporal electrode placements are explored to reduce memory effects. EEG ictal indices may be relied upon for seizure adequacy, and therefore may be used to both guide treatment and predict the outcome of the procedure. Summary Modern ECT is streamlined by augmentation with drugs, hyperventilation, optimizing anesthesia-ECT time interval, and various stimulus parameters guided by seizure adequacy markers. Correspondence to Pavan Kumar Kadiyala, Assistant Professor, Department of Psychiatry, ASR Academy of Medical Sciences, Eluru, AP 534005, India. Tel: +919980731234; e-mail: drkadiyala2@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

Purpose of review In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients. Recent findings A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not. Summary A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected. Correspondence to Jeffrey D. White, MD, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA. Tel: +1 352 273 6575; e-mail: jwhite@anest.ufl.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Manejo de los carcinomas diferenciados de tiroides

Publication date: Available online 5 June 2018
Source:Acta Otorrinolaringológica Española
Author(s): Laura Fernández-Vañes, José Luis Llorente, Patricia García-Cabo, Marta Menéndez, Daniel Pedregal, Juan Pablo Rodrigo, Fernando López
Introducción y objetivosEl tratamiento principal de los carcinomas diferenciados de tiroides es la cirugía seguida de radioyodo. El propósito de este estudio es exponer nuestra experiencia en el manejo de estos tumores.Material y métodoSe presenta un estudio retrospectivo de los 55 pacientes intervenidos quirúrgicamente de un carcinoma diferenciado de tiroides en nuestro hospital entre los años 2007 y 2011.ResultadosLa edad media al diagnóstico fue de 49 años, con un predominio femenino (78% de los casos). El 78% de los pacientes se encontraban en fases iniciales (estadios i y ii). El diagnóstico histopatológico definitivo fue de carcinoma papilar en el 84% y folicular en el 16% restante. A todos, salvo a 2 pacientes (4%), se les realizó una tiroidectomía total, acompañada de linfadenectomía en el 58% de los casos. Un 9% de los pacientes presentó hipoparatiroidismo permanente y aunque un 18% sufrió parálisis recurrencial unilateral transitoria, un 40% de ellos se recuperó completamente a los 6 meses. Se administró radioyodo en el postoperatorio al 89% de los pacientes. Se produjo un 40% de recidivas, la mayor parte de las cuales (29% de los pacientes) se localizaron a nivel cervical. La supervivencia a los 5 años fue del 87%, siendo del 95% en el subtipo papilar y descendiendo al 56% en el folicular (p=0,001).Discusión/conclusionesLos carcinomas diferenciados de tiroides son tumores con un pronóstico excelente tras un tratamiento quirúrgico adecuado previa valoración preoperatoria exhaustiva y seguimiento postoperatorio estricto debido a las tasas significativas de recidiva.Introduction and objectivesRadioiodine is the principal treatment for differentiated thyroid carcinomas. The aim of this study is to present our experience in the management of these tumours.Material and methodWe present a retrospective study of 55 patients operated for differentiated thyroid carcinoma in our hospital between 2007 and 2011.ResultsThe mean age at time of diagnosis was 49 years, and females predominated (78% of cases). Seventy eight percent of the patients were in the initial stages (stages i and ii). The definitive histopathological diagnosis was papillary carcinoma in 84% and follicular carcinoma in the remaining 16%. All of the patients, with the exception of 2 (4%), underwent total thyroidectomy, with lymphadenectomy in 58% of cases. Nine percent of the patients had permanent hypoparathyroidism and although 18% suffered transitory unilateral paralysis, 40% of these female patients had completely recovered after 6 months. Eighty-nine percent of the patients were given radioiodine postoperatively. There was a recurrence rate of 40% most of which was at cervical level (29% of the patients). Survival at 5 years was 87%, 95% of the papillary subtype, falling to 56% of the follicular subtype (P=.001).Discussion/conclusionsThe prognosis for differentiated thyroid carcinomas is excellent after appropriate surgical treatment, thorough preoperative assessment,and strict postoperative follow-up due to the significant recurrence rates.



