Head and Neck Medicine by Alexandros G.Sfakianakis: 10/24/18

Τετάρτη 24 Οκτωβρίου 2018

Transabdominal two-cavity approach for radical nephrectomy combined with inferior vena cava thrombectomy for malignant thrombus caused by renal cell carcinoma: a case series

Advanced renal cell carcinoma in some cases causes malignant intravascular thrombus with the potential for growth into the inferior vena cava or even the right atrium. Renal cell carcinoma is accompanied by ma...

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Monoclonal gammopathy in prostate carcinoma: a case report and review of literature

Monoclonal gammopathy is commonly associated with plasma cell dyscrasia. However, monoclonal gammopathy without bone marrow plasmacytosis in prostate carcinoma has rarely been reported. The association between...

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The physician and hereditary angioedema friend or foe: 62-year diagnostic delay and iatrogenic procedures

Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare autosomal dominant disease characterized by episodes of acute subcutaneous swelling, and/or recurrent severe abdominal pain. The dise...

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Nine year follow-up of a rare case of angioedema due to acquired C1-inhibitor deficiency with late onset and good response to attenuated androgen

Angioedema due to acquired deficiency of C1-inhibitor (C1-INH-AAE) is a rare disease sharing some clinical and laboratory similarities with hereditary angioedema, but with late onset and no positive family his...

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Practicalities of a reduced volume formulation of a C1-INH concentrate for the treatment of hereditary angioedema: real-life experience

Hereditary angioedema (HAE) due to C1 esterase inhibitor (C1-INH) deficiency is characterized by recurrent swelling attacks that can be life-threatening if left untreated. Prompt treatment is vital during acut...

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Apremilast as therapeutic option in a HIV positive patient with severe psoriasis

Dermatologic Therapy, EarlyView.

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Stromal interleukin-33 promotes regulatory T cell-mediated immunosuppression in head and neck squamous cell carcinoma and correlates with poor prognosis

Abstract

Regulatory T cells (Tregs) mediate immunosuppressive signals that can contribute to the progression of head and neck squamous cell carcinoma (HNSCC). Interleukin-33 (IL-33) is defined as an 'alarmin', an endogenous factor that is expressed during tissue and cell damage, which has been shown to promote Treg proliferation in non-lymphoid organs. However, the interaction between IL-33 and Tregs in the HNSCC tumor microenvironment remains uncertain. In this study, we examined IL-33⁺ and Foxp3⁺ cells by immunohistochemistry in 68 laryngeal squamous cell cancer patients, followed by functional analysis of IL-33 in Tregs. In addition, the suppressive function of Tregs was assessed by cell proliferation assays. The level of stromal IL-33 was significantly upregulated in advanced versus early stage HNSCC patients and positively correlated with Foxp3⁺ Treg infiltration as well as a poor prognosis. ST2 is regarded as the only receptor of IL-33. Infiltrated ST2-expressing Tregs were responsive to IL-33, and the percentage of Tregs was increased upon IL-33 stimulation. Functional investigation demonstrated that IL-33 increased the proportion of Foxp3⁺GATA3⁺ Tregs and improved the suppressive functions of Tregs by inducing IL-10 and TGF-β1 as well as decreasing the proliferation of responder T cells. Blockade of ST2 abrogated the immunosuppression caused by IL-33. Our data demonstrate that stromal IL-33 both expands the Treg population and enhances their functions in the tumor microenvironment. Furthermore, stromal IL-33 has prognostic value for tumor progression. Thus, stromal IL-33 is a potential target for future HNSCC immunotherapy.

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Inhibitory functions of PD-L1 and PD-L2 in the regulation of anti-tumor immunity in murine tumor microenvironment

Abstract

Although a role of PD-L1 in the suppression of anti-tumor immunity and its value as a predictive biomarker has been suggested by various preclinical and clinical studies, the precise mechanisms how PD-L1 and PD-L2, another ligand of PD-1, regulate anti-tumor immunity in the tumor microenvironment are yet to be fully explored. Here, we address this issue using PD-L1-deficient tumor cells, PD-L1-knockout (KO) mice, anti-PD-L1 monoclonal antibody (mAb), and anti-PD-L2 mAb. Firstly, PD-L1-deficient or competent tumor cells were inoculated into wild-type or PD-L1-KO mice. Results of tumor growth and mouse survival indicated that both tumor- and host-derived PD-L1 are functional to suppress anti-tumor immunity, while the former contributes predominantly than the latter. Experiments using bone marrow (BM) chimeric mice, generated by transferring PD-L1-KO BM cells into wild-type mice or vice versa, further suggested that PD-L1 expressed on BM-derived hematopoietic cells mediates the suppressive effects on anti-tumor immunity. Secondly, anti-PD-L2 mAb treatment demonstrated a profound synergy with anti-PD-L1 mAb therapy, whereas anti-PD-L2 mAb alone hardly induced any anti-tumor effects, suggesting that PD-L2's function becomes evident when the effects of PD-L1 are abrogated by anti-PD-L1 mAb. Consistent with this notion, PD-L2 expression was upregulated on tumor-associated macrophages (TAM) when mice were treated with anti-PD-L1 mAb. Taken together, our study elucidated the importance of PD-L1 associated with tumor cells and non-tumor host cells, particularly BM-derived hematopoietic cells, as well as PD-L2 inducibly expressed on TAM in the suppression of anti-tumor immunity in the tumor microenvironment.

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What to know about microdermabrasion

Microdermabrasion is a cosmetic procedure, during which a dermatologist removes the top layer of skin. The aim is to create a more youthful, even complexion. Learn more here.

