Understanding the Role of Biofilms and Superantigens in Chronic Rhinosinusitis

Abstract

Purpose of Review

This review explores recent discoveries in our understanding of how biofilms and superantigens contribute to the pathogenesis of chronic rhinosinusitis (CRS). It also examines clinical implications and novel treatment approaches for biofilm-associated CRS.

Recent Findings

While the role of biofilms in CRS has been studied for 14 years, research interest has now turned toward elucidating new methods of biofilm detection, microbial diversity, and novel treatment approaches. Recent studies on biofilm superantigens aim to clarify the immunological mechanisms of upper airway inflammation, particularly the type-2 response seen in nasal polyposis.

Summary

Biofilms are a topic of research interest for their role in the pathogenesis of chronic rhinosinusitis, particularly when they elute superantigens. New studies on this topic focus on the molecular and cellular mechanisms at play.

https://ift.tt/2vdzzwD

Aeroallergens in North-Central Nigeria

Publication date: Available online 25 July 2018

Source: Allergologia et Immunopathologia

Author(s): Dimphna N. Ezikanyi, Gloria Sakwari, Catherine V. Nnamani

Abstract

Introduction and Objectives

Aeroallergens are airborne organic substances which are responsible for allergenic diseases in hypersensitive individuals. People are exposed to their allergens either directly or after their entrance into the interiors. The spatio-temporal pattern of aeroallergens and their relationship with weather variability in Abuja and Nassarawa, North-Central Nigeria was studied.

Materials and Methods

Aerosamples were trapped with modified Tauber-like pollen traps. Samples were collected monthly and centrifuged at 2500 rpm for 5 min and subjected to acetolysis. Meteorological data were collected from the Nigerian Meteorological Agency.

Results and Conclusion

Aeroallergens concentration were unequivocally regulated by weather variables in both locations, indicating the possible use of aeroallergens especially pollen and spores as bio-indicators of weather variations and change. Aeroallergens encountered were fungal spores, pollen, diatom frustules, fern spores, algal cyst/cells in decreasing order of dominance. Among pollen group, Poaceae, Amarathaceae/Chenopodiaceae and Hymenocardia acida dominated. Spores of Smut species, Puccinia, Curvularia and Nigrospora were major contributors among aeromycoflora. Fungal spores morphotype dominated during the rainier months and were major contributors of the aeroallergen spectrum with those belonging to Deuteromycete preponderant. Aeroallergens which were previously identified as triggers of conjunctivitis, asthma, allergic sinusitis and bronchopulmonary allergic diseases were frequently present in both locations. Pollen prevailed more during the harmattan, influenced by northeast trade wind. Pollen component differed and was based on autochthonous source plants, indicating difference in sub-vegetational types.

https://ift.tt/2v8leRO

Motile Ciliary Disorders in Chronic Airway Inflammatory Diseases: Critical Target for Interventions

Abstract

Purpose of Review

Impaired mucociliary clearance has been implicated in chronic upper and lower airway inflammatory diseases (i.e., allergic and non-allergic rhinitis, chronic rhinosinusitis with or without nasal polyps and asthma). How motile ciliary disorders (impaired ciliogenesis, ciliary beating and ultrastructural defects) are implicated in chronic airway inflammatory diseases is not fully understood. Elaboration of the role of motile ciliary disorders may serve as therapeutic targets for improving mucociliary clearance, thereby complementing contemporary disease management.

Recent Findings

We have summarized the manifestations of motile ciliary disorders and addressed the underlying associations with chronic airway inflammatory diseases. A panel of established and novel diagnostic tests and therapeutic interventions are outlined. Physicians should be vigilant in screening for motile ciliary disorders, particularly in patients with co-existing upper and lower airway inflammatory diseases.

Summary

Proper assessment and treatment of motile ciliary disorders may have added value to the management and prevention of chronic airway inflammatory diseases.

https://ift.tt/2v4Jape

Femoral neuropathy following a psoas hitch vesicopexy

A 68-year-old man classified as III on the American Society of Anaesthesiologists (ASA) physical status classification system, with a high-grade papillary urothelial cell carcinoma of the left distal ureter, underwent open retroperitoneal distal ureterectomy followed by a ureteroneocystostomy with a vesico-psoas hitch. Postoperatively, the patient complained of left proximal lower limb weakness, severe pain and hypaesthesia of the ventral left thigh suggestive of femoral neuropathy. After excluding common causes for postsurgical pain, a surgical re-exploration was eventually performed during which the sutures used in the vesicopexy were removed, resulting in almost complete resolution of the symptoms. Electromyographic analysis 4 weeks after discharge confirmed the diagnosis of femoral neuropathy, most likely caused by the sutures used in the vesicopexy. This is a rare complication with major consequences for postoperative recovery.

https://ift.tt/2vdy0yL

Avoiding diagnostic delay for mucopolysaccharidosis IIIB: do not overlook common clues such as wheezing and otitis media

Mucopolysaccharidosis IIIB (MPS IIIB) is an autosomal recessive lysosomal storage disorder. In comparison to Hurler syndrome (MPS I) and Hunter syndrome (MPS II), characteristic facial and physical features tend to be milder and progression of neurological symptoms may initially be slower. Obvious neurological and behavioural symptoms may not appear until age 2–6 years, but once they begin, progression is relentless, leading to death by the early 20s. Although there is currently no known cure for MPS IIIB, enzyme replacement clinical trials are showing hope for delay in the progression of symptoms. Early diagnosis is therefore necessary before neurological symptoms have progressed. In our case, MPS IIIB was diagnosed at an early age because recurrent wheezing and otitis media in conjunction with hepatomegaly were recognised as more than trivial findings. A thorough examination and a definitive proactive decision to perform a liver biopsy resulted in early diagnosis of a rare disease.

https://ift.tt/2LnXeoQ

Frey syndrome following herpes zoster in an otherwise healthy girl

A 12-year-old girl presented with red spots appearing on the left side of her face. The girl was usually healthy and fully vaccinated, including varicella vaccination.

Six years prior to her presentation, she had suffered an episode of blister rash on the left side of her face, including lesions in the ear canal and buccal mucous membrane. A diagnosis of herpes zoster was made, and she was treated with acyclovir with complete skin recovery. A hearing examination demonstrated mild-to-moderate left neurosensory hearing loss.

Since then, she is having short episodes of redness on her face without pain or sweating at the exact distribution of the zoster blisters 6 years ago. The appearance of spots is related to sour foods, such as sour flavoured candies, yoghourt and green apples. The diagnosis of postherpetic Frey syndrome was made, and observational approach was adopted due to the benign character of symptoms.

https://ift.tt/2v0CBEa

Hepatitis C virus infection: 'beyond the liver

There are rare reports of association between hepatitis C virus (HCV) infection and dermatomyositis although cause and effect remains to be proven. We present a clinical case with a probable cause and effect association between these two entities. A 71-year-old woman developed an erythematous exanthem with pruritic and scaly lesions located at the torso and upper limbs associated with heliotrope and Gottron's papules. At the same time, she notice a significant loss of muscular strength. Skin and muscular biopsies made the diagnosis of dermatomyositis and the patient started with prednisolone (60 mg/day) with poor symptoms control. Paraneoplastic syndrome, HIV, hepatitis B virus and syphilis infections were excluded. HCV serology was positive, with a viral load of 58 159 IU/mL (genotype 1a). Therefore, the patient underwent a 12-week treatment with grazoprevir 100 mg and elbasvir 50 mg achieving a sustained virological response with regression of skin lesions and complete recovery of muscular strength (photodocumented before/after treatment). Additionally it was possible to reduce prednisolone dosage to 5 mg/day.

https://ift.tt/2LogO4q

Stroke-induced resolution of primary blepharospasm: evidence for the lenticular nucleus as a control candidate

Primary blepharospasm is an adult-onset focal dystonia characterised by involuntary contractions of the orbicularis oculi, leading to bilateral spasmodic closure of the eyelids. While spasms of this muscle constitute the hallmark of disease, other motor manifestations include increased spontaneous blinking and apraxia of eyelid opening. Originally misdiagnosed as a psychiatric condition, blepharospasm is now well established as being of neurological origin although questions remain as to its pathophysiological mechanisms.

We report a 66-year-old woman who had a 14-year history of primary blepharospasm which completely resolved following a left medial cerebral artery thromboembolic infarct of the lenticular nucleus. This report provides supporting evidence of the lenticular nucleus as a key structure mediating the disease which can lead to functional blindness.

https://ift.tt/2v7R94T

Motile Ciliary Disorders in Chronic Airway Inflammatory Diseases: Critical Target for Interventions

Abstract

Purpose of Review

Impaired mucociliary clearance has been implicated in chronic upper and lower airway inflammatory diseases (i.e., allergic and non-allergic rhinitis, chronic rhinosinusitis with or without nasal polyps and asthma). How motile ciliary disorders (impaired ciliogenesis, ciliary beating and ultrastructural defects) are implicated in chronic airway inflammatory diseases is not fully understood. Elaboration of the role of motile ciliary disorders may serve as therapeutic targets for improving mucociliary clearance, thereby complementing contemporary disease management.

Recent Findings

We have summarized the manifestations of motile ciliary disorders and addressed the underlying associations with chronic airway inflammatory diseases. A panel of established and novel diagnostic tests and therapeutic interventions are outlined. Physicians should be vigilant in screening for motile ciliary disorders, particularly in patients with co-existing upper and lower airway inflammatory diseases.

Summary

Proper assessment and treatment of motile ciliary disorders may have added value to the management and prevention of chronic airway inflammatory diseases.

https://ift.tt/2v4Jape

100% survival after transplantation of 34 Wiskott Aldrich Syndrome patients over 20 years

Publication date: Available online 25 July 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): R. Elfeky, J.M. Furtado-Silva, R. Chiesa, K. Rao, P. Amrolia, G. Lucchini, K. Gilmour, S. Adams, S. Bibi, A. Worth, A.J. Thrasher, W. Qasim, P. Veys

https://ift.tt/2A8Q8zf

Building Bridges for Asthma Care: Reducing School Absence for Inner City Children with Health Disparities

Publication date: Available online 25 July 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Stanley J. Szefler, Michelle M. Cloutier, Miguel Villarreal, Jessica P. Hollenbach, Melanie Gleason, Christy Haas-Howard, Carol Vinick, Agustin Calatroni, Lisa Cicutto, Marty White, Shann Williams, Meghan McGinn, Christine Langton, Donna Shocks, Herman Mitchell, David A. Stempel

Abstract

Background

Children with asthma are at increased risk for experiencing health and educational disparities because of increased school absence. School nurses are well-positioned to support asthma management and improve school attendance.

Objective

To implement and assess the effect of the Building Bridges for Asthma Care Program on improving school attendance and measures of asthma control.

Methods

Children with asthma, ages 5 through 14 years, in the Denver Public School System (n=240) and the Hartford Public School System (n=223) were enrolled in the Building Bridges Program during the 2013-2014 and the 2014-2015 school years and followed until the end of the second school year. The primary outcome was school absence with secondary outcomes including asthma control measured by the Childhood Asthma Control Test (cACT) or the Asthma Control Test (ACT), and rescue inhaler use.

Results

Participants experienced a 22% absolute decrease in school absenteeism; the number of children with an ACT/cACT score below the control threshold of 20 decreased from 42.7% to 28.8% and bronchodilator use >2 times per week declined from 35.8% to 22.9% (all changes were significant, p<.01).