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La audición en la enfermedad ósea de Paget

Publication date: Available online 5 June 2018
Source:Acta Otorrinolaringológica Española
Author(s): Emilio Amilibia Cabeza, Susana Holgado Pérez, Marta Pérez Grau, Carme Moragues Pastor, Francesc Roca-Ribas Serdà, Miquel Quer Agustí
Introducción y objetivosLa enfermedad ósea de Paget (EOP) puede cursar con hipoacusia. Con el objetivo de cuantificar, caracterizar y determinar los factores de riesgo de hipoacusia en un grupo de pacientes con EOP se realiza el presente estudio.MétodosSe realizó un estudio observacional, transversal del tipo casos y controles que incluyó una cohorte de 76 sujetos con diagnóstico de EOP en el grupo caso y un grupo control de 134 sujetos. Se analiza la información clínica, demográfica y audiométrica de los sujetos incluidos.ResultadosEl análisis comparativo entre el grupo de sujetos con EOP y el grupo control determinó que el grupo caso presentaba un umbral medio auditivo mayor (39,51dB) que el grupo control (37,28dB) (p = 0,069) y que presentaba hipoacusia transmisiva con mayor frecuencia (22,76%) que el grupo control (12,05%) (p = 0,0062). El análisis de los factores de riesgo de hipoacusia determinó que la afectación craneal en la gammagrafía ósea, la edad y la HTA, entre otros, constituían factores de riesgo de mayor pérdida auditiva en la EOP.ConclusionesLos sujetos con EOP presentaron una pérdida auditiva más severa y con mayor frecuencia de tipo transmisivo que el grupo control. Los sujetos con afectación de la calota craneal por EOP presentaron mayor pérdida auditiva que los sujetos sin afectación craneal. La afectación de la calota craneal por la EOP y la edad constituyeron factores de riesgo de hipoacusia.Introduction and objectivesPaget's disease of bone (PDB) may lead to hearing loss. The present study was conducted with the aim of measuring, characterizing and determining the risk factors for hearing loss in a group of subjects with PDB.MethodsAn observational, transversal, case-control study was conducted, a cohort of 76 subjects diagnosed with PDB in the case group and a control group of 134 subjects were included. Clinical, demographic and audiometric data were analysed.ResultsThe comparative analysis between the subjects in the PDB group and the control group found that the case group showed higher hearing thresholds (39,51dB) compared with the control group (37.28dB) (P=.069) and presented a greater rate of conductive hearing loss (22.76%) than the control group (12.05%) (P=.0062). The study of risk factors for hearing loss found that skull involvement in bone scintigraphy, age and high blood pressure were risk factors for higher impairment in PDB.ConclusionsThe subjects with PDB showed more profound and a higher proportion of conductive hearing loss than the control group. The patients with PDB and skull involvement presented a more severe hearing loss compared with the subjects without skull involvement. Skull involvement and age were found to be risk factors for hearing loss.



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Olfactory dysfunction out of season in seasonal allergic rhinitis

Olfactory dysfunction (OD) is one of the major symptoms caused by seasonal allergic rhinitis (AR).1 It has been reported that in allergic rhinitis, inflammatory cells infiltrate the olfactory mucosa.2 Moll et al.3 showed that the extra-seasonal score in the 1-butanol threshold test of patients with grass pollen allergy was lower than that of control subjects. It was also reported that all patients had normal olfactory function (OF) prior to the season.1 It is therefore unclear whether OD persists out of pollen season in patients with seasonal AR, especially in patients who do not complain of OD.

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Novel Approaches to Block Complement

The complement system may contribute in many ways to transplant injury, being a promising target for specific therapeutic interventions. There is evidence that the monoclonal anti-C5 antibody eculizumab is effective in the prevention and treatment of early antibody-mediated rejection (ABMR), but terminal complement blockade might be of limited efficiency in chronic rejection. Given the diversity of immunological events triggered by activation steps upstream to C5, in particular, opsonin and anaphylatoxin formation through C3 cleavage, one may argue that, in the specific context of ABMR, inhibition of antibody-triggered classical pathway (CP) activation might be beneficial. Strategies to interfere with key CP component C1 are currently under clinical evaluation and include the therapeutic use of purified C1-inhibitor, which, besides targeting the integrity and function of the C1 complex, also affects components of the lectin pathway, the contact system, the coagulation cascade or surface molecules mediating leukocyte-endothelial interactions. In addition, a monoclonal anti-C1s antibody (BIVV009) has now entered clinical evaluation and was shown to effectively block antibody-triggered CP activation in rejecting kidney allografts. Moreover, modified apheresis techniques for preferential removal of macromolecules, including C1q, may allow for efficient complement depletion, in addition to antibody removal. The availability of effective strategies to interfere with the CP, as well as innovative approaches targeting other pathways, some of them already being tested in clinical trials, will help us figure out how complement contributes to acute and chronic graft injury, and hopefully provide us with new ways to more efficiently counteract rejection. Correspondence: Georg A. Böhmig, Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria, Phone: +43-1-40400-43630, Fax: +43-1-40400-39304, E-mail: georg.boehmig@meduniwien.ac.at Author's specific contribution G.A.B. participated in the conception, writing and revision of the paper F.E. participated in the conception, writing and revision of the paper M.W. participated in the conception, writing and revision of the paper L.R. participated in the conception, writing and revision of the paper Disclosure G.A.B. received research support (unrestricted grants) from Fresenius Medical Care, Bad Homburg, Germany, and True North Therapeutics, Inc., South San Francisco, CA, USA. F.E., M.W. and L.R. declare no conflicts of interest. Funding None Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2M109Rc