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Eikenella corrodens lipopolysaccharide stimulates the pro‐atherosclerotic response in human coronary artery endothelial cells and monocyte adhesion

European Journal of Oral Sciences, EarlyView.

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Association of Quality of Life With Surgical Excision of Head and Neck Melanoma

This study examines the preoperative and postoperative changes in quality of life as perceived and reported by patients who received surgical treatment for Tis or T1a melanoma of the head and neck.

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Herpetic Whitlow—A Case of Inadvertent Inoculation With Melanoma Viral Therapy

This case report describes an occurrence of herpetic whitlow following inadvertent inoculation with melanoma viral therapy

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Association of Psoriasis With Inflammatory Bowel Disease

This systematic review and meta-analysis of 9 studies comprising more than 7 million patients examines the association between psoriasis and inflammatory bowel disease.

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APOA5 and APOC3 Polymorphisms and Hypertriglyceridemia in Bexarotene-Treated CTCL

This case series study examines the association between APOA5 and APOC3 polymorphisms and triglyceride levels in patients with cutaneous T-cell lymphoma before, during, and after treatment with bexarotene.

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Conflict of interest and citation impact among dermatology guideline authors

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The Prevalence of Soft Tissue Calcifications in the Head and Neck Region Using CBCT Among Egyptian Population

Condition: Oral Soft Tissue Conditions
Intervention: Other: presence of soft tissue calcification in head and neck
Sponsors: Maha Samy Elhadidy; Cairo University
Not yet recruiting

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Histopathology of livers in patients with congenital portosystemic shunts (Abernethy malformation): a case series of 22 patients

Abstract

Congenital portosystemic shunt (CPSS) is a congenital anomaly resulting in partial or complete diversion of the portal blood into the systemic circulation. The literature on the histological changes in livers of patients with CPSS is limited. Liver histology of 22 consecutive patients managed in our institution between 2001 and 2016 was reviewed. Twenty-one patients were children at the time of diagnosis. Thirty-two specimens were available and consisted of three explant livers and 29 biopsy samples from 19 patients. Sixteen samples were from wedge biopsies taken at the time of shunt closure. Thirteen were from core needle biopsies taken during clinical work-up. A variable proportion of portal tracts contained prominent thin-walled channels (PTWCs) and arterio-biliary dyads. The proportion of portal tracts containing triads, arterio-biliary dyads and biliary monads varied considerably in the different samples. Dilated inlet venules, increase in the number of portal arteries or the presence of portal arteries of increased size, deposition of copper-associated protein, sinusoidal dilatation, capillarization and intralobular individual arteries were present. Physiological nuclear vacuolation of periportal hepatocytes was absent in most samples from our paediatric patients. Presence of PTWCs, arterial-biliary dyads, increased arterial profiles in portal tracts and lobule and lack of the physiological periportal vacuolated hepatocytes in children are the most characteristic histological changes of CPSS in the liver periphery.

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Apert Syndrome: Intraoperative and Postoperative Hyponatremia

Apert syndrome is one of the acrocephalosyndactilia syndromes that is characterized with calvarial an extremity deformities. Anesthesia management of this syndrome is commonly related with difficult airway. However, hyponatremia is another insistent complication that can occur during craniosynostosis surgeries. Hyponatremia is a common complication during calvarial remodeling surgeries and it can result in serious neurologic damage. Development of mild hyponatremia in a patient with Apert syndrome that went under craniosynostosis surgery was presented in this study. Address correspondence and reprint requests to Isin Gencay, MD, Faculty of Medicine, Department of Anesthesiology and Reanimation, Kirikkale University, Kirikkale, Turkey; E-mail: snyzc@yahoo.com Received 27 March, 2018 Accepted 15 June, 2018 The author reports no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Use of Cepstral Analysis for Differentiating Dysphonic from Normal Voices in Children

Publication date: Available online 23 October 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Fatma Esen Aydinli, Esra Özcebe, Önal İncebay

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Is transcanal tympanoplasty an appropriate surgical treatment for congenital middle ear cholesteatoma with ossicular involvement?

Publication date: Available online 23 October 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Hantai Kim, Shin Young Yoo, Yun-Hoon Choung, Hun Yi Park

Abstract

Objectives

The aims of this study are to analyze the clinical characteristics of congenital middle ear cholesteatoma (CMC), to evaluate the treatment results according to the types of surgical approach, and to suggest the appropriate surgical treatment option in each stage.

Methods

One hundred fifteen children (≤15 years old) with surgically confirmed CMC, who underwent surgery at a tertiary hospital during 1994 to 2012 and were followed up more than 2 years, were enrolled in this study. CMC was classified into four stages by the staging system proposed by Potsic. Clinical characteristics of CMC were analyzed and its association with the rate of residual disease was evaluated.

Results

Based on the location of the lesion, posterior-origin CMCs were detected significantly later (5.5 years old, P = 0.018) and more likely to be in the Stage 3 or 4 (P < 0.001). Residual CMCs were observed in 10 out of 115 cases (8.7%) and were more frequent in the Stage 3 or 4 patients (P = 0.007). However, the rate of the residual disease was not statistically different between anterior- and posterior-origin CMCs (P = 0.101). All 58 cases of CMC in the Stage 1 or 2 were successfully removed by transcanal tympanoplasty with only one residual case (1.7%). In the Stage 3 cases, transcanal tympanoplasty was conducted in 24 out of 29 patients, and the residual disease rate was 12.5% (3 out of 24).

Conclusions

The early stages of CMC were likely to be diagnosed at younger age, and the early diagnosis seemed to show better surgical outcomes with less invasive techniques. Transcanal tympanoplasty can be an effective surgical option for CMCs in the Stage 3.

