Continuous infusion of lipo-prostaglandin E1 for Takayasu’s arteritis with heart failure in an 11-month-old baby: a case report

Takayasu's arteritis is extremely rare in children aged below 6 years. At the onset of Takayasu's arteritis in children, symptoms are varied but differ from those in adults. Corticosteroids are the mainstay of...

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Pediatric lung adenocarcinoma presenting with brain metastasis: a case report

Diagnosis and treatment of primary lung adenocarcinoma in children remains challenging given its rarity. Here we highlight the clinical history, pathological evaluation, genomic findings, and management of a v...

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An Improved Method for Temporary Suture Medialisation of the Middle Turbinates following Endoscopic Sinus Surgery

Background. Middle turbinate (MT) lateralisation with adhesion formation (MiTLAF) is a common complication following endoscopic sinus surgery, frequently resulting in surgical failure, persistence of preoperative symptoms, and delayed secondary complications. Packing materials, splints, or spacers reduce the risk of MiTLAF but often result in postoperative nasal obstruction and discomfort, along with reduced access for irrigation. Temporary suture medialisation of the MTs reduces the risk of MiTLAF and prevents the problems encountered with packing, splints, or spacers. However, the techniques described in the literature are technically challenging and often ineffectual. Methods. We describe a method of suture placement that provides a secure temporary MT medialisation, without the technical challenges of traditional techniques, using a 4-0 Monocryl (Poliglecaprone 25, Ethicon, Somerville, NJ, USA) suture on a 19 mm precision point reverse cutting PS-2 curved needle. We review 25 consecutive patients undergoing sinonasal procedures with our new technique and assess for MiTLAF. Results. In our cohort, only one patient experienced MiTLAF which was not clinically significant. Conclusions. Our method is simple, easy to perform, and highly effective and prevents adhesion formation without the need for postoperative splints or packing.

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Granuloma Annulare’s Triangular Association with Malignancy

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Volumetric changes of the upper airway following maxillary and mandibular advancement using cone beam computed tomography

The objective of this project was to retrospectively evaluate changes in volume of different compartments of the upper airway in response to maxillary, mandibular, and bimaxillary advancement surgeries and to predict the extent of volumetric changes associated with these surgical movements. Pre- and post-surgical cone beam computed tomography scans of 36 patients were evaluated for changes in nasal cavity, nasopharyngeal, oropharyngeal, and hypopharyngeal compartments. The amount of movement for each surgery was measured from skeletal landmarks to reference planes and was correlated with volumetric changes.

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Use of a generic violet light in the surgical management of medication-related osteonecrosis of the jaws: a technical note

Abstract

Purpose

Fluorescence-guided surgery has been recommended for the diagnosis of bone margins in cases of mandibular osteonecrosis. In this article, we report a case in which a generic violet light was used in order to activate bone fluorescence after the administration of tetracycline derivatives, as an alternative to a specific, more expensive equipment that is commercially available for this purpose. The patient had been using alendronate for osteoporosis, resulting in medication-related osteonecrosis of the jaws.

Methods

The treatment protocol includes preoperative administration of doxycycline and the application of a generic violet light during surgery in order to observe the fluorescence of bone in response to excitation through the light emitted by this device.

Results

With an effective visualization of the limit between healthy and devitalized bone tissue, it was possible to perform the necrotic tissue removal. The lesion regressed from stage 2 to stage 0, with no clinical or radiographic evidence of necrotic bone.

Conclusions

These results suggest the feasibility of using a generic violet light source as a low-cost alternative for fluorescence-guided surgery.

https://ift.tt/2PWwZEw

Use of a generic violet light in the surgical management of medication-related osteonecrosis of the jaws: a technical note

Abstract

Purpose

Fluorescence-guided surgery has been recommended for the diagnosis of bone margins in cases of mandibular osteonecrosis. In this article, we report a case in which a generic violet light was used in order to activate bone fluorescence after the administration of tetracycline derivatives, as an alternative to a specific, more expensive equipment that is commercially available for this purpose. The patient had been using alendronate for osteoporosis, resulting in medication-related osteonecrosis of the jaws.

Methods

The treatment protocol includes preoperative administration of doxycycline and the application of a generic violet light during surgery in order to observe the fluorescence of bone in response to excitation through the light emitted by this device.

Results

With an effective visualization of the limit between healthy and devitalized bone tissue, it was possible to perform the necrotic tissue removal. The lesion regressed from stage 2 to stage 0, with no clinical or radiographic evidence of necrotic bone.

Conclusions

These results suggest the feasibility of using a generic violet light source as a low-cost alternative for fluorescence-guided surgery.

https://ift.tt/2PWwZEw

Lipoproteins in Streptococcus gordonii are critical in the infection and inflammatory responses

Publication date: September 2018

Source: Molecular Immunology, Volume 101

Author(s): Hyun Young Kim, A Reum Kim, Ho Seong Seo, Jung Eun Baik, Ki Bum Ahn, Cheol-Heui Yun, Seung Hyun Han

Abstract

Gram-positive bacteria such as Streptococcus gordonii causing life-threatening infective endocarditis are mainly recognized by Toll-like receptor 2 (TLR2). Lipoteichoic acid (LTA) and lipoproteins are representative TLR2 ligands that play important roles in bacterial infection and in host inflammatory responses. In the present study, we generated an LTA-deficient mutant (ΔltaS) and a lipoprotein-deficient mutant (Δlgt) and investigated the contributions of LTA and lipoproteins to bacterial morphology and their effect on induction of proinflammatory cytokines in THP-1 and mouse bone-marrow derived macrophages (BMDMs). Deletion of ltaS and lgt was confirmed by PCR analysis of genomic DNA from each mutant. The mutants with absence of LTA or lipoproteins were examined by SDS-PAGE followed by Western blotting with anti-LTA antibodies and silver staining, respectively. Interestingly, scanning and transmission electron microscopies showed no difference in the bacterial cell morphology or size between the wild-type and the mutants even though substantial changes in the cell size and/or morphology have been reported in other Gram-positive bacteria such as Staphylococcus aureus, Listeria monocytogenes, and Bacillus subtilis. However, S. gordonii wild-type and ΔltaS potently induced the expression of proinflammatory cytokines including TNF-α, IL-8, and IL-1β at the mRNA and protein levels, while Δlgt did not have these effects. Furthermore, lipoproteins purified from S. gordonii also induced the expression of the aforementioned cytokines more potently than the purified LTA. Neither LTA nor lipoprotein induced TNF-α, KC (IL-8 counterpart in mouse), and IL-1β in TLR2-deficient BMDMs. S. gordonii Δlgt was less virulent than the wild-type or ΔltaS in a mouse intraperitoneal infection model. Collectively, these results suggest that S. gordonii lipoproteins, but not LTA, are mainly responsible for the infection and inflammatory responses.

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Reply to Kang and Brooks: Comment on the interpretation of binding of Pra1, the fungal immune evasion protein from Candida albicans to the human C3 and on the conformational changes of C3 upon activation: Kang and Brooks Optimization of biolayer-interferometry-based binding assay of he interaction between the Candida albicans protein Pra1 and complement protein C3

Publication date: Available online 1 September 2018

Source: Molecular Immunology

Author(s): Peter F. Zipfel, Shanshan Luo, Prasad Dasari, Nadine Reiher, Ilse Jacobsen, Niklas Beyersdorf, Andreas Klos, Christine Serka

https://ift.tt/2LS8nK8

Changes in the facial soft-tissue profile after mandibular orthognathic surgery

Abstract

Objectives

To investigate the correlation between soft- and hard-tissue changes after mandibular orthognathic surgery, to generate precise prognostic values for the esthetic treatment outcome of the facial profile.

Material and Methods

In this retrospective study, sagittal changes in the facial soft tissue profile in relation to surgical changes in hard structures after mandibular osteotomy were examined. The sample population included 144 reported adult patients aged 17–50 years who had received combined mandibular orthognathic surgery and orthodontic treatment at the Department of Orthodontics, Ludwig-Maximilians University of Munich, Germany. Both mandibular advancement and mandibular setback cases in monognathic and bignathic osteotomy procedures were included. All subjects had undergone rigid fixation. A cephalometric analysis of presurgical and postsurgical cephalograms was performed, and the correlations between hard-tissue and soft-tissue change ratios were evaluated using a bivariate linear regression analysis.

Results

The lower lip, represented by the landmark Labrale inferius (Li), followed the lower incisor (Ii) by 77%. The soft-tissue B-point (B') followed the B-point (B) by 97% and the soft-tissue Pogonion (Pg') followed the Pogonion (Pg) by 97% in a linear correlation.

Conclusion

The scatterplots show a distinct linear correlation and no significant difference in the direction of the movement. A wider spread for the lower lip (Li/Ii) indicates a lower predictability of the expected lip position, whereas a narrow spread of the chin values (B'/B and the Pg'/Pg) reveals a very good predictability of the postoperative chin position.

Clinical relevance

This study contributes valid data for the soft-tissue profile prediction in orthognathic surgery.