Could Less Be More in Febrile Neutropenia, Too?

Two recent studies inform antimicrobial stewardship in high-risk patients with febrile neutropenia.
Society for Healthcare Epidemiology of America (SHEA)

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Pain, psychiatric comorbidities, and psychosocial stressors associated with Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome affects general and mental health, physical function, and quality of life. Pain, complications, and capillary malformation of the hands are associated with a higher risk of psychiatric illness. Patients with Klippel-Trenuanay syndrome should be screened for potential psychosocial sequelae..

https://ift.tt/2syw0QL

Assessment modalities of non-ionizing three-dimensional images for the quantification of facial morphology, symmetry, and appearance in cleft lip and palate: a systematic review

The use non-ionizing three-dimensional (3D) imaging in cleft lip and palate is an emerging field, but properly designed methods for the assessment of these images are not well established. Therefore, the aim of this study was to review the current literature on the modalities of assessment of non-ionizing 3D images for the quantification of facial morphology, symmetry, and appearance in cleft lip and palate, and to assess the method error of these modalities. A systematic literature search was conducted using MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, Web of Science, and Embase.

https://ift.tt/2Lq95hA

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists

Background Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. Methods In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. Results Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. Conclusions Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments. Accepted for publication March 17, 2018. Address correspondence to: Steven P. Cohen, MD, 550 N Broadway, Suite 301 Baltimore, MD 21029 (e-mail: scohen40@jhmi.edu). Accepted for publication March 17, 2018. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army or the Department of Defense. Because this document has neither been presented to nor approved by either the American Society of Anesthesiologists Board of Directors or House of Delegates, it is not an official or approved statement or policy of the Society. Variances from the recommendations contained in the document may be acceptable based on the judgment of the responsible anesthesiologist. S.P.C. is funded in part by a Congressional Grant from the Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD (SAP grant 111726), which also paid for Open Access publication. The authors declare no conflict 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 Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists

Background Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines. Methods The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls. Results Consensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions. Conclusions Evidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care. Accepted for publication March 7, 2018. Address correspondence to: Steven P. Cohen, MD, 550 N Broadway, Suite 301, Baltimore, MD 21029 (e-mail: scohen40@jhmi.edu). S.P.C. is funded in part by a Congressional grant from the Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD (SAP grant 111726). The authors declare no conflict of interest. The opinions or assertions contained herein are those of the authors, the American Society of Regional Anesthesia and Pain Medicine, and the American Academy of Pain Medicine and do not necessarily reflect the views of the Department of the Army or the Department of Defense. Because this document has neither been presented to nor approved by either the ASA Board of Directors or House of Delegates, it is not an official or approved statement or policy of the Society. Variances from the recommendations contained in the document may be acceptable based on the judgment of the responsible anesthesiologist. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Widening of posterior glottis through rotation of the arytenoid on its axis: Report of nine cases

Bilateral vocal folds' immobility is a challenge in laryngology. Multiple procedures have been proposed to improve breathing by statically enlarging the glottal airway, what also results in loss of voice and aspiration. We proposed a technique to enlarge the posterior glottis by rotating the arytenoids on its axis, imitating the function of the posterior cricoarytenoid muscle, with the objective of evaluating the results regarding decannulation, voice quality, and bronchoaspiration.

https://ift.tt/2JjgLla

Morphology and cochlear implantation in enlarged vestibular aqueduct

The purpose of this work is to explore audiometry following cochlear implantation (CI) in patients with enlarged vestibular aqueduct (EVA) and to investigate the effects of inner ear morphological variation on post CI audiometry.