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Effects of Socioeconomic Status on Children with Hearing Loss

Publication date: Available online 23 October 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Blake Smith, Jessica Zhang, Gina Nhu Pham, Keerthana Pakanati, Nikhila Raol, Julina Ongkasuwan, Samantha Anne

Abstract

Objective

Health care disparities are noted between different socioeconomic groups; it is crucial to recognize and correct disparities, if present, that extend to children with hearing loss. The objective of the study is to evaluate the effect of socioeconomic status (SES) on access to hearing rehabilitation and speech and language therapy and outcomes in children with hearing loss.

Methods

Retrospective Chart Review of children diagnosed with hearing loss at 3 tertiary care academic centers from 2010-2012. Two hundred patients were then randomly selected from each institution for analysis. International and self-pay patients were excluded. They were separated into two groups based on SES using insurance coverage as proxy for financial status (private insurance versus Medicaid). Main outcome measures included number of hearing aid evaluations recommended andcompleted, compliance with hearing aids use, diagnosis on speech therapy evaluations, participation in speech therapy, and outcomes noted on the last speech therapy session in patients' medical record at time of study completion.

Results

600 patients were identified by random selection out of total of 3679 patients. 18 were excluded because they were international pay or self-pay. Of 582 patients, 299 (51.4%) had private insurance and 283 (48.6%) had Medicaid. The pure tone average (PTA) at initial diagnosis did not differ between the two populations (left ear p = 0.74, right ear p = 0.68). There was no significant difference in the number of hearing aid evaluations recommended (p = 0.49), hearing aid evaluation completed (p = 0.68), or documented hearing aid compliance (p=0.68) between the two populations. Similarly, there was no significant difference in the presence of speech delay (p = 0.62), the receipt of speech therapy (p=0.49), or speech language outcomes between the two groups (p= 0.45).

Conclusions

This study suggests that despite lower socioeconomic status, in children with hearing loss, Medicaid allows equivalent access to hearing rehabilitation and speech therapy as their privately insured counterparts and children achieve similar speech and language outcomes.

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Characteristics and Prognosis of Primary Head and Neck Angiosarcomas: A Surveillance, Epidemiology, and End Results Program (SEER) Analysis of 1250 Cases

Abstract

Head and neck angiosarcomas (HN-AS) are rare malignancies with a poor prognosis relative to other soft tissue sarcomas. To date, the HN-AS literature has been limited to short reports and single-institution experiences. This study evaluated patients registered with the Surveillance, Epidemiology, and End Results (SEER) program who had been diagnosed with a primary HN-AS. Predictors were drawn from demographic and baseline tumor characteristics. Outcomes were survival months and cause of death. Kaplan–Meier analyses were used to estimate overall (OS) and disease-specific survival (DSS) rates. Cox proportional hazards regression models were used for multivariate analyses. A total of 1250 patients (mean age 73.3 years) were identified, and nearly all lesions (93.5%) were cutaneous. Two- and 5-year OS rates were 47.3% (95% CI 44.3–50.3) and 26.5% (95% CI 23.7–29.3), while 2- and 5-year DSS rates were 66.6% (95% CI 63.6–69.6) and 48.3% (95% CI 44.5–52.1). In the univariate analyses, age, race, tumor grade, tumor size, AJCC stage, SEER historic stage, and surgery were significant predictors of both OS and DSS. Multivariate regression revealed that independent predictors of poor OS and DSS were older age [OS: HR 1.04 (95% CI 1.02–1.05), p < 0.01; DSS: HR 1.03 (95% CI 1.01–1.05), p < 0.01], increased tumor size [OS: HR 1.01 (95% CI 1.01–1.01), p < 0.01; DSS: HR 1.01 (95% CI 1.01–1.02), p < 0.01], and distant disease [OS: HR 2.97 (95% CI 1.65–5.34), p < 0.01; DSS: HR 4.99 (95% CI 2.50–9.98), p < 0.01]. Age, tumor size, and disease extent were determinants of HN-AS survival. When all other factors were controlled, lower histologic grade and surgery did not improve the risk of death.

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Nontraumatic Parapharyngeal Haematoma: A Rare Lesion

Nontraumatic haematoma of parapharyngeal space is very rare and may cause dysphagia and dyspnea. The authors present a case report of a 74-year-old woman with sudden nontraumatic neck swelling without dyspnea and with left pharyngeal bulging and endolaryngeal displacement. Parathyroid hormone elevation and imaging exams confirmed bleeding from a parathyroid adenoma. Symptoms and signs resolved after one week of conservative treatment. There are few cases of parapharyngeal haematomas caused by parathyroid adenomas. Most patients can be managed without emergent surgery, but close airway monitoring is fundamental.

https://ift.tt/2D2ufCv

Recommandations diagnostiques et thérapeutiques pour les maladies sexuellement transmissibles : herpès génital

Publication date: Available online 23 October 2018

Source: Annales de Dermatologie et de Vénéréologie

Author(s): B. Milpied, M. Janier, J. Timsit, N. Spenatto, E. Caumes, O. Chosidow, L. Sentilhes, M.-V. Senat, Groupe infectiologie dermatologique et infections sexuellement transmissibles (GrIDIST) de la Société française de dermatologie et du Collège national des gynécologues obstétriciens français (CNGOF)

Résumé

Traitement de la primo-infection ou du premier épisode clinique d'herpès génital en cours de grossesse

Le traitement de la primo-infection ou du premier épisode clinique d'herpès génital est basé sur l'aciclovir oral, 200 mg × 5/j pendant 5 à 10 jours en fonction de l'état clinique. Concernant le valaciclovir, la posologie recommandée est de 1 g × 2 jours avec une durée de traitement identique à celle proposée pour l'aciclovir.