Conclusions

Children enrolled in the Building Bridges for Asthma Care Program experienced reduced school absence and improved asthma control.

https://ift.tt/2Oe5J3w

A Revisit to High Jugular Bulb: A Newer Clinical Grading

Abstract

A revisit to high riding jugular bulb with a newer classification. Observational study. Patients in the age group between 15 to 60 years, who underwent various Tympanomastoid and otosclerotic surgeries from April 2015 to 2018, have been included in the study. An analysis was made on high riding jugular bulb which encountered and different anatomical variations were noticed. A total of 531 patients underwent various tympanomastoid surgeries and 48 patients underwent otosclerotic surgeries. Out of which 8% of the cases (n = 49) were noticed to have high riding jugular bulb. In those 49 cases, 81% (n = 37) have Grade I, 11% (n = 5) have Grade II, 6% (n = 3) have grade III, 6% of the case (n = 3) have Grade IV and 2% (n = 1) has Grade V high riding Jugular bulb. Among these the prevalence of Grade I jugular bulb is high followed by Grade II. With the observation of our clinical study the authors have made a revisit to high riding jugular bulb and proposed a new clinical grading for high jugular bulb called BPH, that is Basava Prasad's grading clinical on High jugular bulb (Channa Basava Hubli and K. C. Prasad) as: Grade I high riding jugular bulb up to the level of inferior tympanic annulus. Grade II extending from the level of tympanic annulus up to the inferior margin of the round window niche. Grade III Completely obliterating the round window niche. Grade IV Lies between superior margin of round window niche and stapes. Grade V Abuting the Stapes Arch.

https://ift.tt/2LTcXs0

Varied Presentation of Venous Ectasia Head and Neck: Case Series and Review of Literature

Abstract

Jugular venous ectasia in head and neck region is a rare entity. They may present as asymptomatic neck masses and should be considered in the differential diagnosis of cystic neck masses. Management is individualised based on the patient and includes conservative or surgical management. We hereby report three cases of venous ectasia (2—external jugular and 1—facial vein) managed at our institute.

https://ift.tt/2uPD2C4

Inhibition of ER stress-related IRE1α/CREB/NLRP1 pathway promotes the apoptosis of human chronic myelogenous leukemia cell

Publication date: September 2018

Source: Molecular Immunology, Volume 101

Author(s): Zheng Xu, Huirui Wang, Suhua Wei, Zhencheng Wang, Guanghou Ji

Abstract

Endoplasmic reticulum (ER) stress is induced in chronic myelogenous leukemia (CML) cells. As an important sensor of ER stress, inositol-requiring protein-1α (IRE1α) promotes the survival of acute myeloid leukemia. NLRP1 inflammasome activation promotes metastatic melanoma growth and that IRE1α can increase NLRP1 inflammasome gene expression. This study aimed to investigate the role and molecular mechanism of IRE1α in CML cell growth. We found that overexpression of IRE1α or NLRP1 significantly promoted the proliferation and decreased the apoptosis of CML cells, whereas downregulation of these two genes showed the opposite effects. 4-phenylbutyric acid (4-PBA), an ER stress inhibitor, reduced the expression of IRE1α and NLRP1. IRE1α elevated NLRP1 expression via cAMP responsive element binding protein (CREB) phosphorylation. NLRP1 inflammasome was activated in CML cells and its activation partly reversed ER stress inhibitor-induced cell apoptosis. Furthermore, inhibition of IRE1α/NLRP1 pathway sensitized CML cells to imatinib-mediated apoptosis. Additionally, IRE1α expression was elevated and NLRP1 inflammasome was activated in primary cells from CML patients. Downregulation of IRE1α or NLRP1 suppressed the proliferation and elevated the apoptosis of primary CML cells. Collectively, this study demonstrated that the IRE1α/CREB/NLRP1 pathway contributes to the progression of CML and the development of imatinib resistance. Hence, targeting ER stress-related IRE1α expression or NLRP1 inflammasome activation may block CML development.

https://ift.tt/2LrduFP

Shaping the humoral immune response: Actin regulators modulate antigen presentation and influence B-T interactions

Publication date: September 2018

Source: Molecular Immunology, Volume 101

Author(s): Marianne Burbage, Selina Jessica Keppler

Abstract

B cells are an integral part of the adaptive immune system. During an immune response, the actin cytoskeleton plays a central role in regulating B cell antigen uptake, polarization and presentation as well as B cell migration and interaction with T cells. Genetic defects affecting actin regulators can result in reduced B cell activation, limited antibody production and hence cause disease. In this review, we discuss molecular mechanisms of actin regulation and their involvement in antigen polarisation and presentation, as well as their role in influencing interactions between B and T cells. Improved understanding of these mechanisms is necessary for the development of new therapeutic options modulating humoral immune responses.

https://ift.tt/2v9qyVk

A Revisit to High Jugular Bulb: A Newer Clinical Grading

Abstract

A revisit to high riding jugular bulb with a newer classification. Observational study. Patients in the age group between 15 to 60 years, who underwent various Tympanomastoid and otosclerotic surgeries from April 2015 to 2018, have been included in the study. An analysis was made on high riding jugular bulb which encountered and different anatomical variations were noticed. A total of 531 patients underwent various tympanomastoid surgeries and 48 patients underwent otosclerotic surgeries. Out of which 8% of the cases (n = 49) were noticed to have high riding jugular bulb. In those 49 cases, 81% (n = 37) have Grade I, 11% (n = 5) have Grade II, 6% (n = 3) have grade III, 6% of the case (n = 3) have Grade IV and 2% (n = 1) has Grade V high riding Jugular bulb. Among these the prevalence of Grade I jugular bulb is high followed by Grade II. With the observation of our clinical study the authors have made a revisit to high riding jugular bulb and proposed a new clinical grading for high jugular bulb called BPH, that is Basava Prasad's grading clinical on High jugular bulb (Channa Basava Hubli and K. C. Prasad) as: Grade I high riding jugular bulb up to the level of inferior tympanic annulus. Grade II extending from the level of tympanic annulus up to the inferior margin of the round window niche. Grade III Completely obliterating the round window niche. Grade IV Lies between superior margin of round window niche and stapes. Grade V Abuting the Stapes Arch.

https://ift.tt/2LTcXs0

Varied Presentation of Venous Ectasia Head and Neck: Case Series and Review of Literature

Abstract

Jugular venous ectasia in head and neck region is a rare entity. They may present as asymptomatic neck masses and should be considered in the differential diagnosis of cystic neck masses. Management is individualised based on the patient and includes conservative or surgical management. We hereby report three cases of venous ectasia (2—external jugular and 1—facial vein) managed at our institute.

https://ift.tt/2uPD2C4

Thyroid Cancer Treatment Choice: A Pilot Study of a Tool to Facilitate Conversations with Patients with Papillary Microcarcinomas Considering Treatment Options

Thyroid, Ahead of Print.


https://ift.tt/2mOXHlr

Erratum: Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography

Annals of Cardiac Anaesthesia 2018 21(3):346-346



https://ift.tt/2A6J71O

A curious case of raised gradient across mitral bioprosthetic valve

Monish S Raut, Vijay Mohan Hanjoora, Murtaza A Chishti, Akhil Govil, Rakesh Pandey, Aman Jyoti, Ravi Kumar Mahavar, Shweta Suri Kandpal, Dileep Kumar Singh Rathor

Annals of Cardiac Anaesthesia 2018 21(3):321-322

High Doppler valve gradient is generally suggestive of valve thrombosis. However, it should be corroborated with the finding of restricted leaflet movement to confirm the diagnosis. In the present case, abnormally high gradient was not associated with limited leaflet movements or any valve thrombus.

https://ift.tt/2mHjVW9

Neurogenic stress cardiomyopathy: What do we need to know

Ramachandran Gopinath, Syama Sundar Ayya

Annals of Cardiac Anaesthesia 2018 21(3):228-234

The interaction between the heart and brain is complex and integral to the maintenance of normal cardiovascular function. Even in the absence of coronary disease, acute neuronal injury can induce a variety of cardiac changes. Recent neuroimaging data revealed a network including the insular cortex, anterior cingulate gyrus, and amygdala playing a crucial role in the regulation of central autonomic nervous system. Damage in these areas has been associated with arrhythmia, myocardial injury, higher plasma levels of brain natriuretic peptide, catecholamines, and glucose. Some patients after brain injury may die due to occult cardiac damage and functional impairment in the acute phase. Heart failure adversely influences acute stroke mortality. Troponin and NT-proBNP are elevated in acute brain injury patients, in response to the activated renin–angiotensin–aldosterone system and other neurohumoral changes, as a protective mechanism for sympathoinhibitory activity. Such patients have been shown to be associated with higher short- and long-term mortality. While thrombolysis, neuroprotection, and other measures, alone or in combination, may limit the cerebral damage, attention should also be directed toward the myocardial protection. Early administration of cardioprotective medication aimed at reducing increased sympathetic tone may have a role in myocardial protection in stroke patients. For a full understanding of the brain–heart control, the consequences of disruption of this control, the true incidence of cardiac effects of stroke, and the evidence-based treatment options further research are needed.

https://ift.tt/2AbeGYl

Refractory hypokalemia while weaning off bypass

Rashmi Soori, Aanchal Dixit, Prabhat Tewari

Annals of Cardiac Anaesthesia 2018 21(3):311-312

Hypokalemia is defined as serum potassium level less than 3.5 mEq/L. When the serum level of potassium is less than 3 mEq/L, intravenous potassium supplementation is warranted. A 23 yr old adult female with complaints of dyspnoea (NYHA II) since 6 yrs, dyspnoea (NYHA III) and paroxysmal nocturnal dyspnoea on and off since 2 months, diagnosed with severe mitral stenosis, was posted for mitral valve replacement. After the release of ACC, ECG revealed sine wave pattern, Transesophageal echocardiographic examination revealed global hypokinesia and ABG showed potassium of 2.3 mEq/L. Hypokalemia in cardiac patients can occur due to the effect of poor oral intake, increased renal loss by the secondary hyperaldosteronism in congestive heart failure, loss due to use of digoxin and diuretics like thiazide diuretics, loop diuretics etc. Hypokalemia should be avoided while weaning off cardiopulmonary support as it can lead to atrial and ventricular arrhythmias. Potassium ion is very important for the normal contractility of the heart. Hypokalemia if refractory to intravenous potassium supplementation, concomitant magnesium deficiency should be suspected and treated.

https://ift.tt/2OfqfRo

Sedation effects by dexmedetomidine versus propofol in decreasing duration of mechanical ventilation after open heart surgery