https://ift.tt/2kNpPUO

Monoclonal antibodies for the treatment of atopic dermatitis

Purpose of review To evaluate the treatment revolution atopic dermatitis, the most common inflammatory skin disease, has been going through in recent years, thanks to breakthroughs in disease understanding, delineating the immune fingerprint of atopic dermatitis. Recent findings The treatment for moderate-to-severe atopic dermatitis patients has been largely unchanged for decades and relied on broad-acting immunosuppressants. A huge unmet need existed for effective, well tolerated and narrow-targeted therapeutics. Multiple therapies, targeting various aspects of the complex immune activation of atopic dermatitis, are now assessed in clinical trials, and hold promise for a new era in the treatment of atopic dermatitis, comparable with the treatment shift seen for psoriasis in the last decade. The first effective monoclonal antibody licensed for the treatment of atopic dermatitis, dupilumab, not only offers a much-needed systemic agent for moderate-to-severe patients but also provides strong evidence for the potential role of other monoclonal antibodies in disease management. Summary In this rapidly changing field, new atopic dermatitis-targeted monoclonal antibodies will be reviewed in light of the recently discovered pathomechanisms of the disease. Correspondence to Emma Guttman-Yassky, MD, PhD, Department of Dermatology, Icahn School of Medicine at Mount Sinai Medical Center, 5 E. 98th Street, New York, NY 10029, USA. Tel: +1 212 241 9728/3288; fax: +1 212 876 8961; e-mail: Emma.Guttman@mountsinai.org Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Hypersensitivity reactions to beta-lactams in children

Purpose of review To present the most recent evidence on beta-lactam hypersensitivity reactions in children. Recent findings Drug provocation tests (DPTs) are the gold standard when investigating beta-lactam allergy in children and evidence is increasingly supporting DPTs without skin tests as a safe approach when evaluating children with nonimmediate mild reactions to beta-lactams. Of note, data are limited in the adolescent population, and this attitude may not apply to this age group. Standardization of DPT protocols is required in nonimmediate reactions, as many protocols ranging from 1 to 10 days have been described. The optimal duration of DPT is still unknown, with extended protocols providing slightly more sensitivity and possible higher long-term compliance, at the expense of potential side effects associated with prolonged antibiotic use. On the other hand, 1-day DPTs will identify the vast majority of patients, and the rest will only develop a mild rash during a subsequent full treatment. The natural history of beta-lactam allergy in children is not well studied with recent evidence pointing to the resolution of most confirmed beta-lactam allergies after 3 years. Summary Further studies are needed for the standardization of DPT protocols and to confirm the favourable natural history of beta-lactam drug allergies in children. In addition, multicentric studies are required to confirm the increasingly accepted position of performing DPTs without skin tests in nonimmediate mild reactions to beta-lactams and to further evaluate the possibility of performing DPTs in benign immediate reactions to beta-lactams in children. Correspondence to Jean-Christoph Caubet, Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, 6 Rue Willy-Donze, 1211 Geneva 14, Switzerland. Tel: +41 22 372 4531; fax: +41 22 372 4779; e-mail: Jean-Christoph.Caubet@hcuge.ch Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Does evidence support the use of cat allergen immunotherapy?

Purpose of review Cat allergy can manifest as allergic rhinitis, conjunctivitis and/or asthma. With widespread cat ownership and exposure, cat allergy has emerged as a major cause of morbidity. Cat allergen immunotherapy is a potential disease modifying treatment for patients with cat allergy. We examine evidence on the effectiveness, cost-effectiveness and safety of cat allergen immunotherapy and consider the clinical contexts in which it should be prescribed. Recent findings The European Association of Allergy and Clinical Immunology systematic reviews on allergic rhinitis and asthma along with the accompanying guidelines on allergic rhinitis were used as primary sources of evidence. Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are most common routes of administration for allergen immunotherapy (AIT). A limited number of high-quality studies related to cat dander have shown mixed results in improvements in ocular and nasal symptoms, asthma symptoms, peak expiratory flow rate and medication use scores with subcutaneous immunotherapy. Two studies examining cat dander and cat-related allergy response with sublingual immunotherapy have shown mixed results in terms of symptomatic response. One randomized trial examining intralymphatic immunotherapy has shown a positive symptom response and a favourable safety profile. Although studies have reported mixed results regarding safety of SCIT, adverse events have been reported more commonly with SCIT than SLIT. Summary There is a limited body of high-quality evidence on the effectiveness and safety of cat AIT and no high-quality data on its cost-effectiveness. The available evidence on effectiveness is mixed based on studying a limited array of immunological, physiological and patient-reported outcome measures. Based on this evidence and extrapolating on the wider evidence base in AIT, it is likely that some patients may benefit from this modality of treatment, particularly those with moderate-to-severe disease who are inadequately controlled on allergen avoidance measures and pharmacotherapy and those who are monosensitized to Felix Domesticus 1. Further evidence is, however, required from larger trials before more definitive advice can be offered. Correspondence to Sangeeta Dhami, GP Returner Edinburgh, Edinburgh, UK. E-mail: sangeetadhami@hotmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Needle Biopsy of Routine Thyroid Nodules Should Be Performed Using a Capillary Action Technique with 24- to 27-Gauge Needles: A Systematic Review and Meta-Analysis

Thyroid, Ahead of Print.