Traitement de la récurrence herpétique en cours de grossesse

Il n'y a pas d'étude permettant d'évaluer l'efficacité d'un traitement antiviral sur la symptomatologie en cas de récurrence d'herpès génital pendant la grossesse. Le traitement antiviral par aciclovir ou valaciclovir peut cependant être proposé devant une symptomatologie le justifiant (durée et intensité des symptômes). Le valaciclovir pourra être préféré (efficacité d'utilisation même si les données d'innocuité sont plus nombreuses pour l'aciclovir). Le valaciclovir peut être utilisé à la dose de 1cp à 500 mg per os deux fois par jour pendant 5 jours.

Traitement antiviral prophylactique en cas de grossesse

Chez les femmes ayant eu une infection initiale ou une récurrence pendant la grossesse, bien qu'il n'existe pas de bénéfice démontré du traitement prophylactique pour réduire le risque d'herpès néonatal, il est recommandé de proposer une prophylaxie antivirale à partir de 36 SA (semaines d'aménorrhée) afin de réduire le risque de césarienne pour lésion herpétique. Les antiviraux recommandés sont l'aciclovir à la posologie de 400 mg trois fois par jour per os ou le valaciclovir à la posologie de 500 mg deux fois par jour per os jusqu'à l'accouchement.

Summary

Treatment of the initial infection or first clinical episode of genital herpes

An initial infection or first clinical episode of genital herpes is treated with oral aciclovir 200 mg × 5/d for 5 to 10 days depending on clinical status. The recommended dosage for valaciclovir is 1 g × 2/d and treatment duration is identical to that for aciclovir.

Treatment of herpes recurring during pregnancy

There are no studies of the efficacy of antiviral therapy on the symptoms of genital recurring during pregnancy. However, initial anti-viral treatment using aciclovir or valaciclovir may be given where warranted by symptoms (i.e. duration and severity of symptoms). Valaciclovir may be used instead (equivalent efficacy but better safety data for aciclovir). Valaciclovir may be given at a dosage of 1 × 500 mg b.i.d. p.o. for 5 days.

Prophylactic anti-viral treatment during pregnancy

In female patients presenting an initial infection or infection recurring during pregnancy, although there is no demonstrated benefit for prophylactic treatment in reducing the risk of neonatal herpes, anti-viral prophylaxis is recommended after 36 WA (weeks' amenorrhoea) to limit the need for Caesarean section due to herpetic lesions. The recommended antivirals are aciclovir at a dosage of 400 mg t.i.d p.o. or valaciclovir at a dosage of 500 mg b.i.d. p.o. until delivery.

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Ulcérations buccales aphtoïdes inaugurales d’une maladie inflammatoire chronique de l’intestin induite par le sécukinumab

Publication date: Available online 23 October 2018

Source: Annales de Dermatologie et de Vénéréologie

Author(s): X. Grimaux, S. Leducq, P. Goupille, A. Aubourg, E. Miquelestorena-Standley, M. Samimi

Résumé

Introduction

Le sécukinumab, anticorps monoclonal humanisé ciblant l'interleukine 17A, a été associé à la survenue de maladies inflammatoires digestives. Nous rapportons le cas d'une patiente ayant développé des ulcérations buccales inaugurales d'une maladie inflammatoire chronique intestinale (MICI) induite par le sécukinumab. Cette patiente avait eu six ans auparavant des ulcérations buccales similaires au cours d'un traitement par tocilizumab (ciblant l'IL6R), suggérant un lien immunologique entre les deux épisodes.

Observation

Une femme de 36 ans avait une spondylarthrite ankylosante réfractaire. En 2010, elle avait présenté des ulcérations buccales au cours d'un traitement par tocilizumab. En 2011, le tocilizumab avait été arrêté et l'aphtose résolutive. En 2016, l'introduction du sécukinumab s'accompagnait d'une récidive d'ulcérations buccales aphtoïdes puis d'une iléo-pancolite. Une corticothérapie, puis un traitement par ustékinumab, permettaient une évolution partiellement favorable.

Discussion

Cette patiente a développé une maladie inflammatoire chronique intestinale au cours d'un traitement par sécukinumab, précédée par des ulcérations buccales aphtoïdes. Elle avait développé, six ans auparavant, des ulcérations buccales similaires au cours d'un traitement ciblant l'IL6R. L'IL6 est une cytokine pléiotrope qui peut activer la voie Th17. Ainsi, le tocilizumab a pu induire un effet « anti-IL17-like » expliquant la survenue de lésions buccales aphtoïdes possiblement en lien avec une maladie inflammatoire digestive a minima.

Conclusion

La survenue d'ulcérations buccales au cours d'un traitement par sécukinumab peut être inaugurale d'une maladie inflammatoire chronique intestinale. La notion d'aphtose préalable, notamment au cours de traitements biologiques antérieurs, devrait faire discuter le rapport bénéfices/risques de la prescription d'un anti-IL17.

Summary

Background

Secukinumab, a humanized monoclonal antibody targeting interleukin 17A, has been associated with the development of inflammatory bowel diseases. We report a case of a female patient developing recurrent oral ulcers prior to inflammatory bowel disease induced by secukinumab. The patient had developed similar oral ulcers 6 years earlier while on tocilizumab (targeting IL6R), suggesting an immunological link between the two episodes.