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A bizarre case of accessory larynx in an infant with oeis syndrome

Publication date: Available online 31 August 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Timothy LW. Wong, Marina Mat Baki, Shareena Ishak, Goh Bee See

Abstract

We report a bizarre case of accessory larynx in an infant with OEIS syndrome (omphalocele, cloacal exstrophy, imperforated anus & spinal defects). This is the first reported case in literature of a duplicate accessory larynx which is a mirror image of the true larynx. A congenital duplication of the larynx is a rare anomaly and can present in various forms. In this case, the infant presented with recurrent lung infection and inability to wean off oxygen. Scope revealed severe laryngomalacia in addition to the accessory larynx. Hence, supraglottoplasty was done with aim to resolve the lung and airway problem.

https://ift.tt/2Pw1ujV

Clinical and Surgical Implications of Intraoperative Optical Coherence Tomography Imaging for Benign Pediatric Vocal Fold Lesions

Publication date: Available online 31 August 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Fouzi Benboujja, Christopher Hartnick

Abstract

Introduction

Benign vocal disorders in children include an extensive list of abnormalities creating a variety of debilitating levels of dysphonia. Precise delineation of the benign lesion type and margins may have significant public health implications in children. An innovative technology such as optical coherence tomography (OCT) is being explored to delineate pediatric benign laryngeal lesions. An accurate assessment of the subepithelial morphology may help towards tailoring more personalized therapeutic treatments. This study was established to highlight key morphological and optical features of benign pediatric laryngeal lesions using intraoperative OCT and to suggest clinical implications that arise from such optical imaging.

Methods and materials

This in vivo study was performed at Massachusetts Eye and Ear Infirmary. Intraoperative imaging was performed on twenty-five pediatric patients ranging from 1 year to 16 years of age presenting hoarseness. Three-dimensional OCT images of benign laryngeal lesions or a subsite of the lesion were acquired.

Results

High-resolution OCT images of 25 patients with benign laryngeal lesions such as nodules, cysts, Reinke's edema, vocalis sulcus, and papilloma revealed distinct and specific morphological differences with normal tissue. Nodules show a symmetrical superficial remodeling of the vocal fold epithelial layer and the basement membrane. Cysts have oval-like shape and are either superficial or deeply located in the lamina propria. Sulcus vocalis OCT imaging allows characterizing if the lesion is shallow or deep according to Ford's classification system. Reinke's edema of the mucosa can be observed and quantified, which may lead to suspicion on the underlying social and medical conditions. Finally, the ability to assess margins and depth of invasion of papilloma lesions is demonstrated, raising the possibility to use OCT with angiolytic lasers for patient-tailored treatments.

Conclusions

OCT imaging of benign pediatric vocal lesions is promising as it could improve preoperative decision-making and possibly peroperative imaging-guidance for patient-tailored treatments. An assessment of the optical contrast between healthy and abnormal tissue may help towards a more qualitative and quantitative approach to current standard care, especially when diagnosis remains unclear.

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Cleft Lip and Palate Associated with Hearing Loss in Brazilian Children

Publication date: Available online 31 August 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Ricardo Neves Godinho, Tania Sih, Cássio da Cunha Ibiapina, Márcia Helena Miranda de Freitas Oliveira, Renata Victória Tassara

Abstract

(1) Introduction

Cleft lip and palate children have chronic otitis media related to Eustachian Tube dysfunction and associated conductive hearing loss. In this group of children, communicative skill development limitations, in association with orofacial aesthetics and functional disorders, can lead to behavioral, educational and social problems.

(2) Methods

We evaluated the minimum hearing threshold and the air-bone gap (ABG) in a range from 500 to 4000 Hz for 4 to 14 years old cleft lip and palate children (CLPC). This cross-sectional study took place in a multiprofessional tertiary care center and involved 89 CLPC with bilateral or unilateral postforamen or transforamen malformation, divided into two groups: those aged 4-7 and 8-14 years. The hearing tests of 89 children were evaluated: 53 (group I) aged from 4-7 years (67.9% male) and 36 (group II) aged from 8-14 years (55.6% female).

(3) Results

The minimum hearing threshold 500-4 KHz mean (MHT 500-4 KHz) was 19.4 dB for all children. MHT 500-4 KHz was 21.2 dB and 17.5 dB respectively for the group I and group II. Both groups demonstrated a minimum hearing threshold of up to 70 dB at certain frequencies. The global ABG 500-4 KHz average was 16.6 dB (SD 12.5): 19.7 dB (SD 12.9) in group I and 13.2 dB (SD 11.1) in group II.

(4) Conclusion

The worst hearing thresholds were found in children of 4 to 7 years old: 21.2 dB MHT 500-4 KHz and 19.7 ABG 500-4 KHz, what is a disadvantage for them, as the normal hearing thresholds are up to 15 dB. The children of 8 to 14 years old had MHT 500-4 KHz of 17.5 dB, and ABG 500-4KHZ OF 13.2 with up to 70 dB of hearing loss.

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The inferior turbinate: An autonomic organ

Publication date: Available online 31 August 2018

Source: American Journal of Otolaryngology

Author(s): Drew H. Smith, Christopher Brook, Shahab Virani, Michael P. Platt

Abstract

The inferior turbinate has well-recognized respiratory and immune functions to provide the airway with appropriate warmth, humidification, and filtration of the inspired air while sampling the environment for pathogens. Normal functioning of the inferior turbinate relies on an intact autonomic system to maintain homeostasis within the nasal cavity. The autonomic nervous system innervates the submucosal glands and the vasculature within the inferior turbinate, resulting in control of major turbinate functions: nasal secretions, nasal patency, warmth, and humidification. This review will summarize the autonomic innervations of the turbinates, both the normal and abnormal autonomic processes that contribute to the turbinate functions, and the clinical considerations regarding optimal functioning of the turbinate autonomic system.

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Evaluation of the Safety and Efficacy of Soft Tissue Augmentation with a Compressive-Resistant Collagen Matrix in a Non-Human Primate Model

Publication date: Available online 1 September 2018

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Alan S. Herford, Katina Nguyen, Meagan Miller, Rahul Tandon, Fabrizio Signorino

Abstract

Purpose

The purpose of the present study was to evaluate the safety and efficacy of compression resistant collagen-based cross-linked matrix for augmentation of maxillary and mandibular soft tissue defects in an animal model.

Materials and Methods

Six Rhesus monkeys were subjected to soft tissue grafting in four sites intra-orally; the anterior maxilla was subjected to hard and soft tissue grafting with implant placement. Each site was randomly assigned one of three treatments: a compressive-resistant collagen membrane (CM), a subepithelial connective tissue autograft (SCTG), or sham, where a partial thickness flap was elevated then sutured closed and no further treatment was provided (control). The following methods were used for data collection: in vivo evaluation via periodontal probing, ultrasound, shear modulus elasticity, polyether impressions for volumetric analysis, and in vitro analysis via histological biopsies. In vitro analysis provided by histological measurements and evaluations were performed on non-decalcified sections. Follow-up period was six months.

Results

SCTG and CM demonstrated favorable tissue integration. No adverse reaction or deviation from normal healing processes was detected. CM integrated well in all sites with a variable range of soft tissue volume increase. Volumetric discrepancies were appreciated in the histological analyses and differences were found when CM and SCTG were applied in the anterior maxilla in combination with hard tissue grafting and implant placement. Histological evaluation demonstrated favorable integration, no immunogenic response to the CM, and stable volumetric retention in autograft and CM sites over the experimental period.

Conclusion

Compressive-resistant collagen matrix may be a safe and efficacious alternative for soft tissue augmentation, eliminating the need for a donor site and the consequent reduction of morbidity. While it was possible to observe similar performance between CM and SCTG, further studies will be necessary to estimate the clinical potentiality and describe the limits of the technique.

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Rare association of tetralogy of Fallot with absent pulmonary valve syndrome with anomalous origin of right pulmonary artery from ascending aorta

Description 

A 2-month-old boy presented to the paediatric cardiology department with cyanosis and feeding difficulties. Chest radiograph revealed cardiomegaly, right-sided aortic knuckle and dilated pulmonary artery segment along with mild indentation on the lower trachea and diffusely narrowed left main bronchus (figure 1A). A diagnosis of tetralogy of Fallot (TOF) with absent pulmonary valve syndrome was made on transthoracic echocardiogram; however, origin of right pulmonary artery (RPA) was not well visualised. The patient further underwent CT angiography (CTA) to delineate the cardiac as well as any extracardiac abnormalities.