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Scleromalacia perforans: a case report

Scleromalacia perforans is a rare ocular manifestation of rheumatoid arthritis which can potentially lead to blindness and is a late consequence in the course of the disease. It is an unusual finding for it to...

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Longitudinal studies of the 18 F-FDG kinetics after ipilimumab treatment in metastatic melanoma patients based on dynamic FDG PET/CT

Abstract

Background

Immunotherapy has raised the issue of appropriate treatment response evaluation, due to the unique mechanism of action of the immunotherapeutic agents. Aim of this analysis is to evaluate the potential role of quantitative analysis of 2-deoxy-2-(¹⁸F)fluoro-d-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) data in monitoring of patients with metastatic melanoma undergoing ipilimumab therapy.

Methods

25 patients with unresectable metastatic melanoma underwent dynamic PET/CT (dPET/CT) of the thorax and upper abdomen as well as static, whole body PET/CT with ¹⁸F-FDG before the start of ipilimumab treatment (baseline PET/CT), after two cycles of treatment (interim PET/CT) and at the end of treatment after four cycles (late PET/CT). The evaluation of dPET/CT studies was based on semi-quantitative (standardized uptake value, SUV) calculation as well as quantitative analysis, based on two-tissue compartment modeling and a fractal approach. Patients' best clinical response, assessed at a mean of 59 weeks, was used as reference.

Results

According to their best clinical response, patients were dichotomized in those demonstrating clinical benefit (CB, n = 16 patients) and those demonstrating no clinical benefit (no-CB, n = 9 patients). No statistically significant differences were observed between CB and no-CB regarding either semi-quantitative or quantitative parameters in all scans. On contrary, the application of the recently introduced PET response evaluation criteria for immunotherapy (PERCIMT) led to a correct classification rate of 84% (21/25 patients).

Conclusion

Quantitative analysis of ¹⁸F-FDG PET data does not provide additional information in treatment response evaluation of metastatic melanoma patients receiving ipilimumab. PERCIMT criteria correlated better with clinical response.

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Obturation quality of calcium silicate-based cements placed with different techniques in teeth with perforating internal root resorption: a micro-computed tomographic study

Abstract

Objectives

To evaluate and compare the obturation quality of mineral trioxide aggregate (MTA) and Biodentine placed with hand condensation or indirect ultrasonic activation technique in teeth models simulating perforating internal root resorption (IRR) using micro-computed tomographic (micro-CT) imaging.

Materials and methods

Standardized models with perforating IRR cavities were created using 40 extracted single-rooted human teeth and randomly divided into four groups (n = 10). The specimens were obturated with either MTA or Biodentine and the placement technique applied was either hand condensation or indirect ultrasonic activation. Micro-CT scans were performed for the volumetric analysis of voids and filling materials in the resorption cavities and apical portion of the specimens. Data were analyzed using one-way analysis of variance and paired t test.

Results

No significant difference was observed between the groups in terms of the percentage volume of filling materials (p > 0.05). The apical portion of the specimens significantly presented less percentage volume of filling materials than the resorption cavities in each group (p < 0.05).

Conclusions

No placement technique produced void-free fillings in teeth with perforating IRR. There was no significant difference between the obturation quality of Biodentine and MTA. The obturation quality in the apical portion of the root canals was inferior than that in the resorption cavities.

Clinical relevance

The obturation of the apical region of teeth with perforating IRR is challenging irrespective of the material type and placement technique.