Patients and methods

A 36-year-old female patient had refractory spondylarthrosis. In 2010, she had presented oral aphthous ulcers during treatment with tocilizumab. In 2011, tocilizumab was stopped and the ulcers resolved. In 2016, secukinumab was introduced and led to recurrence of oral aphthous ulcers followed by ileitis-pancolitis. Corticosteroids and ustekinumab resulted in partial remission.

Discussion

The patient developed inflammatory bowel disease during treatment with secukinumab, preceded by recurrent oral aphthous ulcers. She had presented similar oral ulcers 6 years earlier while on a treatment targeting IL6R. IL6 is a pleiotropic cytokine that may activate the Th17 pathway. Thus, tocilizumab could have induced an "anti-IL17-like" effect, accounting for the occurrence of oral aphthous ulcers, possibly related to mild inflammatory bowel disease.

Conclusion

The occurrence of oral ulcers during treatment with secukinumab may herald inflammatory bowel disease. In patients with a previous history of recurrent aphthous stomatitis, especially where induced by previous biologics, consideration must be given to the risk-benefit ratio of prescribing an anti-IL17 antibody.

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Comparative Effects of Sodium Bicarbonate and Intravenous Lipid Emulsions on Reversing Bupivacaine-Induced Electrophysiological Toxicity in a Porcine Experimental Model

BACKGROUND: Bupivacaine cardiotoxicity mainly manifests as inhibition of the cardiac sodium channel, which slows conduction, particularly at the ventricular level. Experimental studies have demonstrated that intravenous lipid emulsions (ILEs) can reduce the cardiotoxic effects of bupivacaine, but the extent of these effects is controversial. Sodium bicarbonate (B) represents the standard treatment of toxicity related to sodium channel–blocking drugs. The aim of this study was to compare the effects of ILEs and B on the speed of recovery from bupivacaine-induced effects on the electrocardiographic parameters. METHODS: Bupivacaine 4 mg/kg was administered to 24 anesthetized pigs. Three minutes after delivering the bupivacaine bolus, the animals were given the following: ILE 1.5 mL/kg followed by 0.25 mL/kg/min (ILE group) and B 2 mEq/kg followed by 1 mEq/kg/h (B group). Controls (C group) were given saline solution, 50 mL followed by 1 mL/kg/h. Electrophysiological parameters were evaluated in sinus rhythm and during right ventricular pacing at several time intervals up to 30 minutes. Data were analyzed as the area under the curve (AUC) for the first 10 minutes (AUC10) or 30 minutes (AUC30). RESULTS: Bupivacaine increased the sinus cycle length, PR interval, and QRS duration. AUC30 of the sinus rhythm QRS duration after antidote administration was significantly different among the 3 groups (P = .003). B group experienced faster recovery from intoxication than the C group (AUC10, P = .003; AUC30, P = .003) or the ILE group (AUC10, P = .018). During the first minute, 50% of the B group (versus 0% of the ILE and C groups) had recovered >30% of QRS duration (P = .011). The trend toward faster recovery in the ILE group than in the C group did not reach significance (AUC10, P = .23; AUC30, P = .06). Effects on the paced QRS duration at a rate of 150 bpm were more intense but with similar results (B versus C group: AUC10, P = .009; AUC30, P = .009; B versus ILE: AUC10, P = .015; AUC30, P = .024). The recovery process of the paced QRS tended to be slower for all antidotes. CONCLUSIONS: In a closed-chest swine model, B was an effective treatment for electrophysiological alterations caused by established bupivacaine toxicity. At clinical doses, B ameliorated bupivacaine electrocardiographic toxicity faster than ILE. Use-dependent effects of bupivacaine are prominent and delay the effects of both antidotes, but B produces faster recovery than ILE. Accepted for publication September 19, 2018. Funding: Supported by a research grant from the Ministry of Economy, Industry, and Competitiveness of Spain, and Fondos Fondo Europeo de Desarrollo Regional. 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 Matilde Zaballos, MD, PhD, Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, C/Tellez, No. 52, 3º D, Madrid 28007, Spain. Address e-mail to mati@plagaro.net. © 2018 International Anesthesia Research Society

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Objective Epidural Space Identification Using Continuous Real-Time Pressure Sensing Technology: A Randomized Controlled Comparison With Fluoroscopy and Traditional Loss of Resistance

BACKGROUND: Performance of epidural anesthesia and analgesia depends on successful identification of the epidural space (ES). While multiple investigations have described objective and alternative methodologies to identify the ES, traditional loss of resistance (LOR) and fluoroscopy (FC) are currently standard of care in labor and delivery (L&D) and chronic pain (CP) management, respectively. While FC is associated with high success, it exposes patients to radiation and requires appropriate radiological equipment. LOR is simple but subjective and consequently associated with higher failure rates. The purpose of this investigation was to compare continuous, quantitative, real-time, needle-tip pressure sensing using a novel computer-controlled ES identification technology to FC and LOR for lumbar ES identification. METHODS: A total of 400 patients were enrolled in this prospective randomized controlled noninferiority trial. In the CP management arm, 240 patients scheduled to receive a lumbar epidural steroid injection had their ES identified either with FC or with needle-tip pressure measurement. In the L&D arm, 160 female patients undergoing lumbar epidural catheter placements were randomized to either LOR or needle-tip pressure measurement. Blinded observers determined successful ES identification in both arms. A modified intention-to-treat protocol was implemented, with patients not having the procedure for reasons preceding the intervention excluded. Noninferiority of needle-tip pressure measurement regarding the incidence of successful ES identification was claimed when the lower limit of the 97.27% confidence interval (CI) for the odds ratio (OR) was above 0.50 (50% less likely to identify the ES) and P value for noninferioirty <.023. results: demographics were similar between procedure groups with a mild imbalance in relation to gender when evaluated through standardized difference. noninferiority of needle-tip pressure measurement was demonstrated fc where pain management patients presented success rate es identification both methodologies ci p=".021" for and l experienced noninferior the novel technology vs or using priori delta conclusions: objective lumbar continuous quantitative real-time compuflo epidural computer controlled anesthesia system resulted rates compared lor cp respectively. benefits this may include nonexposure radiation contrast medium consequently reduced health care costs. accepted publication september funding: clinical trial funded by milestone scientific livingston nj. conflicts interest: see disclosures at end article. number: nct02378727 clinicaltrials.gov. reprints will not be available from authors. address correspondence ralf e. gebhard md department anesthesiology university miami miller school medicine nw ave c-300 fl e-mail rgebhard international research society>