Figure 1

Frontal chest radiograph (A) reveals cardiomegaly, right-sided aortic knuckle and dilated pulmonary artery segment along with mild indentation on the lower trachea and diffusely narrowed left main bronchus. Sagittal oblique maximum intensity projection (B) shows presence of features of tetralogy of Fallot, that is, right ventricular hypertrophy, perimembranous ventricular septal defect and pulmonary annular stenosis....

https://ift.tt/2N9Npea

Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis

Despite being straightforward to collect and key to providing patient-centred, individualised care, the routine use of patient reported outcome measures (PROMs) remains limited in the National Health Service. Herein is described the case of a 69-year-old woman who presented to secondary care with osteoarthritis. Web-based PROMs were used to track the patient's symptoms and function. Lifestyle changes were recommended to manage the osteoarthritis. Monitoring enabled the patient to take control of her disease management. Two years later, she continues to manage her knee symptoms conservatively, recording progress by using a web-based system. This case illustrates how web-based PROMs can be used to support conservative management of knee osteoarthritis by both empowering patients and minimising the burden on secondary care outpatient services.

https://ift.tt/2Cjf1tp

New endoscopic technique for retrieval of large colonic foreign bodies and an endoscopy-oriented review of the literature

Colorectal foreign bodies (FB) are challenging issues for the endoscopist especially if the mostly used methods (polypectomy snare, biopsy forceps or wire-guided 40 mm dilation balloon) failed. We report a case of a 31-year-old man who was admitted in the emergency department for the impaction of a 60 cm long and large-size FB in the sigmoid colon. We failed to remove the FB using several different standard technique because of the rigidity, the smoothness and the size of the object. After all these attempts, we built up a 'home-made' device inserting a 0.035 inch non-hydrophilic guidewire (Metro WireGuide, Cook Medical) doubled into an 8.5 Fr stent-pusher-catheter (Cook Medical) serving as an outer sheet in order to create a noose and we finally succeeded in the endoscopic extraction of the device. We suggest this new technique as a valid option to remove large FBs from the colon and rectum when standard endoscopic methods for FB's extraction fail.

https://ift.tt/2PSid1P

Acute regrowth and dissemination of a mature spinal cord teratoma after partial resection

A 23-year-old man presented with difficulty walking and leg pain and numbness. MRI revealed a cystic mass at Th11–12 and a pineal-region tumour. The patient underwent surgery to resect the thoracic-level mass. The tumour adhered strongly to the neural tissue and could only be partially resected. On pathological examination, the resected tumour was diagnosed as a mature teratoma. The tumour regrew and disseminated within 3 months after resection. Both the spinal cord tumour and the tumour in the pineal region shrank significantly after chemotherapy and radiotherapy. Although the tumour was pathologically diagnosed as a mature teratoma, we suspect that the residual tumour contained an immature or malignant component. Thus, careful follow-up observation is mandatory after partial resection of a mature teratoma. In addition, because teratomas can disseminate in the central nervous system, the presence of teratoma should prompt an examination of both the spinal cord and brain.

https://ift.tt/2C78fqb

Correction: Spontaneous ovarian heterotopic pregnancy

Stanley R, Nair A, Fiallo F. Spontaneous ovarian heterotopic pregnancy. BMJ Case Rep 2018.doi: 10.1136/bcr-2018-225619 [Epub ahead of print 9 Aug 2018].

This article contains an error in the authors list. The correct order of authors is:

Russell Stanley, Francisco Fiallo, and Anjana Nair.

https://ift.tt/2N5rTY2

The changing face of cancer treatments

This case demonstrates the effectiveness and ongoing potential of novel lung cancer therapies, specifically immunotherapy agents such as nivolumab, a T-cell programmed death 1 (PD-1) receptor inhibitor. In this case study, our patient had a significant burden of disease with nodal involvement above and below the diaphragm at the time of diagnosis. They were commenced on standard of care therapy: cisplatin and pemetrexed. Despite five cycles of treatment with these agents, their disease progressed significantly with the development of brain metastasis. The patient was switched to a novel immunotherapy agent, nivolumab, and had a complete response to it. Currently, there is no active disease—the lymph nodes have all regressed, the brain metastases have disappeared (with the help of stereotactic surgery) and no further metastases have developed. The patient is tolerating the treatment well and has had no significant adverse reactions to the immunotherapy agent.

https://ift.tt/2NCaH9v

Rapidly growing cardiac tumour in the right ventricle

Description 

A 77-year-old man with a history of Her2 negative, pancytokeratin-positive gastric cancer and synchronous grade 3a stage 2a follicular lymphoma (FLIPI score 3 at presentation) treated with chemotherapy was referred for transthoracic echocardiography (TTE) after a CT of the abdomen demonstrated an incidental low-density lesion in the right ventricle (RV) concerning for malignancy or thrombus. There was no mass present on TTE 2 months prior. Repeat TTE (figure 1) demonstrated a large echogenic mass causing right ventricular inflow and outflow tract (RVOT) obstruction. A cardiac MRI (figure 2) confirmed the presence of a heterogeneous mass with adherent superficial thrombus in the RV and extending into the RVOT, consistent in appearance with a tumour. On further review, a PET/CT performed 1 month prior to presentation showed a hypermetabolic node at the RV apex (maximum Standardized Uptake Value 5.7) felt to represent an initial metastatic focus, with...

https://ift.tt/2PWfnc4

Klebsiella oxytoca tricuspid valve endocarditis in an elderly patient without known predisposing factors

A 73-year-old man with history of nephrolithiasis was admitted after a witnessed cardiac arrest. In the emergency department, the patient had several runs of ventricular fibrillation treated with defibrillation and amiodarone infusion. Echocardiography revealed reduced ejection fraction with multiple mobile structures attached to the tricuspid valve leaflets. Due to concern for possible endocarditis, the patient was started on broad-spectrum antibiotics. On the following day, a renal ultrasound was performed for acute kidney injury followed by a non-contrast CT scan that revealed an obstructing 21 mm left-sided ureteral stone with pyohydronephrosis. He underwent emergent nephrostomy tube placement. Blood and urine cultures subsequently demonstrated the growth of Klebsiella oxytoca. A follow-up transoesophageal echocardiogram confirmed multiple mobile, hyperechoic masses consistent with vegetations. The suspected source for the endocarditis was from the pyelonephritis. The patient's clinical condition improved after a course of intravenous antibiotics and was discharged on oral antibiotics.

https://ift.tt/2C783qX

Pathological complete response in pancreatic adenocarcinoma with FOLFIRINOX

The report describes a patient who presented to our centre with abdominal pain and significant weight loss due to adenocarcinoma of the tail of the pancreas. The cancer was deemed as 'resectable disease associated with morbid surgical outcomes' due to the local involvement of the vessels and adjacent organs. Given the patient's excellent performance status, the patient underwent neoadjuvant chemotherapy with folinic acid, fluorouracil, irinotecan and oxaliplatin to downstage the tumour for less morbid surgical resection. The patient underwent 12 cycles of chemotherapy with serial imaging which demonstrated positive response to treatment and surgical resection was performed. Surgical pathology revealed no residual tumour and imaging was negative for any extrapancreatic tumour metastasis. This is an unusual case as pancreatic malignancy is usually lethal with poor survival outcomes.

https://ift.tt/2wyYZW1

Oesophageal narrowing during combination chemotherapy in Ewings sarcoma: Is vincristine a culprit?

Vincristine is a widely used chemotherapeutic agent in paediatric oncology. A 7-year-old boy was diagnosed with non-metastatic Ewing's sarcoma of the pelvis. He was started on chemotherapy with vincristine–cyclophosphamide–adriamycin alternate with ifosfamide–etoposide. He developed recurrent vomiting after three cycles of chemotherapy. Evaluation showed oesophageal stricture involving the middle and lower third part. Biopsy was non-conclusive. His symptoms improved with dilatation. A chemotherapy-induced neuropathic dysmotility was suspected, and his chemotherapy was continued with serial dilatation. Vincristine, being neurotoxic, was suspected to be the reason of this morbidity. His need of dilatation decreased, and symptoms improved remarkably after completion of chemotherapy.

Vincristine-induced oesophageal dysmotility is a rare side effect. There is no consensus on management. Omission of this effective agent in such situation is debatable.

https://ift.tt/2Q0W2qe

Simultaneous occurrence of hepatic hydatid cyst and mucinous cystadenoma of the liver in a middle-aged female patient: report of a rare case

We present a rare case of simultaneous occurrence of mucinous cystadenoma of the liver (MCN-L) and a hepatic hydatid cyst (HD-L) in a middle-aged female patient. This is the first case report of a common disease (HD-L) and a rare condition (MCN-H) occurring concurrently. MCN-H of the left lobe was inadequately resected in a rural centre leading to recurrence. She presented with a large upper abdominal lump and upper gastrointestinal symptoms. Radiological investigations and an ultrasound revealed a multilobulated cyst involving both lobes of the liver. There was no ascites. Liver function, basic haematology and renal function were normal. The recurrent MCN-L was removed totally. There was no communication between the MCN-L and the right lobe cyst, which turned out to be a hydatid cyst. The hydatid cyst was evacuated. She was discharged on albendazole and is asymptomatic with no recurrence at 8 months.

https://ift.tt/2wAZxdU

Mitotane-induced dyspnoea: an unusual side effect

Mitotane is a cytostatic antineoplastic agent that is used in the treatment of adrenocortical carcinoma and Cushing's syndrome. The commonly reported side effects associated with mitotane are anorexia, nausea, vomiting, diarrhoea, decreased memory, rash, gynaecomastia, arthralgias and leucopenia. We present a case of a 68-year-old female who developed gradual dyspnoea concurrent with the use of mitotane for the treatment of adrenocortical carcinoma. To the best of our knowledge and literate review, this is the first reported case of dyspnoea associated with the use of this medication. The purpose of this case report is to raise awareness about this uncommon adverse effect of mitotane that may have gone unrecognised on postmarketing surveillance because of under-reporting, lack of case follow-up or other comorbidities masking shortness of breath.