Ahmed Said Elgebaly, Mohab Sabry

Annals of Cardiac Anaesthesia 2018 21(3):235-242

Objective: The objective of this study was to compare the suitability (efficacy and safety) of dexmedetomidine versus propofol for patients admitted to the intensive care unit (ICU) after the cardiovascular surgery for the postoperative sedation before weaning from mechanical ventilation. Background: Sedation is prescribed in patients admitted to the ICU after cardiovascular surgery to reduce the patient discomfort, ventilator asynchrony, to make mechanical ventilation tolerable, prevent accidental device removal, and to reduce metabolic demands during respiratory and hemodynamic instability. Careful drug selection for sedation by the ICU team, postcardiovascular surgery should be done so that patients can be easily weaned from mechanical ventilation after sedation is stopped to achieve a shorter duration of mechanical ventilation and decreased the length of stay in ICU. Methods: A total of 50 patients admitted to the ICU after cardiovascular surgery, aged from 18 to 55 years and requiring mechanical ventilation on arrival to the ICU were enrolled in a prospective and comparative study. They were randomly divided into two groups as follows: Group D patients (n = 25) received dexmedetomidine in a maintenance infusion dose of 0.8 μg/kg/h and Group P patients (n = 25) received propofol in a maintenance infusion dose of 1.5 mg/kg/h. The patients were assessed for 12 h postoperatively, and dosing of the study drug was adjusted based on sedation assessment performed with the Richmond Agitation-Sedation Scale (RASS). The patients were required to be within the RASS target range of −2 to +1 at the time of study drug initiation. At every 4 h, the following information was recorded from each patient such as heart rate (HR), mean arterial pressure (MAP), arterial blood gases (ABG), tidal volume (TV), exhaled TV, maximum inspiratory pressure, respiratory rate and the rapid shallow breathing index, duration of mechanical ventilation, midazolam and fentanyl dose requirements, and financial costs. Results: The study results showed no statistically significant difference between both groups with regard to age and body mass index. Group P patients were more associated with lower MAP and HR than Group D patients. There was no statistically significant difference between groups with regard to ABG findings, oxygenation, ventilation, and respiratory parameters. There was significant difference between both the groups in midazolam and fentanyl dose requirement and financial costs with a value of P < 0.05. Conclusion: Dexmedetomidine is safer and equally effective agent for the sedation of mechanically ventilated patients admitted to the ICU after cardiovascular surgery compared to the patients receiving propofol, with good hemodynamic stability, and equally rapid extubation time.

https://ift.tt/2AamCZV

Transesophageal echocardiography guidance for expedited pulmonary artery catheter insertion and accurate estimation of cardiac output

Monish S Raut, Vijay Mohan Hanjoora, Murtaza A Chisti

Annals of Cardiac Anaesthesia 2018 21(3):339-340



https://ift.tt/2LB4e0Y

Quest for the holy grail: Assessment of echo-derived dynamic parameters as predictors of fluid responsiveness in patients with acute aneurysmal subarachnoid hemorrhage

Ajay Prasad Hrishi, Manikandan Sethuraman, Girish Menon

Annals of Cardiac Anaesthesia 2018 21(3):243-248

Background: Acute aneurysmal subarachnoid hemorrhage (aSAH) is a potentially devastating event often presenting with a plethora of hemodynamic fluctuations requiring meticulous fluid management. The aim of this study was to assess the utility of newer dynamic predictors of fluid responsiveness such as Delta down (DD), superior vena cava collapsibility index (SVCCI), and aortic velocity time integral variability (VTIAoV) in patients with SAH undergoing neurosurgery. Materials and Methods: Fifteen individuals with SAH undergoing surgery for intracranial aneurysmal clipping were enrolled in this prospective study. Postinduction, vitals, anesthetic parameters, and the study variables were recorded as the baseline. Following this, patients received a fluid bolus of 10 ml/kg of colloid over 20 min, and measurements were repeated postfluid loading. Continuous variables were expressed as mean ± standard deviation and compared using Student's t-test, with a P < 0.05 considered statistically significant. The predictive ability of variables for fluid responsiveness was determined using Pearson's coefficient analysis (r). Results: There were 12 volume responders and 3 nonresponders (NR). DD >5 mm Hg was efficient in differentiating the responders from NR (P < 0.05) with a sensitivity and specificity of 90% and 85%, respectively, with a good predictive ability to identify fluid responders and NR; r = 0.716. SVCCI of >38% was 100% sensitive and 95% specific in detecting the volume status and in differentiating the responders from NR (P < 0.05) and is an excellent predictor of fluid responsive status; r = 0.906. VTIAoV >20% too proved to be a good predictor of fluid responsiveness, with a sensitivity and specificity of 100% and 90%, respectively, with a predictive power; r = 0.732. Conclusion: Our study showed that 80% of patients presenting with aSAH for intracranial aneurysm clipping were fluid responders with normal hemodynamic parameters such as heart rate and blood pressure. Among the variables, SVCCI >38% appears to be an excellent predictor followed by VTIAoV >20% and DD >5 mmHg in assessing the fluid status in this population.

https://ift.tt/2uZFp4q

Concomitant diaphragmatic hernia repair with coronary artery bypass grafting surgery

Gokulakrishnan Mohan, Srinivas Kalyanaraman, Sivakumar Ramakrishnan, Sanjay Theodore

Annals of Cardiac Anaesthesia 2018 21(3):304-306

Congenital Bochdalek diaphragmatic hernia (DH) is often diagnosed incidentally in adulthood. It is recommended that all cases of DH be repaired immediately at diagnosis since acute presentation after the complications have already developed has higher morbidity and mortality. A 47-year-old male presented with Grade III angina and dyspnea. A routine chest radiograph revealed bowel shadows in the right thorax, and subsequent computerized tomography (CT) scan confirmed the same. Coronary angiogram revealed coronary artery disease which needed surgery. Off-pump coronary artery bypass grafting followed by DH repair under one-lung ventilation.

https://ift.tt/2LprQWS

Barriers for the referral to outpatient cardiac rehabilitation: A predictive model including actual and perceived risk factors and perceived control

Ali Soroush, Behzad Heydarpour, Saeid Komasi, Mozhgan Saeidi, Parvin Ezzati

Annals of Cardiac Anaesthesia 2018 21(3):249-254

Objective: To assess the roles of demographic factors, actual and perceived risk factors, and perceived control in the referral to cardiac rehabilitation (CR) after coronary artery bypass graft (CABG). Methods: In this cross-sectional study, data related to 312 CABG patients in a hospital of the Western part of Iran, gathered through demographics and actual risk factors' checklist, open single item of perceived heart risk factors, life stressful events scale, and perceived control questionnaire. Data analyzed by binary logistic regression. Results: The results showed that only 8.3% of CABG patients refer to CR. The facilitators of this referral included official employment (P < 0.05), coronary history (P = 0.016), and hyperlipidemia (P = 0.030) but more distance to the CR center (P = 0.042) and perceived physiological risk factor (P = 0.025) are concerned as the barriers for the referral to CR. Conclusion: Providing appropriate awareness about the benefits of CR for patients with regard to their job status, coronary history, and perception about the illness risk factors can be effective in referral to CR. In addition, the presence of CR centers in towns and facilitated achievement to these centers can play a significant role in patients' participation.

https://ift.tt/2LA9BNN

Abnormal mitral valve apparatus in a case of hypertrophic obstructive cardiomyopathy: Intraoperative transesophageal echocardiography

Neelam Aggarwal, Jasbir Singh Khanuja, Sameer Saurabh Arora, Rahul Maria

Annals of Cardiac Anaesthesia 2018 21(3):315-318

Hypertrophic obstructive cardiomyopathy is a relatively common disorder that signifies asymmetric hypertrophy of interventricular septum causing obstruction of the left ventricular outflow tract (LVOT). However, more recent studies have shown that during ventricular systole, flow against an abnormal mitral valve apparatus results in drag forces on the part of the leaflets. The mitral leaflet is pushed into the LVOT to obstruct it. We present a case where intraoperative transesophageal echocardiography played a crucial role in defining the etiology of LVOT obstruction that subsequently helped in deciding the surgical plan.

https://ift.tt/2JVqUEp

Prospective, randomized clinical trial comparing use of intraoperative transesophageal echocardiography to standard care during radical cystectomy

Richa Dhawan, Sajid Shahul, Joseph Devin Roberts, Norm D Smith, Gary D Steinberg, Mark A Chaney

Annals of Cardiac Anaesthesia 2018 21(3):255-261

Purpose: Our prospective, randomized clinical study aims to evaluate the utility of intraoperative transesophageal echocardiography (TEE) in patients undergoing radical cystectomy. Materials and Methods: Eighty patients were randomized to a standard of care group or the intervention group that received continuous intraoperative TEE. Data are presented as means ± standard deviations, median (25th percentile, 75th percentile), or numbers and percentages. Characteristics were compared between groups using independent sample t-tests, Wilcoxon–Mann–Whitney tests or Chi-square tests, as appropriate. All tests were two-sided and P < 0.05 was considered to indicate statistical significance. Results: Both groups had similar preoperative demographic characteristics. There was a significant difference between central line insertion with all insertions in the control group (15%, 6 vs. 0%, 0; P < 0.003). Of all the perioperative complications, 80% occurred in the control group versus 20% in the TEE group, with 21% of controls experiencing a cardiac or pulmonary complication compared to 5% in the TEE group (8 vs. 2, P < 0.04). The control group patients were more likely to have adverse cardiac complications than the TEE group (15%, 6 vs. 3%, 1; P < 0.040). Postoperative cardiac arrhythmia was observed only in the control group (13%, 5 vs. 0%, 0; P <.007). Prolonged intubation was only observed in the control group (10%, 4 vs. 0%, 0; P < 0.017). Conclusion: TEE can be a useful monitoring tool in patients undergoing radical cystectomy, limiting the use of central line insertion and potentially translating into earlier extubation and decreased postoperative cardiac morbidities.

https://ift.tt/2mIPOxP

Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement

Tanveer Singh Kundra, PS Nagaraja, KS Bharathi, Parminder Kaur, N Manjunatha

Annals of Cardiac Anaesthesia 2018 21(3):328-332

Context: Inhaled levosimendan may act as selective pulmonary vasodilator and avoid systemic side effects of intravenous levosimendan, which include decrease in systemic vascular resistance (SVR) and systemic hypotension, but with same beneficial effect on pulmonary artery pressure (PAP) and right ventricular (RV) function. Aim: The aim of this study was to compare the effect of inhaled levosimendan with intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Settings and Design: The present prospective randomized comparative study was conducted in a tertiary care hospital. Subjects and Methods: Fifty patients were randomized into two groups (n = 25). Group A: Levosimendan infusion was started immediately after coming-off of cardiopulmonary bypass and continued for 24 h at 0.1 mcg/kg/min. Group B: Total dose of levosimendan which would be given through intravenous route over 24 h was calculated and then divided into four equal parts and administered through inhalational route 6th hourly over 24 h. Hemodynamic profile (pulse rate, mean arterial pressure, pulmonary artery systolic pressure [PASP], SVR) and RV function were assessed immediately after shifting, at 1, 8, 24, and 36 h after shifting to recovery. Statistical Analysis Used: Intragroup analysis was done using paired student t-test, and unpaired student t-test was used for analysis between two groups. Results: PASP and RV-fractional area change (RV-FAC) were comparable in the two groups at different time intervals. There was a significant reduction in PASP and significant improvement in RV-FAC with both intravenous and inhalational levosimendan. SVR was significantly decreased with intravenous levosimendan, but no significant decrease in SVR was observed with inhalational levosimendan. Conclusions: Inhaled levosimendan is a selective pulmonary vasodilator. It causes decrease in PAP and improvement in RV function, without having a significant effect on SVR.

https://ift.tt/2OiASDa

A Low-dose human fibrinogen is not effective in decreasing postoperative bleeding and transfusion requirements during cardiac surgery in case of concomitant clinical bleeding and low FIBTEM values: A retrospective matched study