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Distraction-Free Induction Zone: A Quality Improvement Initiative at a Large Academic Children’s Hospital to Improve the Quality and Safety of Anesthetic Care for Our Patients

BACKGROUND: Noise in the operating room may cause distractions during critical periods and impair reliable communication between staff. Even momentary inefficiency while administering anesthesia can lead to errors and serious consequences for the patient. Distractions to an anesthesia provider during critical periods such as induction and emergence are a patient safety issue. Because of concerns regarding unacceptable noise levels and distractions during induction of general anesthesia, our institution developed a quality improvement initiative, the "Distraction-Free Induction Zone." The specific aim of this project was to decrease the percentage of cases with a distraction, described as music, unnecessary conversations, or loud noises, occurring during induction of general anesthesia in pediatric otolaryngology operating rooms from 61% to 15%. METHODS: To complete this quality improvement initiative, a multidisciplinary team used improvement science methods, including The Model for Improvement with interventions tested via Plan-Do-Study-Act cycles. We used tools such as the Key Driver Diagram, Pareto Charts, Process Flow Chart, and Plan-Do-Study-Act worksheets. Data were manually collected and entered weekly in an Excel spreadsheet. Statistical process control methods, including a run chart and a P-control chart, were used for data analysis. Our measure was a composite measure in which observation of 1 of the 3 distractions during induction of general anesthesia categorized the case as a case with a distraction. RESULTS: We tested and implemented several interventions via Plan-Do-Study-Act cycles in which 3 main interventions collectively were associated with an observed decrease in distractions during induction of general anesthesia. These included educating the perioperative staff present in the operating room to help them understand that distractions to anesthesia providers represent a patient safety issue, the operating room circulating nurse taking responsibility to pause any music on arrival to the operating room, and the anesthesiologist reminding the staff in the operating room of induction time and/or asking for quiet during induction if a distraction occurs. The percentage of cases with a distraction during induction of general anesthesia in our pediatric otolaryngology operating rooms decreased from 61% to 15% by April 15, 2017 and to 10% by June 5, 2017. CONCLUSIONS: Using improvement science methods, we observed a decrease in distractions during induction of general anesthesia, improved a process, and encouraged change in culture at a large academic children's hospital to enhance the quality and safety of the anesthetic care we provide our patients. Accepted for publication September 19, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Christy J. Crockett, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 2200 Children's Way, Suite 3116, Nashville, TN 37232. Address e-mail to christy.crockett@vumc.org. © 2018 International Anesthesia Research Society

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In Reply: Encouraging a Bare Minimum While Striving for the Gold Standard A Response to the Updated WHO-WFSA Guidelines

No abstract available

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Encouraging a Bare Minimum While Striving for the Gold Standard: A Response to the Updated WHO-WFSA Guidelines

No abstract available

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Dexmedetomidine-Mediated Prevention of Renal Ischemia-Reperfusion Injury Depends in Part on Cholinergic Anti-Inflammatory Mechanisms

BACKGROUND: Organ ischemia-reperfusion injury often induces local and systemic inflammatory responses, which in turn worsen organ injury. These inflammatory responses can be regulated by the central nervous system, particularly by the vagal nerve and nicotinic acetylcholine receptors, which are the key components of cholinergic anti-inflammatory pathway. Activation of the cholinergic anti-inflammatory pathway can suppress excessive inflammatory responses and be a potential strategy for prevention of ischemia-reperfusion injury of organs including the kidney. METHODS: Vagal nerve activity, plasma acetylcholine, catecholamine and inflammatory mediators, renal tissue injury, and cell death were measured in mice with bilateral renal ischemia/reperfusion with or without treatment with dexmedetomidine (Dex), an α2-adrenergic receptor agonist. RESULTS: Dex significantly increased the discharge frequency of the cervical vagal nerve by up to 142 Hz (mean) (P

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Ophthalmologic Anesthesia: Seeing the Forest for the Trees

No abstract available

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Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum: A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network

BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes. METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression. RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P

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In Response

No abstract available

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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Pharmacokinetics of Cefazolin and Vancomycin in Infants Undergoing Open-Heart Surgery With Cardiopulmonary Bypass