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Increased anti- EBV VCA IgG antibody levels are associated with need for surgery in patients developing upper respiratory tract complications

Publication date: August 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 111
Author(s): Hande Arslan, Tuba Çandar, Özge Vural
IntroductionThe immune reaction developing against Ebstein-Barr virus (EBV) infection may be one of the major determinants of severe adenoid hypertrophy (AH) and chronic otitis media with effusion (COME) needing surgery. In this study, we aimed to investigate the relationship between these antibodies and the need for surgery due to complications such as severe AH and COME.MethodsSixty consecutive patients <15 years old who were admitted to our outpatient clinics between January 2014 and December 2015 with severe AH ± COME and underwent adenoidectomy ± ventilation tube insertion and 129 control patients who had a history of EBV infection at least three months before the inclusion to the study without current symptoms of upper airway obstruction and middle ear disease were included in this study. Two groups of patients and a control group were studied: a) children who underwent adenoidectomy alone with no middle ear disease (group 1), b) children with COME and AH who underwent adenoidectomy and tympanostomy with ventilation tube insertion (group 2), and c) control group without adenoid hypertrophy or otitis media with effusion.ResultsPatients who needed surgery (Group 1 and 2) had significantly higher levels of anti-EBV VCA IgG antibodies than control patients (19.8 ± 16.4 vs. 1.7 ± 0.8 S/CO, p < 0.001). Anti-EBV VCA IgM levels did not differ between groups. Group 2 patients had also higher levels of Anti-EBV VCA IgG antibodies than group 1 patients (35.8 ± 16.7 vs. 11.8 ± 8.5 S/CO, p < 0.001). ROC curve analysis resulted in a cut-off point of 2.92 S/CO level for anti-EBV VCA IgG antibodies for need for surgery in EBV infected patients with 97% sensitivity and 98% specificity.ConclusionMarkedly increased serum anti-EBV VCA IgG antibodies in children who developed upper respiratory tract complications such as severe AH and COME may show the significant role of enhanced immune system reaction in the pathogenesis of these complications due to EBV infection.



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Clinical outcomes following Cochlear™ BIA300 bone anchored hearing aid implantation in children

Publication date: August 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 111
Author(s): Jonathan Mark Fussey, Emilie Harterink, Jaspreet Gill, Anne Child-Hymas, Ann-louise McDermott
ObjectiveBone anchored hearing implants (BAHI) have been in use for over 30 years, and are commonly implanted in children for a range of indications. The Cochlear™ BIA300 system was launched in 2010 and used at The Birmingham Children's Hospital from 2011. Here we report the long-term outcomes of children implanted with the Cochlear™ BIA300 BAHI system in our centre.MethodsA retrospective case note analysis was performed to identify outcomes in all children who underwent BIA300 implantation between 2011 and 2013.Results52 children with a total of 78 implants were included. Mean age at implantation was 8.7 years. Mean follow-up was 43.5 months. Overall, 60 (77%) implants developed soft tissue complications requiring treatment. Forty-eight (62%) required topical treatment; 27 (35%) required systemic treatment; and 27 (35%) required surgical soft tissue revision under general anaesthesia.ConclusionsThe Cochlear™ BIA300 system appears to be associated with higher than expected rates of soft tissue reaction in children, with late as well as early soft tissue complications requiring both medical and surgical treatment.



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Improving universal newborn hearing screening outcomes by conducting it with thyroid screening

Publication date: Available online 5 June 2018
Source:International Journal of Pediatric Otorhinolaryngology
Author(s): Rahimi Vida, Ghassem Mohammadkhani, Farzaneh Javadi
ObjectivesOne of the most important factors that can improve hearing screening indicators is testing infants after 48 h of birth. The neonatal thyroid screening program is done during the third to fifth day after birth in many countries. So this screening is done at the appropriate time for hearing screening. The aim of the present study was to evaluate hearing screening outcomes (the referral rate, false positive rate, and positive predictive value) conducted with the thyroid screening at the healthcare centers and compare the results with hospital before discharge the infant.MethodsThis was a prospective exploratory cohort study. The study population included all the newborns at a hospital (group 1) and newborns who were referred to healthcare centers for thyroid screening (group 2), except for infants with risk factors, from March 2012 to December 2017. Transient evoked otoacoustic emissions (TEOAE) and automatic auditory brainstem response (AABR) were used for the evaluation. The results were compared between the two groups.ResultsOf the 4729 newborns, who participated in the study, 3001 were referred from a hospital (group 1) and 1728 from two healthcare centers (group 2). The referral rate in group 1 and 2 was 16.1% and 7.6%, respectively. Also, the false positive rate in group 1 and 2 was 15.9% and 7.6%, respectively. Our study showed that the referral rate and false positive rate of hearing screening in group 2 were significantly lower than that in group 1 (p < 0.001). The positive predictive value in group 1 was significantly higher than that in group 2 (p < 0.05). There was no significant sex difference in any of the variables.ConclusionsOur results showed that performing the hearing screening during the thyroid program, instead of the hospital could be significantly improved screening outcomes and suggest that hearing and thyroid screening together after discharge from the hospital could be a good opportunity to introduce new framework for hearing screening in many countries.