Iuliana-Marinela Lupu, Zineb Rebaine, Laurence Lhotel, Christine Watremez, Stéphane Eeckhoudt, Michel Van Dyck, Mona Momeni

Annals of Cardiac Anaesthesia 2018 21(3):262-269

Background: Studies evaluating the hemostatic effects of fibrinogen administration in cardiac surgery are not conclusive. Aims: We investigated whether the use of a low-dose human fibrinogen in case of clinical bleeding after protamine administration and concomitant low FIBTEM values is effective in reducing postoperative bleeding. Secondary end-point was to investigate the consumption of allogeneic blood products. Setting and Design: This was a retrospective matched study conducted at university hospital. Materials and Methods: Among 2257 patients undergoing surgery with cardiopulmonary (CPB) bypass, 73 patients received a median dose of 1 g human fibrinogen (ROTEM-Fibri group). This group was matched with 73 patients who had not received human fibrinogen (control group) among 390 patients having undergone surgery at the moment FIBTEM analysis was unavailable. Statistical Analysis: Matching was performed for the type and the presence of redo surgery. McNemar and Wilcoxon paired tests were used to respectively compare the categorical and quantitative variables. Results: The CPB bypass time was significantly higher in the ROTEM-Fibri group (P = 0.006). This group showed significantly higher bleeding in the first 12 and 24 h postoperatively (P < 0.001) and required significantly more transfusion of blood products (P < 0.001) and surgical revision (P = 0.007) when compared with the control group. There was no significant difference in the number of thromboembolic complications. Conclusions: These results show that the administration of 1 g of fibrinogen based on low-FIBTEM values and clinical bleeding after protamine administration does not stop bleeding and the need for transfusion of allogeneic blood products.

https://ift.tt/2Aamslh

Sustained ventricular arrhythmias in an asymptomatic child posted for laparoscopic rectopexy: An anesthetist's dilemma?

Kavya R Upadhya, Chandrika Y Ramavakoda, Madhavi Ravindra, Anuradha Ganigara

Annals of Cardiac Anaesthesia 2018 21(3):343-344



https://ift.tt/2mHjrPP

Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study

Kunal Sarin, Sandeep Chauhan, Akshay Kumar Bisoi, Anjali Hazarika, Neena Malhotra, Pratik Manek

Annals of Cardiac Anaesthesia 2018 21(3):270-274

Background: Blood transfusion requirement during neonatal open heart surgeries is universal. Homologous blood transfusion (HBT) in pediatric cardiac surgery is used most commonly for priming of cardiopulmonary bypass (CPB) system and for postoperative transfusion. To avoid the risks associated with HBT in neonates undergoing cardiac surgery, use of autologous umbilical cord blood (AUCB) transfusion has been described. We present our experience with the use of AUCB for neonatal cardiac surgery. Designs and Methods: Consecutive neonates scheduled to undergo cardiac surgery for various cardiac diseases who had a prenatal diagnosis made on the basis of a fetal echocardiography were included in this prospective observational study. After a vaginal delivery or a cesarean section, UCB was collected from the placenta in a 150-mL bag containing 5 mL of citrate–phosphate–dextrose–adenine-1 solution. The collected bag with 70–75 mL cord blood was stored at 2°C–6°C and tested for blood grouping and infections after proper labeling. The neonate's autologous cord blood was used for postcardiac surgery blood transfusion to replace postoperative blood loss. Results: AUCB has been used so far at our institute in 10 neonates undergoing cardiac surgery. The donor exposure in age and type of cardiac surgery-matched controls showed that the neonates not receiving autologous cord blood had a donor exposure to 5 donors (2 packed red blood cells [PRBCs], including 1 for CPB prime and 1 for postoperative loss, 1 fresh frozen plasma, 1 cryoprecipitate, and 1 platelet concentrate) compared to 1 donor for the AUCB neonate (1 PRBC for the CPB prime). Postoperative blood loss was similar in both the groups of matched controls and study group. Values of hemoglobin, total leukocyte count, platelet counts, and blood gas parameters were also similar. Conclusions: Use of AUCB for replacement of postoperative blood loss after neonatal cardiac surgery is feasible and reduces donor exposure to the neonate. Its use, however, requires a prenatal diagnosis of a cardiac defect by fetal echo and adequate logistic and psychological support from involved clinicians and the blood bank.

https://ift.tt/2AbtWEI

Regional analgesia in cardiothoracic surgery: A changing paradigm toward opioid-free anesthesia?

Murali Chakravarthy

Annals of Cardiac Anaesthesia 2018 21(3):225-227



https://ift.tt/2OfqcFc

In Response to “Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study”

Praveen Kumar Neema

Annals of Cardiac Anaesthesia 2018 21(3):275-276



https://ift.tt/2AbUyp2

The unexpected diagnosis of phaeochromocytoma in the anaesthetic room

Louise Kenny, Victoria Rizzo, Jason Trevis, Elena Assimakopoulou, Dierdre Timon

Annals of Cardiac Anaesthesia 2018 21(3):307-310

A 77-year-old man was admitted for aortic valve replacement and combined coronary bypass grafting. Grossly, labile arterial pressures were demonstrated on anesthetic induction prompting cancellation and Intensive Care Unit transfer. Urine analysis identified high normetadrenaline/creatinine ratio, plasma metanephrine, and plasma normetanephrine. A left adrenal lesion on computed tomography scan collectively indicated pheochromocytoma. Laparoscopic adrenalectomy was prioritized at multidisciplinary team before cardiac surgery. Vague symptoms of pheochromocytoma pose a diagnostic problem, being often attributed to common/co-existing pathology. The blood pressure instability on anesthetic required precise control, multidisciplinary input, and awareness of possible diagnosis as a routine intervention for hypotension may have been fatal in view of underlying cardiac pathology.

https://ift.tt/2mKnvz4

Transcatheter aortic valve implantation: General anesthesia using transesophageal echocardiography does not decrease the incidence of paravalvular leaks compared to sedation alone

Cédrick Zaouter, Sara Smaili, Lionel Leroux, Guillaume Bonnet, Sébastien Leuillet, Alexandre Ouattara

Annals of Cardiac Anaesthesia 2018 21(3):277-284

Background: Transcatheter aortic valve implantation (TAVI) is a valid option for patients with severe aortic stenosis judged to be at high surgical risk. For this procedure, there is no agreement on the appropriate type of anesthesia. Sedation offers several advantages, but general anesthesia (GA) leads to less paravalvular leaks (PVLs) probably because of the transesophageal echocardiography (TEE) guidance. The objective was to compare the incidence of PVL among patients receiving conscious sedation (TAVI-S) and patients receiving GA (TAVI-GA). We made the hypothesis that a referral center does not necessitate TAVI-GA to reduce the incidence of moderate-to-severe PVL. Aim: The primary outcome was the incidence of moderate-to-severe PVL at 30 days after the implantation. Design and Setting: This study design was a retrospective observational trial in a university hospital. Methods: The TAVI-S group underwent the procedure under conscious sedation. In the TAVI-GA group, an endotracheal tube and a TEE probe were inserted. After the valve deployment, PVL was assessed by hemodynamic and fluoroscopic measurements in the TAVI-S group. TEE was also used in the TAVI-GA group to evaluate the presence of PVL. When PVL was moderate or severe according to the Valve Academic Research Consortium criteria. Results: TAVI-S and TAVI-GA were accomplished in 168 (67.5%) and 81 (32.5%) patients, respectively. Our results show no difference between the two groups regarding the incidence and grade of PVL. Conclusion: Performing TAVI under GA with TEE guidance is not associated with a lower incidence of moderate and severe PVL.

https://ift.tt/2A79C7o

Echocardiographic evaluation of aorta to right atrial fistula secondary to ruptured sinus of valsalva aneurysm

Ashley V Fritz, Kathryn S Boles, Archer Kilbourne Martin

Annals of Cardiac Anaesthesia 2018 21(3):313-314

We present the case of a 37 year old male who presented with new onset dyspnea, tachycardia, palpitations, and chest tightness. His initial work up demonstrated a dilated pulmonary artery with reflux of contrast dye in to the IVC. Transthoracic echocardiogram identified a "windsock" appearance indicating Sinus of Valsalva aneurysm (SVA) and severe aortic regurgitation. As a result, the patient was taken for emergent surgery where the windsock tissue was surgically repaired with bovine pericardial patch. This case illuminates the uncommon occurrence of SVA and the ability to recognize these findings on multiple imaging modalities including transthoracic, transesophageal two and three dimensional echocardiography as well as direct surgical field visualization.

https://ift.tt/2mHj9sd

Vallecular cyst in the pediatric population: Evaluation and management

Publication date: Available online 25 July 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Youjin Li, Alexandria L. Irace, Natasha D. Dombrowski, Antonio R. Perez-Atayde, Caroline D. Robson, Reza Rahbar

Abstract

Objective

To review the presentation of pediatric vallecular cysts and outline an approach for evaluation and management.

Methods

Medical records of patients diagnosed with vallecular cyst between 2005 and 2017 were reviewed. Data on demographics, clinical characteristics, diagnostic methods, surgical procedures, and outcomes were collected and analyzed. A comprehensive literature search for pediatric cases of vallecular cyst was conducted for comparative analysis.

Results

Twenty patients underwent surgery for congenital vallecular cysts during the study period. Age at diagnosis ranged from birth to 8 years (median age = 1.1 years). The most common preoperative symptom was inspiratory stridor (45%) followed by feeding difficulties (40%). Eight patients (40%) initially presented with laryngomalacia and 7 (35%) with feeding difficulties. Imaging was obtained in 16 patients and consisted of plain films, ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). Marsupialization of the cyst was performed in all 20 patients. Three patients (15%) presented with recurrence.

Conclusion

Vallecular cysts can cause feeding difficulties due to upper airway obstruction and pressure at the laryngeal inlet. Diagnostic work-up for vallecular cysts should include a detailed medical history, complete head and neck examination including endoscopic examination, and appropriate imaging, as each of these components complements the histopathologic findings. Our findings indicate that performing marsupialization is associated with low rate of recurrence or complication.

https://ift.tt/2K0EjL8

Interdisciplinary aerodigestive care model improves risk, cost, and efficiency

Publication date: Available online 25 July 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): R. Paul Boesch, Karthik Balakrishnan, Rayna M. Grothe, Sherilyn W. Driscoll, Erin E. Knoebel, Sue L. Visscher, Shelagh A. Cofer

Abstract

Objective

This study sought to evaluate the impact of an interdisciplinary care model for pediatric aerodigestive patients in terms of efficiency, risk exposure, and cost.

Methods

Patients meeting a standard clinical inclusion definition were studied before and after implementation of the aerodigestive program.

Results

Aerodigestive patients seen in the interdisciplinary clinic structure achieved a reduction in time to diagnosis (6 vs 150 days) with fewer required specialist consultations (5 vs 11) as compared to those seen in the same institution prior. Post-implementation patients also experienced a significant reduction in risk, with fewer radiation exposures (2 vs 4) and fewer anesthetic episodes (1 vs 2). Total cost associated with the diagnostic evaluation was significantly reduced from a median of $10,374 to $6,055.