https://ift.tt/2MDN8AR

NUT carcinoma: a rare and devastating neoplasm

Description 

A 45-year-old woman with no significant medical history had 1 month of productive cough empirically treated with azithromycin and dyspnoea on exertion. She was never a smoker and denied any constitutional symptoms, including unexpected weight loss. A CT of the chest was performed after she developed haemoptysis, which demonstrated a 6.3x4.6 cm right hilar mass with hilar, subcarinal and cardiophrenic adenopathy (figure 1A). She underwent bronchoscopy which revealed complete occlusion of the right middle lobe by a tumour extending into the bronchus intermedius. Debridement of this mass was performed, with re-establishment of airway patency to the right lower lobe. Pathology from the debrided tumour as well as the subcarinal lymph node was consistent with poorly differentiated non-small cell lung carcinoma with Thyroid Transcription Factor 1 (TTF-1) and Programmed Death-Ligand 1 (PD-L1) negativity. Due to high clinical suspicion, the tissue samples were transferred to another facility for additional assessment. MRI...

https://ift.tt/2wA14kt

Elbow instability following lateral collateral ligament complex avulsion fracture and joint interposition: an uncommon presentation

The lateral collateral ligament (LCL) complex of the elbow is a capsuloligamentous structure, critical for elbow stability. Though isolated ligamentous injuries have been reported in literature, there are no studies reporting avulsion fractures of the lateral ligamentous complex of the elbow with joint incarceration in a child. An 11-year-old boy presented to the emergency department after a fall from height, with pain and swelling to the lateral side of his left elbow. Radiographs established a fracture of the lateral condyle and CT imaging confirmed an avulsion of the lateral ligamentous complex, with fragments in the inferior radiocapitellar joint. Examination under anaesthesia revealed an unstable elbow with restricted extension, and the child underwent joint debridement and open reduction internal fixation of LCL complex with cannulated screws. At the final follow-up at 15 months, the child regained preinjury level of function.

https://ift.tt/2MIbnOq

Association of giant retinal tear with iridofundal coloboma in a case of paediatric retinal detachment

Description 

A 6-year-old boy presented with history of sudden-onset painless diminution of vision oculus dexter (OD) since the last six hours. The vision loss was preceded by a sudden shower of floaters. There was no history of recent or remote trauma, and no positive family history of ocular illness could be elicited from the parents. Visual acuity was perception of light with accurate projection of rays OD and 20/20 oculus sinister (OS). A typical and complete iris coloboma with keyhole pupil was noted OD. There was no sign of trauma in either eye. Intraocular pressures measured to 6 mm Hg OD and 13 mm Hg OS. Dilated fundus examination showed type II choroidal coloboma involving the macula (Ida Mann classification) with total rhegmatogenous retinal detachment OD. Peripheral examination revealed a giant retinal tear (GRT), extending almost five clock hours, with a posterior flap falling over the posterior pole (figure 1). OS was...

https://ift.tt/2C3GpLA

Infective endocarditis due to Atopobium vaginae: a rare association between genital infection and endocarditis of the tricuspid valve

Atopobium vaginae is an anaerobic gram-positive organism associated with genitourinary infections. Bacteraemia is rare, with only two cases reported in the literature. This case describes an 18-year-old type 1 diabetic, presenting with sepsis and haemoptysis, on a background of poor dental hygiene and recurrent hospital admissions. Blood cultures grew A. vaginae and echocardiogram revealed a large tricuspid valve lesion. Despite medical therapy, symptoms of pulmonary emboli continued and she therefore underwent surgical resection of the lesion. Histopathological findings were of a vegetation; culture of the lesion was negative but 16S ribosomal PCR was positive, detecting 16S rRNA of A. vaginae. The patient was treated with 4 weeks of vancomycin and made a good recovery. To our knowledge, this represents the first report of infective endocarditis due to this organism. We also provide a review of the literature, including comparing published drug susceptibility data with consensus breakpoints for antimicrobial agents.

https://ift.tt/2Q0Vsc2

Palpebral cutaneous melanomas: a review of 17 cases from a tertiary center

International Journal of Dermatology, EarlyView.


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Autologous Platelet Rich Fibrin: Can it Secure a Better Healing ?

Publication date: Available online 31 August 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Sheetal Kapse, Sanidhya Surana, M. Satish, Syed Erfan Hussain, Sunil Vyas, Deepak Thakur

Abstract

Objective

To evaluate the efficacy of platelet rich fibrin (PRF) in the healing of impacted mandibular third molar (M3) extraction sockets.

Study Design

This study included 30 patients with bilaterally symmetrical impacted M3 (total n = 60) requiring transalveolar extraction. All patients were randomly provided numbers; left-sided odd numbered M3 patients and right-sided even numbered patients were categorized into group A (test group), while the other side of the mouth was classified as "Group B" (control group). Group A M3 extraction sockets received PRF, while group B sockets were closed without PRF. Patients were evaluated for pain and swelling on post-operative days 1,3,7, and 14. Bone healing was compared on the 8^th and 16^th post-operative weeks. ANOVA and Tukey multiple comparison tests were applied for statistical analysis.

Results

A total of 30 patients between the age of 18 to 40 yearsparticipated in this study. The overall post-operative pain score (VAS) and facial swelling percentages were lower for group A compared to group B (p<0.05). Early bone healing was also evident on the 8^th and 16^th week post-operative radiographs in group A (p < 0.001).

Conclusion

Use of autologous PRF aids in earlier and better wound healing in a controlled manner.

https://ift.tt/2wJqb4D

Early Detection of Cherubism with Eventual Bilateral Progression: A Literature Review and Case Report

Publication date: Available online 1 September 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Tyler J. Holley, Peter J. Giannini, Nagamani Narayana, Valmont P. Desa

Abstract

Cherubism is a rare familial disease of childhood that commonly affects the bilateral mandible and maxilla and typically resolves in adulthood. It has been shown to have a male predilection and has been mapped to the SH3BP2 gene. Only two cases of unilateral cherubism have been documented in the literature, with the first case eventually affecting the contralateral side. Although rare, unilateral cherubism presents a diagnostic dilemma to the surgeon. This case report describes a unique presentation of unilateral cherubism that progressed to affect the contralateral side and describes some of the considerations for surgeons in the diagnosis and treatment of unilateral benign giant cell lesions of the jaws.

https://ift.tt/2MHoI9L

Longitudinal morphometric analysis of dental arch of children with cleft lip and palate: 3D stereophotogrammetry study

Publication date: Available online 31 August 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Eloá Cristina Passucci Ambrosio, Chiarella Sforza, Márcio De Menezes, Daniele Gibelli, Marina Codari, Cleide Felício Carvalho Carrara, Maria Aparecida Andrade Moreira Machado, Thais Marchini Oliveira

Abstract

Purpose

This study aimed to perform a longitudinal morphometric analysis of the alterations of the maxillary dental arches of children with cleft lip and palate before and after the primary lip and/or palate surgeries using three-dimensional stereophotogrammetry system.

Methods

The sample consisted of dental casts of 60 children with unilateral complete cleft lip (UCL) and unilateral complete cleft lip and palate (UCLP). Dental arches were evaluated at pre-cheiloplasty (T1), post-cheiloplasty (T2), and 1 year after palatoplasty (T3). Independent t test and Mann-Whitney test were used for intergroup comparisons, and Paired T test, Wilcoxon test, and Repeated-measures ANOVA followed by Tukey test were used for intragroup comparisons.

Results

At T1, the intercanine and intertuberosity distances of group UCLP were statistically greater than those of group UCL. At T2, the maxillary dimensions significantly increased, except for the intertuberosity distance in UCL. Between T1 and T3, the intercanine distance and the anterior length decreased significantly, while the intertuberosity distance and the total length of the palate increased significantly.

Conclusion

According to our results, the primary lip surgery changed the development of the dental arches, evidently in children with UCLP. The primary palate surgery interfered in the growth of the anterior palatal region in group UCLP. The children with UCLP had more restricted development of the maxillary dental arch than children with UCL.

https://ift.tt/2N48RkZ

Isolated gluteal metastasis three years after sufficiently treated oral squamous cell carcinoma: case report and literature review

Publication date: Available online 31 August 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Andreas Naros, Hannes Weise, Michael Krimmel, Siegmar Reinert

Abstract

Metastases from oral squamous cell carcinoma usually occur in the cervical lymph nodes. Distant skeletal muscle metastases are exceedingly rare and have been reported only in sporadic cases.

A 70-year-old male patient was diagnosed with non-metastatic oral SCC (pT4aN0M0). The patient underwent successful surgical treatment involving tumor resection and selective neck dissection of both sides, including adjuvant radiotherapy. After three years of uneventful course, with no clinical or radiographic evidence for local recurrence or metastasis, an isolated distant metastasis in the gluteal muscles was diagnosed. Patient deceased seven months after diagnosis despite further surgical resection and adjuvant chemotherapy.