BACKGROUND: Gram-positive bacteria account for nearly three-quarters of all surgical site infections. Antibiotic prophylaxis against these bacteria with cephalosporins or, in select circumstances, with vancomycin is considered standard of care for prevention of surgical site infections. There is little evidence to describe the optimal dosing regimen for surgical site infection prophylaxis in infants undergoing cardiac surgery, and a great deal of institutional variability exists in dosing prophylactic antibiotics. We designed this study to describe an optimal dose regimen for cephalosporin and vancomycin based on pharmacokinetic evidence for infant open-heart surgery on cardiopulmonary bypass. METHODS: Two separate cohorts of infants undergoing cardiac surgery with cardiopulmonary bypass were evaluated. Plasma concentrations of vancomycin (cohort 1, N = 10) and cefazolin (cohort 2, N = 10) were measured, and mixed-effects pharmacokinetic models were constructed for each drug. Simulations of various dosing regimens were performed to describe an appropriate dosing regimen necessary to maintain antibiotic concentrations above the susceptibility cutoff for staphylococci. RESULTS: Both cefazolin and vancomycin plasma concentration versus time profiles were characterized by a 2-compartment model. Subject weight was a significant covariate for V1 for vancomycin. Subject age was a significant covariate for V1 for cefazolin. Cardiopulmonary bypass did not influence concentration versus time profiles. Simulations demonstrated that a 1-hour vancomycin infusion (15 mg·kg−1), repeated every 12 hours and a 10-minute infusion of cefazolin (30 mg·kg−1), repeated every 4 hours maintained plasma concentrations above 4 μg·mL−1 and 16 μg·mL−1, for vancomycin and cefazolin, respectively. Both concentrations are above the minimum inhibitory concentration 90 for most susceptible staphylococci. CONCLUSIONS: Prophylactic treatment of vancomycin 15 mg·kg−1 infused >1 hour with 12-hour redosing and cefazolin 30 mg·kg−1 infused >10 minutes with 4-hour redosing will maintain serum levels of each antibiotic above the susceptibility cut-offs for susceptible staphylococci in infants undergoing cardiac surgery. Cefazolin levels may be adequate for some, but not all, Gram-negative bacteria. The effect of cardiopulmonary bypass on pharmacokinetics is negligible. Accepted for publication September 19, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Clinical Trials Registry: NCT01619982. Reprints will not be available from the authors. Address correspondence to Jerry Ingrande, MD, MS, Department of Anesthesiology, University of California, San Diego School of Medicine, 402 Dickinson St, Hillcrest, CA 92103. Address e-mail to jingrande@ucsd.edu. © 2018 International Anesthesia Research Society

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KDF1 is a novel candidate gene of non-syndromic tooth agenesis

Publication date: Available online 23 October 2018

Source: Archives of Oral Biology

Author(s): Binghui Zeng, Hui Lu, Xue Xiao, Xinlin Yu, Sijie Li, Ling Zhu, Dongsheng Yu, Wei Zhao

Abstract

Objective

Tooth agenesis (TA) is featured by congenital loss of teeth, and can be divided into two subtypes, non-syndromic TA (NSTA) and syndromic TA (STA). Although 12 candidate genes of NSTA have been revealed, the genetic basis of NSTA needs to be further studied. We noticed an overlap of candidate genes between NSTA and STA, and hypothesized that some candidate genes of STA may be new candidate genes of NSTA.

Methods

Sanger sequencing, whole exome sequencing, bioinformatics analyses and immunohistochemical staining were performed to reveal the genetic basis of the patients in a family with NSTA.

Results

No pathogenic mutation was found in the 12 candidate genes of NSTA. We screened the variants of 76 STA candidate genes and identified a novel pathogenic mutation c.G908C (p.R303 P) inKeratinocyte Differentiation Factor 1 (KDF1). This mutation was cosegregated with the disease in the family. Bioinformatics analyses predicted the mutation to be pathogenic. Immunohistochemical staining of kdf1 in developing tooth germs indicated that kdf1 expression is important for the development of teeth.

Conclusions

This study identifiedKDF1 as a novel candidate gene for NSTA. STA candidate genes may be a promising source of new NSTA genes.

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Reduced ADAM8 Levels upon Non-surgical Periodontal Therapy in Patients with Chronic Periodontitis

Publication date: Available online 23 October 2018

Source: Archives of Oral Biology

Author(s): Tanawat Nimcharoen, Win Pa Pa Aung, Anupong Makeudom, Thanapat Sastraruji, Sakornrat Khongkhunthian, Benyapha Sirinirund, Suttichai Krisanaprakornkit, Pattanin Montreekachon

Abstract

Objective

To determine effect of non-surgical periodontal treatment on a disintegrin and metalloproteinase 8 (ADAM8) levels in gingival crevicular fluid (GCF) of patients with chronic periodontitis (CP) in comparison with those of patients with gingivitis and to find correlations between ADAM8 levels and clinical parameters.

Design

Twenty-two and eleven patients with CP and gingivitis, respectively, were examined for four clinical parameters, probing depth, clinical attachment level, gingival and plaque indices. GCF from the selected gingivitis or peri

odontitis sites with distinct severities was sampled by Periopaper strips. The non-surgical treatments, including scaling and/or root planing and oral hygiene instruction, were provided for all patients. Clinical measurements and GCF sampling were repeated at three months after the treatments. ADAM8 concentrations were analyzed by ELISA and normalized by GCF volumes or total protein amounts.

Results

All patients exhibited significant improvement of almost every clinical parameter after treatment, whereas the median ADAM8 concentrations were significantly decreased at the moderate and severe periodontitis sites of patients with CP (p < 0.05). Moreover, the significantly positive correlations between ADAM8 concentrations and four clinical parameters were found in both moderate and severe groups (p < 0.05).

Conclusion

ADAM8 concentrations were decreased by non-surgical periodontal therapy in patients with chronic periodontitis at the moderate and severe sites and were correlated with four clinical parameters, implying that GCF ADAM8 levels reflect inflammatory and bone-resorbing activities in the periodontal pocket.

https://ift.tt/2CzJlhA

Effect of non-surgical periodontal therapy on salivary metabolic fingerprint of generalized chronic periodontitis using nuclear magnetic resonance spectroscopy

Publication date: Available online 23 October 2018

Source: Archives of Oral Biology

Author(s): Federica Romano, Gaia Meoni, Valeria Manavella, Giacomo Baima, Giulia Maria Mariani, Stefano Cacciatore, Leonardo Tenori, Mario Aimetti

ABSTRACT

Objective

Metabolomic analysis of saliva proved its accuracy in discriminating patients with generalized chronic periodontitis (GCP) from healthy subjects by identifying specific molecular signatures of the disease. There is lack of investigations concerning the effect of periodontal treatment on individual metabolic fingerprints. Therefore, the aim of this study was to determine whether non-surgical periodontal therapy could change salivary metabolomic profile in GCP to one more similar to periodontal health.