Conclusion

This is the first study to utilize a pre-post cohort to evaluate the reduction in diagnostic time, risk exposure, and cost attributable to the reorganization of existing resources into an interdisciplinary care model. This suggests that such a model yields improvements in care quality and value for aerodigestive patients, and likely for other pediatric patients with chronic complex conditions.

https://ift.tt/2LFaXab

Post-treatment sequelae and management of primary laryngeal NK/T-cell lymphoma: A case report

Publication date: Available online 25 July 2018

Source: American Journal of Otolaryngology

Author(s): Joseph B. Meleca, Andrea Hanick, Eric Lamarre, Paul C. Bryson

Abstract

Outcome objectives

1.

Describe the presentation and treatment options of laryngeal NK/T-Cell lymphoma

2.

Discuss post-chemoradiotherapy sequelae and airway management

Methods

Case Report, April 2016.

Results

A 27-year-old female presented with a three-week history of flu-like symptoms including sore throat, myalgia and insidious nasal congestion. Her hospital course was complicated by pancytopenia, extensive GI bleed of unknown origin and fever. Radiographic studies revealed multifocal centrilobular ground-glass lung nodules, splenomegaly, frontal and paranasal sinus opacification and mucosal thickening and inflammatory process of false and true vocal cords with concentric multi-level narrowing. Extensive rheumatologic, hematologic and infectious workup failed to demonstrate an etiology. Flexible laryngoscopic and bronchoscopic examinations with biopsies exhibited a diffuse supraglottic and glottic exophytic, "heaped-up" infiltration; limited vocal cord motion; and airway narrowing to 3 mm. Pathology yielded NK/T-Cell lymphoma with PET/CT confirming nasopharyngeal and laryngeal involvement sparing the brain and other distant structures. During treatment, the patient's airway became increasingly compromised requiring tracheostomy. Flexible laryngoscopic examination after four rounds of SMILE (dexamethasone, methotrexate, ifosfamide, l-asparaginase, and etoposide) chemotherapy and subsequent radiotherapy with 50 Gy in 25 fractions revealed complete glottic stenosis with alteration of the laryngeal anatomy and a pin-hole aperture seen posteriorly through the tracheostomy. Two dilation procedures performed one month apart, improved her airway considerably which allowed for successful decannulation. She continues to be disease-free post treatment but has persistent supraglottic and glottic scar and has developed tracheal stenosis at her tracheostomal site.

Conclusions

NK/T-Cell lymphoma of the larynx has been rarely described. Herein, we describe the sequalae of treatment and the requisite airway management.

https://ift.tt/2Oiseoc

Necrotizing epiglottitis treated with early surgical debridement: A case report

Publication date: Available online 25 July 2018

Source: American Journal of Otolaryngology

Author(s): Clare Richardson, Prashanth Thalanayar Muthukrishnan, Chelsea Hamill, Vidya Krishnan, Freedom Johnson

Abstract

Objective

Necrotizing supraglottitis is a rare but potentially morbid infection most often seen in immunocompromised patients. All reported cases have utilized intravenous antibiotic therapy as the mainstay of treatment and many have had associated morbidities.

Methods

We describe a case of a 50-year-old previously healthy female who presented with necrotizing epiglottis and was treated with immediate surgical debridement followed by directed antibiotic therapy.

Results

Our patient rapidly recovered with no further invasive interventions. On follow up she had no further complications or functional deficits.

Conclusions

Although uncommon, providers should be aware of the potential benefits of early debridement when treating patients with similar pathology. Early surgical intervention should be considered to avoid local tissue loss, airway interventions, and long-term sequelae.

https://ift.tt/2LOmPU8

Improvement of sinonasal mucociliary function by endoscopic sinus surgery in patients with chronic rhinosinusitis

Publication date: Available online 25 July 2018

Source: American Journal of Otolaryngology

Author(s): Mohsen Naraghi, Neda Baghbanian, Melorina Moharari, Amene Saghazadeh

Abstract

Objectives

Mucociliary clearance is an important defense mechanism for upper and lower airway. Chronic rhinosinusitis has been frequently associated with mucociliary dysfunction. Endoscopic sinus surgery (ESS) is recommended for treatment-resistant sinusitis in order to improve mucociliary function. The present study investigated the effect of ESS on the saccharin time (mucociliary clearance time) in relation to symptom profile assessed by the Sino-nasal Outcome Test (SNOT)-22, and disease severity based on the Lund-Kennedy endoscopic scores and Lund-Mackay computed tomographic (CT) scores.

Method

The present cohort study included 22 patients with chronic rhinosinusitis who were considered a candidate for ESS due to lack of response to medical treatment. Saccharin test was used before and 3 months after ESS to evaluate changes in mucociliary function. The CT scan was used for preoperative assessment of sinonasal anatomy. In addition, diagnostic nasal endoscopy was performed before and 3 months after ESS. The CT scan and nasal endoscopy findings were respectively analyzed based on the Lund-Mackay and the Lund-Kennedy staging systems recommended for chronic rhinosinusitis. Symptom severity was assessed from before to 3 months after ESS using SNOT-22.

Results

The present study showed decreased saccharin time in patients with chronic rhinosinusitis three months after ESS. The mean pre-operative and post-operative saccharin time were 23.4 and 16.9 min, respectively. There was also a trend toward significance for the effect of changes in the SNOT-22 scores on changes in saccharin time. By contrast, no effects of age, gender, pre-operative Lund-Mackay CT scores, and changes in Lund-Kennedy endoscopy scores were observed on post-ESS saccharin time.

Conclusion

The study confirms that ESS in patients with treatment-resistant chronic rhinosinusitis confers improvement in performance on the saccharin test of mucociliary function.

https://ift.tt/2OiO62P

Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters

Publication date: Available online 25 July 2018

Source: Auris Nasus Larynx

Author(s): Maria Doulaptsi, Alexandros Karatzanis, Emmanuel Prokopakis, Stylianos Velegrakis, Alexia Loutsidi, Athina Trachalaki, George Velegrakis

Abstract

Objective

Descending goiter has been a focus of controversy in thyroid surgery until nowadays. This study aims to investigate the diagnosis and treatment options of thyroid goiters extending into the mediastinum and the thoracic cavity.

Methods and materials

A retrospective study was conducted assessing all cases of substernal goiter managed in a tertiary care referral center within 22 years. Demographics, clinical, operative, anatomical, and pathological data of the patients were recorded and analyzed.

Results

Among 3.028 total thyroidectomies, 212 procedures for substernal goiters were studied. All cases underwent total thyroidectomy. The surgical approach was cervical in all but two cases. A very low rate of complications and zero mortality were noted. Incidence of malignancy on permanent histology was 16%.

Conclusion

Descending goiter constitutes a major indication for thyroid surgery. The overwhelming majority of descending goiters may be managed surgically through a neck incision. In experienced hands good results with low morbidity should be expected. Such cases should be considered as challenging, however, and therefore management in a referral center may be necessary in order to ensure optimal results.

https://ift.tt/2AbusTd

The density and distribution of acral melanocytic nevi and acral melanomas on the plantar foot

https://ift.tt/2v91Swa

Preservation of Sebaceous Glands and PPARγ Expression in Central Centrifugal Cicatricial Alopecia

https://ift.tt/2LkDVwJ

Melanoma risk after in vitro fertilization: A review of the literature

The role of female sex hormones in the pathogenesis of malignant melanoma (MM) remains controversial. While melanocytes appear to be hormonally responsive, the effect of estrogen on MM cells is less clear. Available clinical data does not consistently demonstrate that increased endogenous hormones from pregnancy, or increased exogenous hormones from oral contraceptive pills and hormone replacement, impact MM prevalence and outcome.

https://ift.tt/2v91M7M

Practical Needle Driver Cleaning Technique When Using Fast Absorbing Plain Gut Sutures for Facial Defect Repair

https://ift.tt/2LkEwyt

Midfacial growth and dental arch relationships in bilateral cleft palate following secondary alveolar bone grafting and orthodontic intervention: Factors predicting a Le Fort I osteotomy at age 18

To evaluate midfacial growth and dental arch relationships in patients treated for bilateral cleft lip and palate (BCLP).

https://ift.tt/2JRECIh

Upper-eyelid weight implants for patients with lagophthalmos—comparison of rigid and flexible implants1

For treatment of lagophthalmos, metallic weight implants can be inserted in the upper eyelid to aid eyelid closure. Rigid and flexible implants are available. The objective of this study was to investigate the effect of implant type and patient variables on the survival of lid load implants.

https://ift.tt/2mL6q88

Upper-eyelid weight implants for patients with lagophthalmos—comparison of rigid and flexible implants1

Publication date: Available online 25 July 2018

Source: Journal of Cranio-Maxillofacial Surgery

Author(s): Niels Christian Pausch, Christoph Kuhnt, Dirk Halama

Abstract

Introduction

For treatment of lagophthalmos, metallic weight implants can be inserted in the upper eyelid to aid eyelid closure. Rigid and flexible implants are available. The objective of this study was to investigate the effect of implant type and patient variables on the survival of lid load implants.

Materials and Methods

Forty-four patients with lagophthalmos were recruited to undergo upper-eyelid weight implantation. The predictor variable was type of implant inserted (rigid or flexible). The outcome variable was survival of the inserted implant (survival or extrusion). Other study variables were demographic data (age, gender), implant features (material, weight), and other conditions, such as history of radiation. An NMLE test was used to compare implant survival, depending on implant type (flexible versus rigid). Other variables were analysed by use of a χ² test.

Results

Forty-four participants were recruited, 29 female (65.9%) and 15 male (34.1%). Forty-six implants (23 rigid implants, 50.0%; 23 flexible implants, 50.0 %) were inserted (bilateral implantation in two patients). The average weight of implants used was 1.76 g (range 1.4–2.2 g). One to two years after surgery, average vertical aperture (eyelid gap) for the closed eye was 0.65 mm (range 0–4 mm). Incidence of extrusion was 15.2% (one in the rigid implant group, 2.2%; six in the flexible implant group, 13.0%). Incidence of extrusion was significantly higher for flexible implants than for rigid implants (p = 0.0273).