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Unusual cause of obstructive uropathy: bilateral steinstrasse

Description 

A 45-year-old man presented with decreased urinary output (<150 mL per 24 hours), anorexia, nausea and bilateral flank pain for 1 week. His serum creatinine potassium were 12.9 mg/dL and 6.0 mEq/L, respectively. He had no associated comorbidity. He had history of bilateral renal pelvic stones for which he underwent extracorporeal shock wave lithotripsy (ESWL) 2 months back, first for the right kidney (single session) then 2 weeks later for the left kidney (single session). His renal function was normal before undergoing ESWL (serum creatinine 0.9 mg/dL). No check X-ray had been done after ESWL. A plain X-ray was done that showed bilateral steinstrasse (figure 1) and on ultrasonography he had hydronephrosis in both kidneys. This caused acute renal failure due to obstructive uropathy. He was taken up for haemodialysis urgently. After two sessions of haemodialysis, he was taken up for stenting of bilateral ureters. After stenting, his renal function...

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Unusual case of hypocalcaemia

Description 

A 33-year-old woman presented with 1 week of dizziness and bilateral leg and hand cramps with associated numbness and tingling. She stated she was diagnosed with hypocalcaemia when she was approximately 8 years old, but could not elaborate further. She was a poor historian with learning disabilities and admittedly was non-compliant with treatment.

Physical examination revealed a round face, short stature (4'10'') and obesity (body mass index 39) with no neck scars. Her extremities were notable brachydactyly of her feet (figure 1) as well as brachydactyly of her fourth and fifth fingers (figure 2) with a positive Archibald's sign (figure 3). X-ray of her hands was significant for shortening of the fourth and fifth metacarpals (figure 4). EKG was remarkable for prolonged QT interval (figure 5). Brain CT revealed extensive calcification in the basal ganglia (figure...

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Severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury

Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.

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ALL relapse with multiple cranial nerve palsies and toxic leukoencephalopathy: treatment failure with treatment toxicity

Description 

Acute lymphoblastic leukaemia (ALL) is one of the most common malignancies of childhood. ALL is treated with high doses of methotrexate (MTX) to prevent central nervous system (CNS) and haematological relapses. MTX is administered intravenously and via intrathecal route.1 MTX can cause neurotoxicity by disrupting CNS folate homeostasis or by direct neuronal damage. MTX-induced acute toxic leukoencephalopathy can result in acute neurological deficit, seizures or encephalopathy.2 We report a 27-year-old diagnosed case of ALL who presented with neurological symptoms 2 years after she was started with intensive and maintenance phase of chemotherapy. She took multiple cycles (24) of intrathecal MTX in her intensive phase and was subsequently followed up regularly after her maintenance phase for bone marrow aspiration, which showed reduced blast cells compared with the earlier report. Few weeks after completing her chemotherapy, she complained of visual blurring in the right eye followed by...

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Differential diagnosis for chronic hypokalaemia

Doctors will often see patients with chronic hypokalaemia, frequently this is secondary to gastrointestinal losses, diuretics or renal disease. However, in this case report we review a rarer cause of chronic hypokalaemia—Gitelman syndrome (GS).

GS is an uncommon genetic disorder which causes primary renal tubular hypokalaemic metabolic alkalosis with secondary hypomagnesaemia and hypocalciuria. Although rare, it is important to remember GS when considering differential diagnoses for chronic hypokalaemia. We report the case of a woman who presented to the ophthalmology department with sclerochoroidal calcification. An ophthalmologist was reviewing the medical literature, which prompted them to investigate for GS. A diagnosis was formed at that time based on the blood and urine chemistry results. However, later we were able to offer the patient genetic testing, which confirmed our provisional diagnosis.

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Gitelman syndrome and primary hyperparathyroidism: a rare association

Gitelman syndrome(GS) is a rare autosomal recessive salt-losing tubulopathy of young adults, characterised by hypokalaemia, hypomagnesaemia, hypocalciuria and secondary hyperaldosteronism. Hypercalcaemia due to hypocalciuria in these patients is extremely rare.