Design

Unstimulated whole saliva of 32 controls and 19 GCP patients were obtained prior to and 3 months after conventional staged non-surgical periodontal therapy. Metabolic profiling was performed using Nuclear Magnetic Resonance (NMR) spectroscopy, followed by univariate and multivariate paired approaches to assess the changes introduced by the therapy.

Results

In GCP group, periodontal treatment led to an improvement in all clinical parameters (p < 0.001). The accuracy of the multivariate model in discriminating the metabolomic profile of each GCP patient at two time points was 92.5%. Despite the almost perfect separation of the spectra in the metabolic space, the univariate analysis failed to identify significant variations in single metabolite content. The post-treatment metabolic profile of GCP patients could not be assimilated to that of healthy controls who exhibited different levels of lactate, pyruvate, valine, proline, tyrosine, and formate.

Conclusions

Based on these data, NMR-spectroscopic analysis revealed that, despite significant changes in the overall metabolomic fingerprint after non-surgical therapy, GCP patients maintained a distinctive metabolic profile compared to healthy individuals.

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Characteristics and Prognosis of Primary Head and Neck Angiosarcomas: A Surveillance, Epidemiology, and End Results Program (SEER) Analysis of 1250 Cases

Abstract

https://ift.tt/2O3HQu7

KDF1 is a novel candidate gene of non-syndromic tooth agenesis

Publication date: Available online 23 October 2018

Source: Archives of Oral Biology

Author(s): Binghui Zeng, Hui Lu, Xue Xiao, Xinlin Yu, Sijie Li, Ling Zhu, Dongsheng Yu, Wei Zhao

Abstract

Objective

Methods

Sanger sequencing, whole exome sequencing, bioinformatics analyses and immunohistochemical staining were performed to reveal the genetic basis of the patients in a family with NSTA.

Results

Conclusions

This study identifiedKDF1 as a novel candidate gene for NSTA. STA candidate genes may be a promising source of new NSTA genes.

https://ift.tt/2ApD1rC

Reduced ADAM8 Levels upon Non-surgical Periodontal Therapy in Patients with Chronic Periodontitis

Publication date: Available online 23 October 2018

Source: Archives of Oral Biology

Author(s): Tanawat Nimcharoen, Win Pa Pa Aung, Anupong Makeudom, Thanapat Sastraruji, Sakornrat Khongkhunthian, Benyapha Sirinirund, Suttichai Krisanaprakornkit, Pattanin Montreekachon

Abstract

Objective

Design

Results

Conclusion

https://ift.tt/2CzJlhA

Effect of non-surgical periodontal therapy on salivary metabolic fingerprint of generalized chronic periodontitis using nuclear magnetic resonance spectroscopy

Publication date: Available online 23 October 2018

Source: Archives of Oral Biology

Author(s): Federica Romano, Gaia Meoni, Valeria Manavella, Giacomo Baima, Giulia Maria Mariani, Stefano Cacciatore, Leonardo Tenori, Mario Aimetti

ABSTRACT

Objective

Design

Results

Conclusions

https://ift.tt/2Apw0al

Cervical Spine Movement in a Cadaveric Model of Severe Spinal Instability: A Study Comparing Tracheal Intubation With 4 Different Laryngoscopes

Background: This study compared the Macintosh blade direct laryngoscope, Glidescope, C-Mac d-Blade, and McGrath MAC X-blade video laryngoscopes in 2 cadaveric models with severe cervical spinal instability. We hypothesized that the Glidescope video laryngoscope would allow for intubation with the least amount of cervical spine movement. Our secondary endpoints were glottic visualization and intubation success. Methods: In total, 2 fresh cadavers underwent maximal surgical destabilization from the craniocervical junction to the cervicothoracic junction by a neurosurgical spine specialist, with subsequent neutral positioning of the heads with surgical head fixation devices. On each cadaver, 8 experienced anesthesiologists performed four intubations with the 4 laryngoscopes in random order. Lateral radiographic measurements determined vertebral displacement during intubation. Results: Cervical spine displacements were not significantly different amongst video laryngoscopes. Cormack-Lehane Grade 1 views were achieved with all attempts with each of the 3 video laryngoscopes; intubation attempts with the Macintosh blade achieved only grade 3 or grade 4 views. Intubation was successful every time with a video laryngoscope but only during 1 of 16 intubation attempts with the Macintosh blade. Conclusions: In a cadaveric model with maximally destabilized cervical spines, cervical spine movement was observed during attempted laryngoscopy using each of 3 video laryngoscopes, although there was no significant difference between the laryngoscopes. Given cervical spine displacement occurred, these video laryngoscopes do not prevent cervical spine motion during laryngoscopy. However, with improved glottic visualization and intubation success, video laryngoscopes are superior to the Macintosh blade in both cervical spine safety and intubation efficacy in the model studied. Supported by Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center. The authors have no conflicts of interest to disclose. Address correspondence to: Jia W. Romito, MD, Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068 (e-mail: Jia.Romito@utsouthwestern.edu). Received March 5, 2018 Accepted September 19, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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