Conclusions

The study results suggest that flexible implants are more likely to perforate the skin. The assumed advantages of the expensive chain lid weight must, therefore, be re-evaluated.

https://ift.tt/2NIdTAe

Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters

Descending goiter has been a focus of controversy in thyroid surgery until nowadays. This study aims to investigate the diagnosis and treatment options of thyroid goiters extending into the mediastinum and the thoracic cavity.

https://ift.tt/2Lr9XqM

Reply

Publication date: Available online 25 July 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Silvia Bulfone-Paus, Rajia Bahri, Mohamed H. Shamji, Adnan Custovic, Paul J. Turner

https://ift.tt/2v7aUtl

Mast cell activation test versus basophil activation test and related competing issues

Publication date: Available online 25 July 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Salvaore Chirumbolo, Geir Bjørklund, Antonio Vella

https://ift.tt/2LlTBQe

Bimaxillary orthognathic surgery with a conventional saw compared with the piezoelectric technique: a longitudinal clinical study

The only cutting technique used for osteotomies in orthognathic surgery for many years has been a saw, but recently piezoelectric surgery has been introduced as a possible alternative. The aim of this study was to find out if piezoelectric surgery can be more comfortable for patients having orthognathic surgery. A total of 25 patients with dentofacial deformities (seven male and 18 female), were treated from January 2016 to September 2017. In 11 patients, osteotomies were made using a conventional saw, while in 14 a piezoelectric device was used.

https://ift.tt/2OfT8gh

Non-vascularised fibular bone graft after vascular crisis: compensation for the failure of vascularised fibular free flaps

After reconstruction of a segmental mandibular defect with a fibular free flap, a vascular crisis can be detected clinically and a "no-flow" phenomenon found during re-exploration. Traditional methods used to solve this include removal of the failed flap and delayed mandibular reconstruction, or restoration of the defect with a functional reconstruction plate or contralateral fibular free flap. Our aim therefore was to investigate under what circumstances it is feasible to use a non-vascularised fibular bone graft (NVFB) as a free bone graft after the failure of a vascularised fibular free flap.

https://ift.tt/2AaiDwC

Association Between Mediterranean Anti-inflammatory Dietary Profile and Severity of Psoriasis

This cohort study uses a self-completed questionnaire by respondents in the French NutriNet-Santé study to evaluate the association between a Mediterranean anti-inflammatory dietary profile and the severity of psoriasis.

https://ift.tt/2AjJfvl

RCM and En Face Histopathologic Correlation of the Dermoscopic “Circle Within a Circle” in LM

This case report describes a process by which the dermoscopic "circle within a circle" feature can be correlated with findings of reflectance confocal microscopic (RCM) and en face histopathologic findings from a lentigo maligna lesion.

https://ift.tt/2mJ3x7R

Violaceous Patches in the Axilla

A man in his 40s presented with dark red, circular lesions in his right axilla without pain, blisters, or other symptoms; after resolution with a topical cream, similar lesions appeared in his left axilla and inguinal folds 5 months later. What is your diagnosis?

https://ift.tt/2AbsUZw

Increasing Minority Representation in the Dermatology Department

This Viewpoint reviews Johns Hopkins' successful experience in increasing the number of faculty physicians in dermatology from groups underrepresented in medicine and suggests steps that other institutions can take to replicate this success.

https://ift.tt/2OcMYxo

Facial-Aging App Availability in Waiting Rooms as a Potential Opportunity for Skin Cancer Prevention

This survey study explores whether a single exposure of adult patients in a waiting room to an app that approximates facial UV damage may lead to altered UV protection behavior.

https://ift.tt/2A7cEZx

Performance of Dermatology Physician Assistants—Reply

In Reply We thank Marghoob et al for the opportunity to address their concerns regarding our study. Number needed to biopsy (NNB) (or excise) is a well-established measure consistent with prior publications, including studies by Marghoob and colleagues. While NNB can vary with disease prevalence, patients in both cohorts in our study had similar rates of keratinocyte carcinomas and invasive melanomas. Patients were also similarly distributed by age and sex, and our NNB findings remained consistent when patients with a melanoma history were excluded.

https://ift.tt/2mJAyQY

Performance of Dermatology Physician Assistants

To the Editor In a recent issue of JAMA Dermatology, Anderson et al aimed to compare skin cancer diagnostic accuracy of physician assistants (PAs) with that of dermatologists (MDs) and used the number needed to biopsy as the main outcome measure.

https://ift.tt/2AjITF1

Characteristics and Skin Cancer Risk Behaviors of US Adult Sunless Tanners

This secondary analysis of a cross-sectional study using data from the 2015 National Health Interview Survey assesses the demographic characteristics and skin cancer risk behaviors of US adults who are sunless tanners.

https://ift.tt/2Ohv8tl

Incidence of Endemic Human Cutaneous Leishmaniasis in the United States

This observational study reviews cases of endemic human leishmaniasis occurring in the United States, mostly in Texas, over a 10-year period.

https://ift.tt/2AjI9zJ

Multiples Myelom

https://ift.tt/2LxpJQl

Moderne Diagnostik des multiplen Myeloms

Zusammenfassung

Hintergrund

Kaum eine Erkrankung in der Hämatologie entwickelt sich so dynamisch wie das multiple Myelom (MM) in den letzten Jahren. Dies betrifft sowohl therapeutische wie auch diagnostische Möglichkeiten.

Ziel

In diesem Übersichtsartikel werden die gegenwärtige Standarddiagnostik des MM dargestellt und ein Ausblick auf zukünftige Diagnostika aufgezeigt.

Ergebnisse und Schlussfolgerung

In absehbarer Zeit wird die Überprüfung einer persistierenden minimalen Resterkrankung nach Therapie sowie der Einsatz funktioneller Bildgebung Einzug in die Standarddiagnostik des MM halten. Die ersten positiven Studienergebnisse für zielgerichtete Therapien für genetisch determinierte Myelomsubgruppen – Venetoclax für t(11;14)-positive Patienten – legen zudem die Notwendigkeit einer Ausweitung der genetischen Diagnostik für MM-Patienten nahe.

https://ift.tt/2NJ8qZP

Vorbereitung zur Facharztprüfung HNO

https://ift.tt/2LkuEEN

Silastic “Spring” Spacers for Use Following Endoscopic Sinus Surgery

Abstract

The prevention of middle turbinate lateralization, and middle meatal synechiae formation, is the key to maintain a patent ostiomeatal complex following endoscopic sino-nasal surgery (ESS). Different techniques have been described to prevent this undesirable outcome, however, most of them are invasive, expensive, uncomfortable and/or obstructive. We present our technique to modified silastic sheets to circumvent these problems and improve ventilation and drainage of sinuses after surgery. The aim of this paper is to present how this silastic sheeting can be easily customized to the shape of the ethmoid cavity after ESS, allowing for ventilation of the aerated sinonasal cavities and at the same time preventing problematic synechiae/scar formation. A practical and easy technique to customize silastic stents following ESS is presented. Silastic sheets could be easily customized of the ethmoid cavity after ESS providing an excellent alternative to reduce middle turbinate lateralization and synechiae formation.

https://ift.tt/2v4vuuB

Silastic “Spring” Spacers for Use Following Endoscopic Sinus Surgery

Abstract

The prevention of middle turbinate lateralization, and middle meatal synechiae formation, is the key to maintain a patent ostiomeatal complex following endoscopic sino-nasal surgery (ESS). Different techniques have been described to prevent this undesirable outcome, however, most of them are invasive, expensive, uncomfortable and/or obstructive. We present our technique to modified silastic sheets to circumvent these problems and improve ventilation and drainage of sinuses after surgery. The aim of this paper is to present how this silastic sheeting can be easily customized to the shape of the ethmoid cavity after ESS, allowing for ventilation of the aerated sinonasal cavities and at the same time preventing problematic synechiae/scar formation. A practical and easy technique to customize silastic stents following ESS is presented. Silastic sheets could be easily customized of the ethmoid cavity after ESS providing an excellent alternative to reduce middle turbinate lateralization and synechiae formation.

https://ift.tt/2v4vuuB

Ocriplasmin in the Treatment of Vitreomacular Traction in a Patient with Central Retinal Vein Occlusion: A Case Report

Aim: To investigate the efficacy of intravitreal injection of ocriplasmin (JETREA®) in the treatment of vitreomacular traction (VMT). Materials and Methods: An 81-year-old man with VMT associated with central retinal vein occlusion in his left eye, was treated with a single intravitreal injection of ocriplasmin (25 μg). Best corrected visual acuity (BCVA), ocular fundus, and optical coherence tomography were examined before and after treatment. Results: Complete release of VMT produced a reduction of central macular thickness, ranging from 459 to 141 μm. BCVA remained stable. Discussion and Conclusions: The use of ocriplasmin was effective in the treatment of VMT. Ocriplasmin represents a valid alternative to conventional pars plana vitrectomy.
Case Rep Ophthalmol 2018;9:357–364

https://ift.tt/2NKvszz

Heterotopic Gastrointestinal Cyst of the Oral Cavity Radiology–Pathology Correlation

Abstract

Heterotopic gastrointestinal cyst of the oral cavity is a rare congenital lesion that may arise from ectopic undifferentiated endodermal cells. Imaging, particularly MRI, is useful for surgical planning. On MRI, the cysts typically demonstrate high signal on T2-weighted sequences and variable signal on T1-weighted sequences, which can resemble other conditions, such as dermoids. On histology, the appearance of these lesions can be variable, and may include stratified squamous, simple and ciliated columnar, as well as foveolar and intestinal-type epithelia, often surrounding by smooth muscle. Complete surgical excision is the treatment of choice.

https://ift.tt/2JXVD3o

Clear Cell Odontogenic Carcinoma: Occurrence of EWSR1-CREB1 as Alternative Fusion Gene to EWSR1-ATF1

Abstract

Clear cell odontogenic carcinoma (CCOC) is a rare, low-grade malignant epithelial neoplasm, occurring in the jawbones, mainly affecting the mandible of elderly patients. In addition to hyalinizing clear cell carcinoma of the salivary gland, it is one of the epithelial neoplasms known to harbor an EWSR1-ATF1 fusion. Therefore, a link between these tumors seems plausible. We describe six cases of CCOC showing EWSR1 rearrangements, with two cases being positive for the ATF1 partner gene using FISH analysis. In one case, an EWSR1-CREB1 fusion was identified using RT-PCR, which we report for the first time in this tumor type. The other three cases investigated by FISH were negative for ATF1, CREB1 and CREB3L2. In conclusion, our data show that EWSR1-CREB1 is an alternative fusion gene to EWSR1-ATF1 in CCOC.

https://ift.tt/2mKh7rf

Is orbital floor a reliable and useful surgical landmark in endoscopic endonasal surgery?: a systematic review

The orbital floor is considered as an important intraoperative reference point in endoscopic sinonasal surgery. The aim of this review is to evaluate its reliability and usefulness as a surgical landmark in en...

https://ift.tt/2Lp0xMA

Heterotopic Gastrointestinal Cyst of the Oral Cavity Radiology–Pathology Correlation

Abstract

Heterotopic gastrointestinal cyst of the oral cavity is a rare congenital lesion that may arise from ectopic undifferentiated endodermal cells. Imaging, particularly MRI, is useful for surgical planning. On MRI, the cysts typically demonstrate high signal on T2-weighted sequences and variable signal on T1-weighted sequences, which can resemble other conditions, such as dermoids. On histology, the appearance of these lesions can be variable, and may include stratified squamous, simple and ciliated columnar, as well as foveolar and intestinal-type epithelia, often surrounding by smooth muscle. Complete surgical excision is the treatment of choice.

https://ift.tt/2JXVD3o

Clear Cell Odontogenic Carcinoma: Occurrence of EWSR1-CREB1 as Alternative Fusion Gene to EWSR1-ATF1

Abstract

Clear cell odontogenic carcinoma (CCOC) is a rare, low-grade malignant epithelial neoplasm, occurring in the jawbones, mainly affecting the mandible of elderly patients. In addition to hyalinizing clear cell carcinoma of the salivary gland, it is one of the epithelial neoplasms known to harbor an EWSR1-ATF1 fusion. Therefore, a link between these tumors seems plausible. We describe six cases of CCOC showing EWSR1 rearrangements, with two cases being positive for the ATF1 partner gene using FISH analysis. In one case, an EWSR1-CREB1 fusion was identified using RT-PCR, which we report for the first time in this tumor type. The other three cases investigated by FISH were negative for ATF1, CREB1 and CREB3L2. In conclusion, our data show that EWSR1-CREB1 is an alternative fusion gene to EWSR1-ATF1 in CCOC.

https://ift.tt/2mKh7rf

Mukoide Pseudozysten – wann wie therapieren?