Distant metastases are mostly accompanied by systemic spread of tumor cells. Thus, the prognosis is generally very poor. The therapeutic concept of surgical tumor resection and adjuvant chemotherapy failed to significant improving the patient's prognosis in the present case.

https://ift.tt/2wBK9hy

Gorham's Disease of the Mandible: A Report of Two Cases and A Literature Review

Publication date: Available online 31 August 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Sheng Zhang, Dandan Wu, Liqiang Shi, Yuxing Zhang, Kaiping Long, Yun Fan, Bing Zhu, Xiaohang Jin, Yan Ren, Chunli Zhang, Pei Wang

Abstract

Gorham's disease is a rare disorder of unknown etiology characterized by the clinical and radiological disappearance of bone. Since the etiology is unknown, diagnosis is difficult. Therefore, radiographic manifestations play a vital role in the diagnosis of this disease. Thus far, there has been no completely effective treatment. Most remedies are limited to symptom management. Despite the fact that any bone can be affected, one of the most prevalent sites is the maxillofacial region. In this paper, two cases of Gorham's disease involving the maxillofacial region are reported, including preoperative and postoperative radiographic features.

https://ift.tt/2N5ndBu

Prevalence, initiating factor and treatment outcome of medication-related osteonecrosis of the jaw - a four year prospective study

Publication date: Available online 31 August 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Fredrik Hallmer, Gunilla Andersson, Bengt Götrick, Gunnar Warfvinge, Jonas Anderud, Tore Bjørnland

ABSTRACT

Objectives

Prevalence of MRONJ is reported with a wide range and a standard therapy has not yet been established. The aim was to analyse the prevalence and initiating factors of MRONJ and the outcome of surgical therapy.

Study design

In a prospective cohort study, all patients diagnosed with MRONJ in the region of Skåne were included. Predictor variables (co-morbidity, site, stage, gender) and initiating factors (tooth extraction, periodontitis) were recorded. Surgical treatment was sequestrectomy or block resection and the outcome variable was healing after 2 months. To estimate the prevalence, data on the use of bisphosphonate and denosumab were used.

Results

Fifty-five patients with MRONJ were identified. The prevalence of MRONJ for patients on oral bisphosphonates was 0.043%, on intravenous bisphosphonates 1.03% and on high dose denosumab 3.64%. Periodontal disease preceded development of MRONJ in 41 patients. Fifty patients were treated surgically and followed up for at least 2 months. Lesions progressed to remission or healing in 80.0% of patients treated with sequestrectomy and in 92.5% of patients treated with block resection.

Conclusion

The prevalence of MRONJ in Sweden is low. Periodontitis is the most common initiating factor. The treatment outcome of MRONJ demonstrates healing in most patients treated surgically.

https://ift.tt/2ND1ldR

Feasibility of a combination of intraoral UHFUS and CBCT in the study of peri-implantitis.

Publication date: Available online 31 August 2018

Source: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Author(s): Rossana Izzetti, Saverio Vitali, Mario Gabriele, Davide Caramella

Abstract

Objectives: To investigate the combination of intraoral ultra-high frequency ultrasound (UHFUS) and cone beam computed tomography (CBCT) in the evaluation of hard and soft tissues in a case of peri-implantitis.

Methods: A 57-year-old patient was referred for pain and numbness of the chin after implant placement and subsequent guided bone regeneration (GBR) procedure. Clinical examination revealed a hard tumefaction of the mandibular mucosa with mild mobility of the implants. Assessment with UHFUS was undertaken for the study of width, degree of tissue alteration, and vascularity of the swollen mucosa, while CBCT was used to evaluate the bone surrounding the implants and the possible impingement of the inferior alveolar nerve.

Results: A combination of CBCT and UHFUS was effective in the evaluation of GBR complications in peri-implantitis, revealing alterations in the periosteum secondary to suboptimal GBR treatment. This was the first study to use UHFUS to evaluate the characteristics of oral soft tissues.

Conclusions: UHFUS is a promising tool for the diagnosis of complicated soft tissue diseases. When used with CBCT, it can provide useful information on oral and maxillofacial diseases involving hard and soft tissue in a non-invasive way, with reduced radiation dose exposure.

https://ift.tt/2N5n94I

Predictive potential and need for standardization of PD-L1 immunohistochemistry

Abstract

Checkpoint inhibitors targeting the PD-1/PD-L1 axis are a promising treatment option in several tumor types. PD-L1 expression detected by immunohistochemistry is the first clinically validated predictive biomarker for response to PD-1/PD-L1 inhibitors, though its predictive value varies significantly between tumor types. With the approval of pembrolizumab monotherapy for treatment-naïve, advanced non-small cell lung cancer, PD-L1 testing has to become broadly available in pathology laboratories. When PD-L1 testing started to be introduced in routine pathology practice, there were several open issues, which needed to be addressed in order to provide accurate results. This review will discuss the complex biological background of PD-L1 as predictive biomarker, summarize relevant clinical trials in NSCLC illustrating the origin of different PD-L1 expression cutoffs and scorings, and address issues important for PD-L1 testing including the analytical comparability of the different clinical trial-validated PD-L1 immunohistochemistry assays, the potential of laboratory-developed tests, and an overview of the different scoring algorithms.

https://ift.tt/2LJKjZz

Age-related hearing loss and cognitive decline — The potential mechanisms linking the two

Publication date: Available online 1 September 2018

Source: Auris Nasus Larynx

Author(s): Yasue Uchida, Saiko Sugiura, Yukiko Nishita, Naoki Saji, Michihiko Sone, Hiromi Ueda

Abstract

The amount of attention to age-related hearing loss (ARHL) has been growing, not only from the perspective of being one of the most common health conditions affecting older adults, but also from the perspective of its relation to cognition. Results from a number of epidemiological and laboratory studies have demonstrated a significant link between ARHL and cognitive decline. The Lancet International Commission on Dementia, Prevention, Intervention, and Care has estimated that mid-life hearing loss, if eliminated, might decrease the risk of dementia by nine percent, since hearing loss is a modifiable age-associated condition linked to dementia. Despite numerous research efforts, elucidation of the underlying causal relationships between auditory and cognitive decline has not yet reached a consensus.

In this review article, we focused on the hypotheses of etiological mechanisms between ARHL and cognitive decline: (1) cognitive load hypothesis; (2) common cause hypothesis; (3) cascade hypothesis; and (4) overdiagnosis or harbinger hypothesis. Factual evidence obtained in previous studies was assessed to understand the link between ARHL and cognitive decline or dementia. Additionally, an overview of the conceivable effects of hearing intervention, e.g., hearing aids and cochlear implants, on cognition were presented, and the role of hearing aid use was considered for the relevant hypotheses.

We should continue to strive for social enlightenment towards the importance of 'hearing well', and cultivate a necessity for hearing screening among patients at risk of cognitive decline.

https://ift.tt/2PRXxXL

Young Otolaryngologists of International Federation of Oto-rhino-laryngological Societies (YO-IFOS) committees

Publication date: Available online 31 August 2018

Source: European Annals of Otorhinolaryngology, Head and Neck Diseases

Author(s): T. Ayad, K. Stephenson, D. (A.L.) Smit, O. Ben-Ari, R. Késmárszky, J. Lechien, S. Sobol, C. Meller, Z. Sargi, R. Maunsell, R.D. De Siati, H. Jia, V. Krishnan, H. North, E.G. Eter, O. Metwaly, S. Peer, N. Teissier, L. Sowerby, P. Hong

https://ift.tt/2wwHXsc

Transcervical styloidectomy in Eagle's syndrome

Publication date: Available online 31 August 2018

Source: European Annals of Otorhinolaryngology, Head and Neck Diseases

Author(s): P. Pigache, C. Fontaine, J. Ferri, G. Raoul

Abstract

Eagle's syndrome is a rare disease responsible for polymorphic head and neck symptoms, often resulting in delayed diagnosis. The diagnosis of Eagle's syndrome is based on the presence of suggestive clinical signs associated with pain on palpation of the styloid process in the tonsillar fossa, a positive lidocaine test and elongation of the styloid process on 3D CT scan. The most commonly proposed curative treatment is styloidectomy, which allows complete resolution of symptoms in the great majority of cases. This procedure can be performed via a transoral approach or a transcervical approach. After briefly reviewing the embryology and anatomy of the styloid diaphragm region, the authors describe the transcervical styloidectomy technique performed in their department. This simple technique is based on anatomical imperatives designed to limit the operating time and avoid damage to neurovascular structures.

https://ift.tt/2NAXiyI

1. Fel d 1 and Fel d 4 levels in cat fur, saliva and urine

Publication date: Available online 31 August 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Suzanne M. Kelly, Jacob Karsh, Jennifer Marcelo, Douglas Boeckh, Nate Stepner, Bryan Santone, Jimmy Yang, William H. Yang

https://ift.tt/2LIvFlu

Cluster Analysis Of Occupational Asthma Due to Isocyanates

Publication date: Available online 31 August 2018

Source: Journal of Allergy and Clinical Immunology

Author(s): Paola Mason, Anna Chiara Frigo, Maria Cristina Scarpa, Piero Maestrelli, Gabriella Guarnieri

https://ift.tt/2otu9uc

Early warning scores in the perioperative period: applications and clinical operating characteristics