A 25-year-old healthy woman was referred to the Endocrinology clinic for evaluation of persistent hypokalaemia. She presented with fatigue, myalgias, cramps and paraesthesia. Her physical examination was normal. Laboratory workup revealed: K⁺ 2.7 mEq/L (r.v.3.5–5.1), 24 hours urinary K⁺ 84.7 mEq/24 hours (r.v.25–125), Mg²⁺ 0.71 mg/dL (r.v.1.6–2.6), 24 hours urinary Mg²⁺ 143.1 mg/24 hours (r.v.73–122), Ca²⁺ 12 mg/dL (r.v.8.4–10.2), aldosterone 47.1 ng/mL (r.v. 4–31) and active renin 374.7 uUI/mL (r.v.4.4–46.1). She was diagnosed with GS and was treated with spironolactone, oral K⁺ and Mg²⁺ supplementation. Further investigation confirmed hypercalcaemia due to primary hyperparathyroidism owing to a single parathyroid adenoma. Following parathyroidectomy serum calcium normalised.

Current knowledge favours that hypomagnesaemia in patients with GS protects them from hypercalcaemia. In this context of multiple electrolyte imbalances, correction of hypomagnesaemia is a challenge and should be done carefully. Like in our patient, aetiology of hypercalcaemia should be promptly diagnosed and reversed.

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Serious life-threatening multifocal infection in a child, caused by Panton-Valentine leucocidin-producing Staphylococcus aureus (PVL-MSSA)

Groin pain is a frequently occurring complaint in presentations to the Emergency Department. Muscular sprain is often a differential diagnosis, however serious conditions such as pyomyositis should not be ignored. This case report presents a child with atraumatic right groin pain, which was initially diagnosed as a muscular sprain. The patient later re-presented out of hours to the Emergency Department with what was found to be extensive pelvic abscesses. He was subsequently found to have bilateral pneumonia and later developed a pericardial effusion and osteomyelitis of the right iliac bone, sacroiliac joint and sacrum. With multiple surgical interventions and appropriate antibiotics, he made a full recovery and was discharged home after a total admission time of 41 days. The causative organism was found to be Panton-Valentine leucocidin-positive methicillin-susceptible Staphylococcus aureus.

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Aspiration and altered airway anatomy: a presentation with a twist

Description 

A 60-year-old woman presented to our hospital with severe hypercapnic respiratory failure in the absence of a prior smoking history. She reported a 1-day history of increased dyspnoea and a cough productive of green sputum. Her medical history was significant for severe idiopathic scoliosis, cleft palate repair, rheumatoid arthritis, hypothyroidism and recurrent lower respiratory tract infections. She was obtunded on presentation and required 24 hours of mechanical ventilation.

A CT thorax was performed to further investigate her acute deterioration. Considerable distortion of thoracic anatomy secondary to kyphoscoliosis was noted. Right lower lobe atelectasis due to extrinsic compression of the bronchus intermedius by thoracic vertebrae and left lower lobe consolidation were reported (figures 1–3). Due to the vertical orientation of the left main bronchus (LMB), aspiration pneumonia was suspected (figure 2). Our patient initially improved with antimicrobial therapy, dietary modifications and...

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Rapidly involuting congenital haemangioma of the liver

Rapidly involuting congenital haemangiomas (RICHs) are rare benign vascular tumours of infancy. They are generally asymptomatic, but can present with thrombocytopaenia and coagulopathy. Significant complications including life-threatening bleeding, high-output heart failure and liver failure, though rare, can occur. RICHs generally regress by 12–14 months of age and can be managed clinically with symptomatic treatment, watchful waiting and close monitoring of the size of the haemangioma. Medical management (corticosteroids, propranolol) has not shown to be effective, in contrast to infantile haemangioma which will not regress spontaneously and has been noted to respond to medical therapy. Awareness of this diagnosis is important to prevent unnecessary medical and surgical intervention. Here, we present a case of a full-term infant with RICH who presented with thrombocytopaenia and abnormal coagulation profile. The coagulopathy was treated symptomatically, while the lesion was observed with serial ultrasounds and gradually decreased in size.

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Laryngeal Basaloid Squamous Cell Carcinoma with a Substantial Spindle Cell Component: Case Presentation and Updated Review of Literature

Abstract

Basaloid squamous cell carcinoma with spindle cell component is an uncommon aggressive variety of squamous cell carcinoma with only a few reported cases in literature. Histologically a combination of basaloid squamous cell carcinoma and spindle cell squamous cell carcinoma is appreciated and immunohistochemistry serves a role in differentiation from malignant neoplasms of salivary gland or neuro-endocrine origin. Prime treatment modality is combination of surgery and external beam radiotherapy. A case of basaloid squamous cell carcinoma with proliferation of bizarre mesenchymal component is being reported here with an updated literature review.

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Quality Of Care In Dental Institutes

Publication date: May–August 2018
Source:Journal of Oral Biology and Craniofacial Research, Volume 8, Issue 2
Author(s): Divya Mehrotra




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