Zusammenfassung

Die Therapie der mukoiden Pseudozysten muss eine hohe Neigung zu Lokalrezidiven berücksichtigen. Aktuell stehen sowohl etablierte konservative als auch effektive operative Therapieverfahren zur Verfügung. Die Entscheidung über die geeignete Behandlungsmethode wird in Abhängigkeit von Lokalbefund und Beschwerden unter Berücksichtigung möglicher Nebenwirkungen getroffen. In dieser Übersicht werden Vor- und Nachteile der nichtinvasiven therapeutischen Optionen diskutiert. Zudem werden bewährte chirurgische Verfahren vorgestellt. Im Anschluss wird ein Therapiealgorithmus vorgeschlagen. Bei rezidivierenden und symptomatischen Läsionen mit Schmerzen oder Deformierung der Nagelplatte kann eine operative Therapie durch Exzision und Verschluss mittels kleiner Lappenplastik erwogen werden.

https://ift.tt/2NIk1s4

The use of cranial resection templates with 3D virtual planning and PEEK patient-specific implants: A 3 year follow-up

Publication date: Available online 25 July 2018

Source: Journal of Cranio-Maxillofacial Surgery

Author(s): S.E.C.M. van de Vijfeijken, R. Schreurs, L. Dubois, A.G. Becking, A.G. Becking, L. Dubois, L.H.E. Karssemakers, D.M.J. Milstein, S.E.C.M. van de Vijfeijken, P.R.A.M. Depauw, F.W.A. Hoefnagels, W.P. Vandertop, C.J. Kleverlaan, T.J.A.G. Münker, T.J.J. Maal, E. Nout, M. Riool, S.A.J. Zaat

Abstract

Purpose

The aim of this study was to evaluate the accuracy of resection templates in cranioplasties in order to facilitate a one-stage resection and cranial reconstruction. Patients and methods: In three cases, cranial resections were combined with direct reconstructions using the principles of computer-aided design, manufacturing, and surgery. The precision of the resection template was evaluated through a distance map, comparing the planned and final result.

Results

The mean absolute difference between the planned and actual reconstructed contour was less than 1.0 mm. After 3 years, no clinical signs of infection or rejection of the implants were present. The computed tomography scans showed no irregularities, and the aesthetic results remained satisfactory.

Conclusion

One-stage resection and cranial reconstruction using a resection template, control template, and a prefabricated patient-specific implant of poly(ether-ether-ketone) (PEEK) proved to be a viable and safe method.

https://ift.tt/2mEZzga

Morphometric analysis of Arcuate eminence: A Distinctive landmark for middle cranial fossa approach

Publication date: Available online 25 July 2018

Source: Journal of Cranio-Maxillofacial Surgery

Author(s): Anup Singh, Rajeev Kumar, David Victor Kumar Irugu, Rakesh Kumar, Prem Sagar

Abstract

Background

The arcuate eminence (AE) is a bony prominence on the middle fossa plate of the temporal bone, hypothesized to be variably associated with superior semicircular canal (SSC) relief, temporal lobe sulcus, and subjacent air cells. We present various morphometric parameters of the AE, as seen using a middle fossa approach.

Materials and methods

The study used 18 formalin-preserved cadaveric human temporal bones. Various morphological and morphometric parameters pertaining to topographic orientation of the AE in relation to surrounding landmarks used in a middle mossa approach were noted, before and after microdissection of the AE under a Leica M320 F12 microscope, using otologic microdrills and suction irrigation. The morphometric parameters were analyzed using ImageJ 1.46r software.

Results

The overall incidence of AE was 83% (n = 15/18). The most common shape and pattern noted were linear (53.3%, 8/15) and dual arc (46.7%, 7/15), respectively. Mean angle between the AE and SSC was 19°, with a standard deviation of 15° and a range of 2–49°. The AE overlapped the SSC in 40% (6/15) of bones, and did not correspond to the SSC in 7% of cases. A partially overlapping positional correspondence was noted in 53.3% (8/15).

Conclusion

When present, the AE corresponds to the SSC in 40% of cases, but it can serve as a rough guide to the SSC in up to 93% of cases. Surgeons need to be familiar with the varying morphology of AEs in order to execute a rapid and safe dissection during middle fossa approaches.

https://ift.tt/2A6aPfp

Clinical and molecular features of X-linked hyper IgM syndrome – An experience from North India

Publication date: Available online 25 July 2018

Source: Clinical Immunology

Author(s): Amit Rawat, Babu Mathew, Vignesh Pandiarajan, Ankur Jindal, Madhubala Sharma, Deepti Suri, Anju Gupta, Shubham Goel, Adil Karim, Biman Saikia, Ranjana W. Minz, Kohsuke Imai, Shigeaki Nonoyama, Osamu Ohara, Silvia Clara Giliani, Luigi D. Notarangelo, Koon-Wing Chan, Yu-Lung Lau, Surjit Singh

Abstract

X-linked hyper IgM Syndrome (XLHIGM), the most frequent form of the Hyper IgM syndromes is a primary immune deficiency resulting from a mutation in the CD40 ligand gene (CD40LG). We analyzed the clinical and laboratory features of ten patients with XLHIGM, who were diagnosed at a tertiary care hospital in North India. Most common infections were sinopulmonary infections (80%) and diarrhea (50%). Sclerosing cholangitis and necrotising fasciitis were noted in one patient each. Three novel mutations in CD40LG (c.429_429 delA, p. G144DfsX5; c.500 G > A, p.G167E and c.156 G > C, p.K52 N) were detected. In addition, we found one missense mutation, two splice site mutations and two large deletions, which have been previously reported. Four (4) patients had expired at the time of analysis. We report the first series of XLHIGM from North India where we have documented unique features such as pulmonary alveolar proteinosis and infections with Mycobacterium sp.

https://ift.tt/2v46vaG

Allergic conversion of protective mucosal immunity against nasal bacteria in chronic rhinosinusitis with nasal polyposis

Publication date: Available online 25 July 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Kazuya Takeda, Shuhei Sakakibara, Kazuo Yamashita, Daisuke Motooka, Shota Nakamura, Marwa Ali El Hussien, Jun Katayama, Yohei Maeda, Masanobu Nakata, Shigeyuki Hamada, Daron M. Standley, Masaki Hayama, Takashi Shikina, Hidenori Inohara, Hitoshi Kikutani

Abstract

Background

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is characterized by eosinophilic inflammation and polyposis at the nose and paranasal sinus and a high concentration of IgE in nasal polyps (NPs). The causative antigen and pathogenesis of CRSwNP remain unknown.

Objective

We aimed to identify reactive allergens of IgE antibodies produced locally in NPs of CRSwNP patients. We also attempted to unravel the differentiation pathway of IgE-producing B cells in the NPs.

Methods

IgE reactivity of CRSwNP patients was investigated by characterizing single cell-derived monoclonal antibodies. T cell response against identified allergens was investigated in vitro. NP-infiltrating lymphocytes were characterized by flow cytometry. Immunoglobulins expressed in NPs were analyzed by high-throughput immunoglobulin (HTS Ig) sequencing.

Results

About 20% of isolated IgE antibodies derived from NP-residing plasmablasts (PBs) specifically recognized surface determinants of nasal bacteria such as Staphylococcus aureus, Streptococcus pyogenes, and Haemophilus influenzae. A Th2 response against S. pyogenes was observed in CRSwNP patients. Flow cytometric analysis revealed sizable germinal center B-like and PB subsets expressing IgE on the cell surface in NPs. HTS Ig analysis highlighted the clonal connectivity of IgE with IgG and IgA₁. The Iε−Cα₁ circle transcript was detected in NPs.

Conclusions

In CRSwNP patients, nasal bacteria-reactive B cells differentiate into IgE-producing B cells through IgG/A₁-IgE class switching, suggesting that allergic conversion of the mucosal response against nasal bacteria underlies disease pathogenesis.

Graphical abstract

https://ift.tt/2NIP3jx

Role of Interleukin-35 in sublingual allergy immunotherapy

Publication date: Available online 25 July 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Mohamed H. Shamji, Janice A. Layhadi, Daniela Achkova, Lubna Kouser, Alan Perera-Webb, Natália C. Couto-Francisco, Rebecca Parkin, Tomokazu Matsuoka, Guy Scadding, Philip G. Ashton-Rickardt, Stephen R. Durham

ABSTRACT

Background

Grass pollen-specific immunotherapy involves immunomodulation of allergen-specific T helper 2 cell (Th2) responses and induction of IL-10⁺ and/or TGF-β⁺CD4⁺CD25⁺ regulatory T cells (iTregs). IL-35⁺CD4⁺CD25⁺Foxp3^- T (iT_R35) cells have been reported as a novel subset of iTregs with modulatory characteristics.

Objective

To investigate the mechanisms underlying the induction and maintenance of immunological tolerance induced by IL-35 and iT_R35 cells.

Methods

The biological effects of IL-35 was assessed on Group II innate lymphoid cells (ILC2s), dendritic cells (DCs) primed with TSLP, IL-25 and IL-33, B and Th2 cells by flow cytometry and qRT-PCR. Grass pollen-driven Th2 cell proliferation and cytokine production was measured by [³H]-thymidine and Luminex MagPix, respectively. iTr35 cells were quantified in grass pollen allergics (SAR, n=16), sublingual immunotherapy-treated patients (SLIT, n=16) and non-atopic controls (NAC, n=16).

Results

SAR had elevated proportions of ILC2s (P=.002), IL5⁺ (P=.042), IL13⁺ (P=.042) and IL5⁺IL13⁺ILC2s (P=.003) compared to NAC. IL-35 inhibited IL-5 and IL-13 production by ILC2s in the presence of IL-25 or IL-33 (P=.031) and allergen-driven Th2 cytokines by T_eff cells. IL-35 inhibited CD40L, IL-4 and IL-21-mediated IgE production by B cells (P=.015), allergen-driven T cell proliferation (P=.001) and Th2 cytokine production by primed DCs. iT_R35 cells suppressed Th2 cell proliferation and cytokine production. In addition, allergen-driven IL-35 levels and iT_R35 cells were elevated in SLIT (all, P<.001) and NAC (all, P<.001) compared to SAR.

Conclusion

IL-35 and iT_R35 cells are potential novel immune-regulators induced by SLIT. The clinical relevance of SLIT may be underscored by the restoration of protective iT_R35 cells.