Purpose of review Early warnings scores are designed to detect clinical deterioration and promote intervention at the earliest possible moment. Although the ultimate effects on patient outcomes are unclear, early warning scores are now legally mandated in several countries. Here, we review the performance of early warning scores in surgical and perioperative populations. Recent findings Early warning scores can be used to screen for postoperative deterioration and surgical complications. We describe a framework to evaluate the balance between missed events and warning signals that are not followed by an adverse event (nonevents). In large surgical cohort studies, the missed event rates ranged between 19 and 69% and the nonevent rates ranged between 72 and 99% for 'optimal' threshold early warning sores. Recent investigations have shown that there may be a substantial discrepancy between the theoretical benefits shown in validation studies and the practical clinical implementation of early warning scores, which may partly explain the absence of measurable benefit from these systems. Summary Early warning scores may facilitate protocolized escalation of care for patients at risk of adverse events and can be used in surgical and postoperative patients, but high nonevent rates and practical implementation problems can restrict their usefulness. Correspondence to Harm-Jan de Grooth, MD, Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands. Tel: +31 6 46 37 15 07; e-mail: h.degrooth@vumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2LIrING

What we can learn from Big Data about factors influencing perioperative outcome

Purpose of review This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. Recent findings The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. Summary Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising. Correspondence to Jurgen C. de Graaff, MD, Department of Anesthesiology, Medical Center, SB-3646, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 10 704 34964; e-mail: j.degraaff@erasmusmc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2N5ehvU

Perioperative cognitive evaluation

Purpose of review This article reviews the recent clinical evidence published between January 2017 and June 2018 – related to perioperative cognitive evaluation. Namely, new insights into risk factors, prevention, diagnosis and diagnostic tools and treatment. Recent findings Several risk factors (preoperative, intraoperative and postoperative) have been found to be associated with the development of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). Short-term and long-term postoperative consequences can be reduced by targeting risk factors, introducing preventive strategies and including frequent cognitive monitoring. Administration of medications such as ketamine, opioids and benzodiazepines are associated with increased cognitive dysfunction. Prevention of POD/POCD starts with creating an environment, which promotes return to preoperative baseline functioning. This includes frequent monitoring of cognitive status, access to rehabilitation and psychological and social supports, and avoiding polypharmacy. In addition, patients should have early access to their sensory aids and maintain normal circadian rhythm. Treatment of POD/POCD has pharmacological and nonpharmacological approaches. Summary Clinical evidence on POD/POCD is continuously evolving, which is essential in guiding clinical management to provide the highest quality of clinical care. Correspondence to Federico Bilotta, MD, PhD, Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University, Rome, Italy. Tel: +39 6 8608273; fax: +39 6 8608273; e-mail: bilotta@tiscali.it Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2PkB5VO

Comprehensive Long‐Term Safety of Adalimumab from Eighteen Clinical Trials in Adult Patients With Moderate to Severe Plaque Psoriasis

British Journal of Dermatology, Volume 0, Issue ja, -Not available-.


https://ift.tt/2LGdltf

Shifting weaning practices in Early Neolithic Cis‐Baikal, Siberia: New insights from stable isotope analysis of molar micro‐samples.

International Journal of Osteoarchaeology, Volume 0, Issue ja, -Not available-.


https://ift.tt/2PX5URR

Case 27-2018: A 3-Year-Old Boy with Seizures

Presentation Of Case. Dr. Caitlin E. Naureckas Li (Pediatrics): A 3-year-old boy was admitted to this hospital during the summer because of a seizure. The patient had been well until 3 days before admission, when one episode of emesis occurred. The following evening, he was fussy, and on the third…

https://ift.tt/2PTbioW

Case 26-2018: A 48-Year-Old Man with Fever, Chills, Myalgias, and Rash

Presentation of Case. Dr. William G. Tsiaras: A 48-year-old man was evaluated at this hospital because of fever, chills, myalgias, diarrhea, and a diffuse rash. The patient had been in his usual state of good health until about 3 weeks before admission, in the late spring, when he noted the onset…

https://ift.tt/2Ne7Wyx

Case 25-2018: A 63-Year-Old Man with Syncope

Presentation of Case. Dr. William J. Hucker: A 63-year-old man was evaluated at this hospital because of syncope. Approximately 13 years before admission, the patient had an out-of-hospital cardiac arrest and was found to have multivessel coronary artery disease. He underwent coronary-artery bypass…

https://ift.tt/2wvCYs3

Case 24-2018: A 71-Year-Old Man with Acute Renal Failure and Hematuria

Presentation of Case. Dr. Joshua Z. Drago (Medicine): A 71-year-old man was transferred to this hospital because of worsening renal function and hematuria. Three weeks before this admission, the patient's wife became ill with chills, fatigue, and myalgias, and she thought she had influenza. A few…

https://ift.tt/2PsYSTR

Protective effects of metformin, statins and anti-inflammatory drugs on head and neck cancer: A systematic review

Publication date: October 2018

Source: Oral Oncology, Volume 85

Author(s): Constanza Saka Herrán, Enric Jané-Salas, Albert Estrugo Devesa, José López-López

Abstract

The main objective of this study was to evaluate the effect of metformin, statins and anti-inflammatory drugs (NSAIDs) on head and neck cancer (HNC). Specifically, the potential beneficial effects on risk, survival and recurrence based on epidemiological studies.

PRISMA guidelines were followed. After searching MEDLINE (PubMed), IBECS, LILACS and the Cochrane Central Register for Controlled Trials, 13 studies met the inclusion criteria and so underwent qualitative synthesis (six studies for metformin and seven for NSAIDs). No studies were found for statins. Studies varied in their methodological quality. Meta-analyses showed that metformin exerts significant beneficial effects on HNC risk (RR = 0.71 95% CI 0.61–0.84) and overall survival (RR = 1.71 95% CI 1.20–2.42). Qualitative synthesis also suggests an apparently dose-response relationship and increased benefit when administered alone. The pooled-analyses yielded an almost significant effect of NSAIDs on HNC risk (RR = 0.86 95% CI 0.74–1.01). No associations were found between aspirin use and the risk of HNC (RR = 0.98 95% CI 0.77–1.24) and overall survival (RR = 1.10 95% CI 0.89–1.36).

Metformin appears to have beneficial effects on HNC risk and overall survival, with an apparently dose-response relationship and increased benefit when administered alone. NSAIDs also seem to have a modest beneficial effect on HNC risk. No definitive conclusions can be reached for aspirin as the evidence available was proved inconsistent. Further research by means of well designed and conducted studies are needed to determine firm clinical implications. Standardized assessment methods for HNC outcomes should be established and account for known confounding factors such as smoking and alcohol consumption.

https://ift.tt/2NB4ASZ

Mesenteric fibromatosis in a patient with a history of neuroblastoma: a case report

Abstract

Mesenteric fibromatosis (MF) is a locally aggressive proliferative spindle cell lesion of the mesentery. A 34-year-old male presented with increasing abdominal pain and constipation. On workup, patient was found to have a large pelvic mass on CT A/P concerning for cancer. The patient underwent surgical excision of >15 cm intra-abdominal tumor along with adherent small bowel section. Histology of the tumor showed a spindle cell lesion consistent with MF. Previous reports have shown association of MF with Gardner syndrome and familial adenomatous polyposis. We present the first reported case of MF in a patient with previous neuroblastoma.

https://ift.tt/2PqIJy9

Real‐world use of apremilast for patients with psoriasis in Japan

The Journal of Dermatology, EarlyView.


https://ift.tt/2wyFHAT

Atypical pemphigus developed in a patient with urothelial carcinoma treated with nivolumab

The Journal of Dermatology, EarlyView.


https://ift.tt/2LMjDaS

A Prospective Observational Cohort Study of Calls for Help in a Tertiary Care Academic Operating Room Suite

While significant literature exists on hospital-based "code calls," there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1–1.8), corresponding to a rate of 5.0 (3.8–6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR. Accepted for publication June 11, 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 Cameron J. Ricks, MD, Department of Anesthesiology and Perioperative Care, University of California, Irvine School of Medicine, 333 The City Blvd W, Suite 2150, Orange, CA 92868. Address e-mail to cricks@uci.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2LLVu43

Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents

BACKGROUND: Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Secondgeneration drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS: The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS: A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0.90, 91–180, 181–365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0–90 days and 3.4 (0.8 to 15.3) at 91–180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS: The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT. Accepted for publication March 9, 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 Gregory A. Nuttall, MD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Address e-mail to Gnuttall@mayo.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2wzzsg9

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial

BACKGROUND: Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. METHODS: This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 and 10 μg/kg or an equal volume of saline. RESULTS: Visual analog scale scores were significantly better (P2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P

https://ift.tt/2LLMlbR

Caution in Using Gadolinium-Based Contrast Agents in Interventional Pain Procedures

No abstract available

https://ift.tt/2ouzDVO

Reversal of Deep Pipecuronium-Induced Neuromuscular Block With Moderate Versus Standard Dose of Sugammadex: A Randomized, Double-Blind, Noninferiority Trial

BACKGROUND: Certain surgical interventions may require a deep neuromuscular block (NMB). Reversal of such a block before tracheal extubation is challenging. Because anticholinesterases are ineffective in deep block, sugammadex 4 mg/kg has been recommended for the reversal of rocuronium- or vecuronium-induced deep NMB. However, this recommendation requires opening 2 vials of 200 mg sugammadex, which results in an increase in drug costs. Therefore, we sought a less expensive solution for the induction and reversal of deep NMB. Although the optimal dose of sugammadex for antagonism of deep block from pipecuronium has not been established, data pertaining to moderate block are available. Accordingly, we hypothesized that sugammadex 2 mg/kg would be a proper dose to reverse deep pipecuronium block, enabling us to avoid cost increases. In the present study, we compared sugammadex 2 mg/kg with the standard dose of 4 mg/kg for reversal of deep block from pipecuronium. METHODS: This single-center, randomized, double-blind, 2 parallel-arms, noninferiority study comprised 50 patients undergoing general anesthesia with propofol, sevoflurane, fentanyl, and pipecuronium. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch SX). Noninferiority margin was specified beforehand as an increase in reversal time of no

https://ift.tt/2LLV9hN

Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case–Control Study

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy. Accepted for publication July 3, 2018. Funding: This work was supported by the University of Michigan Health System Department of Anesthesiology. Support for REDCap (Research Electronic Data Capture) reported in this publication was provided by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000433. E.A.S.C. is supported by a grant from the Burroughs Wellcome Foundation. P.T. was supported by a grant from the Robert Wood Johnson Foundation (Princeton, NJ), Harold Amos Medical Faculty Development Program (award 69779). B.T.B. is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Bethesda, MD) under Award Number K08HD075831. No source of funding had a role in any stage of the study, analysis, or writing of this manuscript. Conflicts of Interest: See Disclosures at the end of the article. This work was presented, in part, at the 48th Society for Obstetric Anesthesia and Perinatology Annual Meeting, Boston, MA, May 18–22, 2016. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Sydney Behrmann, BS, is currently affiliated with the University of Michigan Medical School, Ann Arbor, Michigan; Anthony Chau, MD, MMSc, is currently affiliated with the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia; Caitlin Clancy, BA, BSN, RN, is currently affiliated with the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Stephanie Lin, MD, is currently affiliated with the Department of Perinatal Medicine, Marian Regional Medical Center, Santa Maria, California; Kristina Priessnitz, BS, is currently affiliated with the Michigan State College of Human Medicine, East Lansing, Michigan; Anuj Shah, MD, is currently affiliated with the Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan. Reprints will not be available from the authors. Address correspondence to Melissa E. Bauer, DO, Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to mbalun@med.umich.edu. © 2018 International Anesthesia Research Society

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In Response

No abstract available

https://ift.tt/2NDeLXe

Preoperative Salivary Cortisol AM/PM Ratio Predicts Early Postoperative Cognitive Dysfunction After Noncardiac Surgery in Elderly Patients

BACKGROUND: The diagnosis of postoperative cognitive dysfunction (POCD) requires complicated neuropsychological testing and is often delayed. Possible biomarkers for early detection or prediction are essential for the prevention and treatment of POCD. Preoperative screening of salivary cortisol levels may help to identify patients at elevated risk for POCD. METHODS: One hundred twenty patients >60 years of age and undergoing major noncardiac surgery underwent neuropsychological testing 1 day before and 1 week after surgery. Saliva samples were collected in the morning and the evening 1 day before surgery. POCD was defined as a Z-score of ≤−1.96 on at least 2 different tests. The primary outcome was the presence of POCD. The primary objective of this study was to assess the relationship between the ratio of AM (morning) to PM (evening) salivary cortisol levels and the presence of POCD. The secondary objective was to assess the relationship between POCD and salivary cortisol absolute values in the morning or in the evening. RESULTS: POCD was observed in 17.02% (16 of 94; 95% confidence interval [CI], 9.28%–24.76%) of patients 1 week after the operation. A higher preoperative AM/PM salivary cortisol ratio predicted early POCD onset (odds ratio [OR], 1.56; 95% CI, 1.20–2.02; P = .001), even after adjusting for the Mini-Mental Sate Examination score (odds ratio, 1.55; 95% CI, 1.19–2.02; P = .001). The area under the receiver operating characteristic curve for the salivary cortisol AM/PM ratio in individuals with POCD was 0.72 (95% CI, 0.56–0.88; P = .006). The optimal cutoff value was 5.69, with a sensitivity of 50% and specificity of 91%. CONCLUSIONS: The preoperative salivary cortisol AM/PM ratio was significantly associated with the presence of early POCD. This biomarker may have potential utility for screening patients for an increased risk and also for further elucidating the etiology of POCD. Accepted for publication July 18, 2018. Funding: Supported by the National Natural Science Foundation of China (81720108013, 81571059); Jiangsu Provincial Special Program of Medical Science (BL2014029); Scientific Research Innovation Project for Graduate Students of Jiangsu Universities, Jiangsu, China (SJZZ16_0290); and China Postdoctoral Science Foundation Funded Project (Project No: 2015M580473). 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). Y. Han, L. Han, and M.-M. Dong contributed equally to this work and share first authorship. Reprints will not be available from the authors. Address correspondence to Jun-Li Cao, MD, PhD, Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai Rd, Quanshan District, Xuzhou City 221002, Jiangsu Province, China. Address e-mail to caojl0310@aliyun.com. © 2018 International Anesthesia Research Society

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Anticipated Rates and Costs of Guideline-Concordant Preoperative Stress Testing

BACKGROUND: Current guidelines recommend that patients have preoperative assessment of cardiac risk and functional status, and that patients at "elevated" cardiac risk with poor or unknown functional status be referred for preoperative stress testing. Little is known about current rates of testing or resultant medical costs. We set out to estimate the expected rates of preoperative stress testing and resultant costs if physicians in the United States were to follow current guidelines and to investigate differences that would arise from 2 risk prediction methods included in current guidelines. METHODS: We applied 2 risk prediction tools (Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest) included in current American College of Cardiology/American Heart Association guidelines to a multicenter prospective registry of patients undergoing surgery in the United States in 2009. We then calculated expected rates of preoperative cardiac stress testing if physicians were to follow American College of Cardiology/American Heart Association guidelines, expected nationwide direct medical expenditures that would result (in 2017 US dollars), and agreement beyond chance between the 2 risk prediction tools. RESULTS: Current guidelines recommend considerable spending on preoperative stress testing. Guideline-recommended spending would differ substantially depending on the risk prediction tool used and the reliability of the functional status assessment. Rates of testing and resultant spending are likely much greater among patients at "elevated" risk, compared with patients at "low" risk. Two guideline-recommended risk assessment tools, Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest, have poor agreement beyond chance across the currently recommended risk threshold. CONCLUSIONS: Preoperative stress testing is likely a considerable source of medical spending, despite unproven benefit. Which perioperative risk assessment tool clinicians should use, what risk thresholds are appropriate for patient selection, and the reliability of the functional status assessment all warrant further attention. Accepted for publication July 23, 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 Matthew A. Pappas, MD, MPH, Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Stop G-10, Cleveland, OH 44195. Address e-mail to pappasm@ccf.org. © 2018 International Anesthesia Research Society

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Building a Bridge Between Pediatric Anesthesiologists and Pediatric Intensive Care

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields. Accepted for publication July 3, 2018. M. M. Longacre, MD, MM, and A. M. Bader, MD, MPH, are currently affiliated with the Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women's Hospital, Boston, Massachusetts. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Mckenna M. Longacre, MD, MM, Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to mmlongacre@partners.org. © 2018 International Anesthesia Research Society

https://ift.tt/2osLH9P

Use of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator During Preoperative Risk Discussion: The Patient Perspective

BACKGROUND: The American College of Surgeons (ACS) National Surgical Quality Improvement Program Surgical Risk Calculator (ACS Calculator) provides empirically derived, patient-specific risks for common adverse perioperative outcomes. The ACS Calculator is promoted as a tool to improve shared decision-making and informed consent for patients undergoing elective operations. However, to our knowledge, no data exist regarding the use of this tool in actual preoperative risk discussions with patients. Accordingly, we performed a survey to assess (1) whether patients find the tool easy to interpret, (2) how accurately patients can predict their surgical risks, and (3) the impact of risk disclosure on levels of anxiety and future motivations to decrease personal risk. METHODS: Patients (N = 150) recruited from a preoperative clinic completed an initial survey where they estimated their hospital length of stay and personal perioperative risks of the 12 clinical complications analyzed by the ACS Calculator. Next, risk calculation was performed by entering participants' demographics into the ACS Calculator. Participants reviewed their individualized risk reports in detail and then completed a follow-up survey to evaluate their perceptions. RESULTS: Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, serious complication, and length of stay compared to low-risk patients (P

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Traumatic Brain Injury in Flies

No abstract available

https://ift.tt/2osLyDj

Observation of Complement Protein Gene Expression Before and After Surgery in Opioid-Consuming and Opioid-Naive Patients