Graphical abstract

https://ift.tt/2LzLleQ

Heterotopic Gastrointestinal Cyst of the Oral Cavity Radiology–Pathology Correlation

Abstract

Heterotopic gastrointestinal cyst of the oral cavity is a rare congenital lesion that may arise from ectopic undifferentiated endodermal cells. Imaging, particularly MRI, is useful for surgical planning. On MRI, the cysts typically demonstrate high signal on T2-weighted sequences and variable signal on T1-weighted sequences, which can resemble other conditions, such as dermoids. On histology, the appearance of these lesions can be variable, and may include stratified squamous, simple and ciliated columnar, as well as foveolar and intestinal-type epithelia, often surrounding by smooth muscle. Complete surgical excision is the treatment of choice.

https://ift.tt/2JXVD3o

Clear Cell Odontogenic Carcinoma: Occurrence of EWSR1-CREB1 as Alternative Fusion Gene to EWSR1-ATF1

Abstract

Clear cell odontogenic carcinoma (CCOC) is a rare, low-grade malignant epithelial neoplasm, occurring in the jawbones, mainly affecting the mandible of elderly patients. In addition to hyalinizing clear cell carcinoma of the salivary gland, it is one of the epithelial neoplasms known to harbor an EWSR1-ATF1 fusion. Therefore, a link between these tumors seems plausible. We describe six cases of CCOC showing EWSR1 rearrangements, with two cases being positive for the ATF1 partner gene using FISH analysis. In one case, an EWSR1-CREB1 fusion was identified using RT-PCR, which we report for the first time in this tumor type. The other three cases investigated by FISH were negative for ATF1, CREB1 and CREB3L2. In conclusion, our data show that EWSR1-CREB1 is an alternative fusion gene to EWSR1-ATF1 in CCOC.

https://ift.tt/2mKh7rf

Electric saw face self-mutilation on a 22-year-old schizophrenic man: Case report

Publication date: Available online 25 July 2018

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Eduardo Zancopé, Flávio Rafael Daher Cozac, Alan Fernando Panarello, Leandro Valentini Junqueira Zoccoli, Karla Zancopé

Abstract

Schizophrenia is a debilitating psychiatric disorder that affects a large segment of the population. It is managed mainly through pharmacotherapy and family engagement is mandatory in the process. This paper shows a case of self-mutilation on a 22-year-old man that cut his mandible with an electric saw trying to modify his chin in order to better his appearance.

https://ift.tt/2uOGqgt

Longevity of composite build-ups without posts—10-year results of a practice-based study

Abstract

Aim

The aim of this prospective, non-interventional, multi-center, practice-based study was, firstly, to evaluate the longevity of composite build-ups in endodontically treated teeth (ETT) without post placement and, secondly, to analyze factors influencing the success of these composite build-ups.

Methodology

Each of seven general dental practitioners placed up to 50 composite build-ups without additional posts in ETT. Teeth were restricted to incisors, canines, and premolars. Several clinical data were recorded for 192 coronal restorations on ETT in 192 patients. Cox proportional hazard models were applied to analyze associations between clinical factors and time until failure.

Results

Within a follow-up period of 10 years, 167 restorations were judged as successful [mean success time, 110 (105–115) months] and 180 teeth survived [mean survival time, 114 (110–119) months]. The main failure type was fracture of the restoration (n = 15). The annual failure rate was 2.4%. In bivariate Cox regression, both factors such as number of restored tooth surfaces and adhesive were significantly associated with the failure rate. In multivariate Cox proportional hazards regression, none of the investigated factors were significantly associated with the failure rate.

Conclusion

For composite build-ups in ETT without post placement, high success rates could be found after up to 10 years of observation time. Within the limitations of the present study, none of the analyzed factors such as "tooth type" or "number of restored tooth surfaces" was a significant predictor for the failure rate.

Clinical relevance

Endodontically treated teeth can be successfully directly restored with composite build-ups even when no additional post is inserted.

Trial registration

The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00012882).

https://ift.tt/2v0gXjx

Repeated Testing With the Hypertonic Saline Assay in Mice for Screening of Analgesic Activity

BACKGROUND: In vivo animal assays are a cornerstone of preclinical pain research. An optimal stimulus for determining the activity of potential analgesics would produce responses of a consistent magnitude on repeated testing. Intraplantar (i.pl.) injection of hypertonic saline (HS) in mice produces robust nociceptive responses to different analgesics, without evidence of tissue damage. Here, we investigated whether the nociceptive response is changed by repeating the injection at different times and sites in a mouse and whether it is attenuated by morphine. METHODS: We conducted randomized and blinded experiments to assess responses to repeated i.pl. 10% HS in female CD-1 mice. An injection of HS was followed by a second injection into the same hind paw at 4 hours, 24 hours, or 7 days. A separate group of mice each received i.pl. injections at 5, 10, and 15 days. In 2 independent experiments, 30 minutes after initial HS injections in the ipsilateral hind paw, mice received HS injection into the contralateral hind paw or ipsilateral forepaw. The ability of morphine to block the nociceptive responses was examined by injecting morphine at 5-day intervals. RESULTS: Repeated injection of HS did not alter the responses at 4 hours (84 vs 75 seconds; mean difference [95% CI], −9 [−40 to 23]; P = .6), 24 hours (122 vs 113 seconds; −6 [−24 to 12]; P = .5), or 7 days (112 vs 113 seconds; −0.3 [−12 to 11]; P = .95) or at multiple injections (day 0, 122 seconds vs day 5, 121 seconds; −0.3 [−28 to 27], P > .99; day 10, 118 seconds; 2.5 [−36 to 41], P = .99; day 15, 119 seconds; 2 [−36 to 38], P = .99). A previous hind paw injection did not change the responses of the contralateral hind paw (right, 93 seconds versus left, 96 seconds; −3 [−20 to 13], P = .7) or of the ipsilateral forepaw (forepaw after HS, 146 seconds versus forepaw after 0.9% saline, 149 seconds; −3 [−28 to 22], P = .8). Morphine dose-dependently attenuated HS responses (control, 94 seconds versus 4 mg/kg, 66 seconds; 29 [−7 to 64], P = .12; versus 10 mg/kg, 27 seconds; 67 [44–90], P

https://ift.tt/2v6XldE

Minimum Alveolar Concentration-Awake of Sevoflurane Is Decreased in Patients With End-Stage Renal Disease

BACKGROUND: End-stage renal disease (ESRD) has been shown to be associated with abnormal neural function. Clinically used inhaled anesthetic agents typically exert their effect through multiple target receptors in the central nervous system. Pathological changes in the brain may alter sensitivity to inhaled anesthetic agents. This study aimed to determine the minimum alveolar concentration-awake (MACawake) of sevoflurane in patients with ESRD compared to patients with normal renal function. METHODS: Patients underwent inhalational induction of anesthesia and received sevoflurane at a preselected concentration according to a modified Dixon "up-and-down" method starting at 1.0% with a step size of 0.2%. The concentration of sevoflurane used for each consecutive patient was increased or decreased based on a positive or negative response to verbal command in the previous patient. Serum neuron-specific enolase, a biomarker of impaired neurons, was also measured. RESULTS: Forty-one patients were enrolled: 20 with ESRD and 21 as controls. The MACawake of sevoflurane in patients with ESRD was significantly lower than that observed in the control group (0.56% [standard deviation {SD} = 0.10%] vs 0.67% [SD = 0.08%]; P = .031). Patients with ESRD exhibited higher serum neuron-specific enolase levels compared to the control group (16.4 ng/mL [SD = 5.0] vs 8.7 ng/mL [SD = 2.9]; P

https://ift.tt/2LkoX9Y

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication

No abstract available

https://ift.tt/2v3QIc1

Preoperative Continuation Versus Interruption of Oral Hypoglycemics in Type 2 Diabetic Patients Undergoing Ambulatory Surgery: A Randomized Controlled Trial

Patients with type 2 diabetes mellitus receiving oral hypoglycemic drugs (OHDs) are usually instructed to stop them before surgery. We hypothesize that continuing OHD preoperatively should result in lower perioperative blood glucose (BG) levels. Ambulatory surgery patients with type 2 diabetes mellitus on OHDs were randomized to continue (n = 69) or withhold (n = 73) OHDs preoperatively. Log-transformed BG levels at pre-, intra-, and postoperative periods were analyzed. Perioperative BG levels were significantly lower (mean, 138 mg/dL; 95% confidence interval, 130–146 mg/dL) in the group that continued versus the group that discontinued OHDs (mean, 156 mg/dL; 95% confidence interval, 146–167 mg/dL; P

https://ift.tt/2LlDRfX

Capnography, Esophageal Intubation, and Capnomanaging Cardiac Arrests in the Operating Room

No abstract available

https://ift.tt/2v00hsl

Influence of Nasal Tip Lifting on the Incidence of the Tracheal Tube Pathway Passing Through the Nostril During Nasotracheal Intubation: A Randomized Controlled Trial

BACKGROUND: For safe nasotracheal intubation without middle turbinate injury, the tracheal tube should pass through the lower pathway, which is beneath the inferior turbinate and immediately above the nasal floor of the nostril. The purpose of this study was to assess the influence of nasal tip lifting on the incidence of passing preformed nasal Ring-Adair-Elwyn (RAE) tubes through the lower pathway during nasotracheal intubation. METHODS: Patients were randomly assigned to a "nasal tip lifting group" or a "neutral group." For patients in the nasal tip lifting group, an investigator pulled the nasal tip in a cephalad direction when inserting a preformed nasal RAE tube into the nostril after induction of anesthesia. For patients in the neutral group, a tube was inserted with the nasal tip in a neutral position. The pathway by which the tube passed in each patient was identified using a fiberscope. The incidence of the tube passing through the lower pathway was compared between the 2 groups. The incidence of epistaxis was also evaluated. RESULTS: Eighty-six patients were enrolled and completed the study protocol. The incidence of the tracheal tube passing through the lower pathway was significantly higher in the nasal tip lifting group (79.1%) than in the neutral group (51.2%) (relative risk, 1.55; 95% confidence interval, 1.11–2.15; P = .007). Although the incidence of epistaxis was not different between the groups (18.6% vs 32.6%; P = .138), it was lower when the tracheal tube passed nasal cavity through the lower pathway (14.3%) than the upper pathway (46.7%), regardless of the randomized group with adjustment for potentially confounding variables (odds ratio, 0.19; 95% confidence interval, 0.07–0.54; P = .002). CONCLUSIONS: The nasal tip lifting maneuver helped to guide preformed nasal RAE tubes into the lower pathway during nasotracheal intubation. Accepted for publication June 18, 2018. Funding: None. The authors declare no conflicts of interest. Clinical trial number and registry URL: ClinicalTrials.gov (NCT03102255) (https://ift.tt/2v6X4Ya). Reprints will not be available from the authors. Address correspondence to Jung-Man Lee, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Republic of Korea. Address e-mail to jungman007@gmail.com. © 2018 International Anesthesia Research Society

https://ift.tt/2Lp5Z1S

A Survey of Charge Sensitivity and Charge Awareness Among Intensive Care Unit Providers in a Large Academic Medical Center

Little is known about charge sensitivity or charge awareness among intensive care unit (ICU) providers in the United States. In a survey of 295 ICU providers at a large, academic medical center, 92.5% of respondents agreed that controlling health care expenses is partly their responsibility. However, 87.4% of respondents reported that they did not know the charges for most of the tests and medications they prescribe. Among surveyed participants, the correct charge for a medical procedure or test was selected only 35% of the time. While ICU providers overwhelmingly agree that controlling expenses is their responsibility, charge awareness is low and likely limits their ability to make value-based decisions. Accepted for publication June 19, 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 Adam J. Kingeter, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Ave S MAB 422, Nashville, TN 37232. Address e-mail to Adam.Kingeter@vanderbilt.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2Ln2Hwb

Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1

No abstract available

https://ift.tt/2LnA9CH

Dynamic Indices: Use With Caution in Spontaneously Breathing Patients

No abstract available

https://ift.tt/2v6E1wO