Opioids may influence inflammation. We compared genes associated with pain and inflammation in patients who consumed opioids (3–120 mg of oral morphine equivalents per day) with those who did not for differential expression. White blood cells were assayed in 20 patients presenting for total lower extremity joint replacement. We focused on messenger ribonucleic acid expression of complement proteins. We report that the expression of a complement inhibitor, complement 4 binding protein A, was reduced, and the expression of a complement activator, complement factor D, was increased in opioid-consuming patients. We conclude that opioid consumption may influence expression of complement activators and inhibitors. Accepted for publication July 12, 2018. Funding: Supported in part by the Department of Anesthesiology at the University of Utah. 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). Clinical trial number and registry URL: This study is not subject to ClinicalTrials.gov review because the study is not a clinical trial and does not involve an intervention or investigational use of a device or drug. Reprints will not be available from the authors. Address correspondence to Ken B. Johnson, MD, Department of Anesthesiology, University of Utah, 30 N 1900 E RM 3C444, Salt Lake City, UT 84112. Address e-mail to ken.b.johnson@hsc.utah.edu. © 2018 International Anesthesia Research Society

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Intravenous Lidocaine for the Prevention of Cough: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: It remains unclear to what extent intravenous lidocaine prevents cough and whether there is dose-responsiveness and risk of harm. METHODS: We searched electronic databases to January 1, 2017 for randomized trials comparing intravenous lidocaine with placebo for the prevention of cough in surgical patients. Primary outcome was the incidence of cough. Data were analyzed using a random-effects model and were expressed as risk ratio (RR) and number needed to treat (NNT) with 95% confidence interval. RESULTS: In 20 trials in adults (n = 3062) and 5 trials in children (n = 445), intravenous lidocaine 0.5–2 mg·kg−1 was tested for the prevention of intubation-, extubation-, or opioid-induced cough. Twenty-two trials included only American Society of Anesthesiologists I or II patients; 3 trials (n = 99) also included American Society of Anesthesiologists III patients. Lidocaine was associated with a lower incidence of cough compared to placebo in adults and children, irrespective of dosage and cough etiology. Data from adults suggested dose-responsiveness; with 0.5 mg·kg−1, RR was 0.66 (0.50–0.88) and NNT was 8 (5.4–14.3); with 1 mg·kg−1, RR was 0.58 (0.49–0.69) and NNT was 7 (4.6–8.9); with 1.5 mg·kg−1, RR was 0.44 (0.33–0.58) and NNT was 5 (3.3–5.2); and with 2 mg·kg−1, RR was 0.39 (0.24–0.62) and NNT was 3 (2.0–3.4). Adverse effect reporting was sparse. CONCLUSIONS: Within a range of 0.5–2 mg·kg−1, intravenous lidocaine dose dependently prevents intubation-, extubation-, and opioid-induced cough in adults and children with NNTs ranging from 8 to 3. The risk of harm in high-risk patients remains unknown. Accepted for publication April 12, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. 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 Sara Clivio, MD, Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland. Address e-mail to sara.clivio@cardiocentro.org. © 2018 International Anesthesia Research Society

https://ift.tt/2osLofb

Global Anesthesia

No abstract available

https://ift.tt/2wxfR09

Incentive-Based Game for Allaying Preoperative Anxiety in Children: A Prospective, Randomized Trial

BACKGROUND: Induction of anesthesia can be distressing both for children and their parents. Nonpharmacological behavioral interventions can reduce the anxiety of children without significant adverse effects as seen with sedative medications. We hypothesized that the use of incentive-based game therapy in conjunction with parental involvement would be a simple and cost-effective intervention in reducing the preoperative anxiety in children. METHODS: Eighty children between the age group of 4 and 8 years scheduled to undergo surgery were randomly assigned to a control group (n = 40) and intervention group (n = 40). Children in the intervention group participated in an incentive-based game in the preoperative room. Anesthesia was induced with parental presence in both the groups. The modified Yale Preoperative Anxiety Scale (mYPAS) score to measure the anxiety of the children during induction was taken as the primary outcome. Induction Compliance Checklist score and parental satisfaction were assessed as secondary outcomes. RESULTS: The mYPAS score of children in the intervention group was significantly less than the control group during anesthesia induction. The mean difference (95% confidence interval [CI]) of the mYPAS at induction between the 2 groups was 20 (95% CI, 16–24; P

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Ganglion Cyst of the Temporomandibular Joint Mimicking Auriculotemporal Neuralgia

Ganglion cysts within the temporomandibular joint (TMJ), although uncommon, typically present with swelling, pain, trismus, and difficulty with mastication. The authors report an unusual case of a ganglion cyst in the TMJ of a 52-year-old man who presented with chief complaints of severe headaches and dizziness that had not subsided following treatment with medication, trigger point injections, or sphenopalatine ganglion blocks. The cyst appeared as a nonenhancing, T2 hyperdensity adjacent to the left TMJ condyle on magnetic resonance imaging, supported by the presence of chronic erosion and remodeling of the anterior aspect of the left condylar head on computed tomography. The cyst was surgically removed, and the patient reported that the migraines and accompanying dizziness had ceased 6 months postoperatively. The patient's presentation and improvement following surgery suggest that the location of the cyst in the TMJ and its proximity to the course of the auriculotemporal nerve may have caused auriculotemporal neuralgia, mimicking the symptoms of migraine. Address correspondence and reprint requests to Christopher Michael Runyan, MD, Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27157; E-mail: crunyan@wakehealth.edu Received 4 May, 2018 Accepted 2 July, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

https://ift.tt/2LL7kv6

Could Nasal Surgery Affect Multilevel Surgery Results for Obstructive Sleep Apnea?

Objective: To study the role of nasal surgery as a part of multilevel surgery for management of obstructive sleep apnea (OSA). Methods: All patients underwent multilevel surgery for relieving OSA symptoms and they were classified according to type of surgical intervention into: group A (20 patients), who underwent hyoid suspension (Hyoidthyroidpexy), tonsillectomy, suspension (El-Ahl and El-Anwar) sutures and nasal surgery (inferior turbinate surgery). Group B (20 patients), who underwent hyoid suspension (Hyoidthyroidpexy), tonsillectomy and suspension sutures. Pre and postoperative sleep study, Epworth sleepiness scale, snoring score were reported and compared. Results: Apnea hypoapnea index (AHI) dropped significantly in both groups. The mean preoperative AHI was significantly less in patients who had no nasal obstruction (P = 0.0367), while the difference in postoperative values was nonsignificant (P = 0.7358). The mean Epworth sleepiness scale improved significantly in both groups, but the difference between pre and postoperative values in both groups was nonsignificant. The lowest oxygen saturation elevated significantly in both groups, but the difference between pre and postoperative values in both groups was nonsignificant. As regards snoring scores, they dropped significantly in both groups. The preoperative snoring score was reported to be significantly more in patients who had associated nasal obstruction (group A) (P = 0.0113). But after surgery the difference in postoperative values was nonsignificant (P = 0.1296). Conclusion: Treatment of nasal obstruction should be considered a crucial component in the comprehensive management plan for OSA patients as it has significant impact on the patients' AHI and snoring. Address correspondence and reprint requests to Mohammad Waheed El-Anwar, MD, Otorhinolaryngology, Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Sharkia Governorate, Egypt, Postal Code +20 552307830; E-mail: mwenteg1973@gmail.com Received 12 May, 2018 Accepted 2 July, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Three Skulls Dating from the French Revolutionary Years Diagnosed with Tinea Capitis: A Paleopathologic Approach

The Musée Dupuytren was a Parisian pathology museum established in 1835. This museum hosted 3 skulls with severe craniofacial lesions initially tagged as aggressive forms of tinea capitis. The aim of this study was to investigate these specimens and discuss the initial diagnosis. Historical investigations were conducted based on the biographic data from the tags of the 3 skulls and entries on the catalog of the museum. Age was determined using dentition and the patency of cranial base synchondroses. The computed tomography scans were performed using standard medical devices. The 3 skulls were from the late 18th to early 19th century. Skull № 1 was a 5-year-old child and presented with microcephaly and extensive vault osteolysis compatible with an aggressive benign lesion, a malignant tumor, or a chronic infection. Skull № 2 was a 12- to 18-year-old teenager and presented with symmetrical porotic hyperostosis compatible with undernutrition and various hematologic conditions causing prolonged anemia, but also with chronic inflammation and/or infection. Skull № 3 was also from a 12- to 18-year-old teenager and presented with focal temporal osteolysis compatible with an aggressive benign or a low-grade malignant temporal soft-tissue lesion or with chronic infection. These skulls contribute to the understanding of the concept of tinea in the 19th century. They are furthermore windows on the sanitary and social conditions in Paris in the years following the French revolution and during the Napoleonian wars. Address correspondence and reprint requests to Roman Hossein Khonsari, MD, PhD, Service de Chirurgie Maxillofaciale and Chirurgie Plastique, Hôpital Universitaire Necker – Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; E-mail: roman.khonsari@aphp.fr Received 26 January, 2018 Accepted 1 April, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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