Σάββατο 10 Νοεμβρίου 2018
Practical guide for the management of systemic toxicity caused by local anesthetics
Abstract
Systemic toxicity from local anesthetics can occur in any of the wide range of situations in which these agents are used. This practical guide is created to generate a shared awareness of the prevention, diagnosis, and treatment of local anesthetic systemic toxicity among all medical professionals who perform nerve blocks. Systemic toxicity of local anesthetic is induced by an increase of its protein-unbound plasma concentration. Initial symptoms are characterized by central nervous system signs such as excitation, convulsions, followed by loss of consciousness and respiratory arrest. These symptoms are often accompanied with cardiovascular signs such as hypertension, tachycardia and premature ventricular contractions. Further increase of plasma concentration of local anesthetic induces bradycardia, conduction disturbances, circulatory collapse and asystole. The incidence of local anesthetic systemic toxicity is 1–11 cases per 10,000. Infants, patients with decreased liver function and low cardiac output are vulnerable to systemic toxicity. When performing regional anesthesia, the guideline-directed monitoring, securing a venous line, preparation of medication to treat convulsions and lipid emulsions are required. For prevention of local anesthetic systemic toxicity, small-dose, divided administration, using agents with low toxicity such as ropivacaine and levobupivacaine, performing an aspiration test are recommended. If systemic toxicity is suspected, halt administration of local anesthetic, request assistance, secure venous line, airway, administration of 100% oxygen and if necessary tracheal intubation and artificial respiration should be immediately performed. Benzodiazepines are recommended to treat convulsions. Administration of 20% lipid emulsion according to the protocol is recommended to treat severe hypotension and arrhythmia.
https://ift.tt/2PjDxAB
Recovery Pattern following Bimaxillary Orthognathic Surgery: Differences between Sexes
The investigators hypothesized there would be differences between the sexes in recovery pattern following bimaxillary orthognathic surgery as measured by patient responses at 5 weeks postprocedure. A total of 378 participants underwent bimaxillary orthognathic surgery with or without adjunctive procedures. Participants received questionnaires 5 weeks postsurgery when they visited the outpatient clinic. The questionnaires include variances in surgical factors by sex, and postoperative symptoms which were most difficult to tolerate experiences by sex, respectively.
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Inhibition of dentin matrix‐bound cysteine cathepsins by potassium fluoride
Matrix metalloproteinases (MMPs) and cysteine cathepsins (CCs) can break down unprotected type I collagen fibrils in dentin matrix. This study investigated the use of potassium fluoride (KF) as a potential inhibitor of MMPs and CCs in dentin. Demineralized dentin beams were divided into groups (n = 10 in each group) and incubated in artificial saliva (AS, control), either alone or with one of seven concentrations of KF (6–238 mM fluoride) for 1, 7, and 21 d. After 21 d, all groups were further aged in AS for 6 months. Total MMP activity was screened using the colorimetric MMP assay. The activities of MMP‐2 and MMP‐9 were investigated using gelatin zymography. At the end of each incubation, changes in loss of dry mass and CC‐mediated or total dissolution of collagen peptides were measured via precision weighing, C‐terminal crosslinked telopeptide of type I collagen (CTX), and hydroxyproline (HYP) assays. The beams were examined using scanning electron microscopy. After 21 d, total MMP activities, dry mass loss, and CTX release for the groups exposed to 179 and 238 mM fluoride were significantly lower compared with the control group. After 6 months, all groups showed similar total MMP activity, dry mass loss, and HYP release, and CTX levels were significantly lower when the fluoride concentration was ≥24 mM. Calcium fluoride (CaF2)‐like precipitates were observed over the beams. In summary, KF significantly inhibited the catalytic activity of dentin matrix‐bound CCs but did not seem to be effective for MMP‐mediated activity.
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High‐risk symptoms do not predict gastric cancer precursors
Abstract
Background & Study Aims
Gastric intestinal metaplasia (GIM) is the most common precursor of gastric cancer. Our aim is to determine if presenting symptoms predict gastric cancer precursor lesions in a high‐risk population.
Patient and Methods
Consecutive unique patients evaluated by endoscopy for upper gastrointestinal symptoms at the Los Angeles County Hospital between 2010 and 2014 were evaluated. Presenting symptoms were classified as low‐ or high‐risk depending on the procedure indication as coded using the Clinical Outcomes Research Initiative (CORI) system. Endoscopy and histology results were used to classify findings as benign, GIM, high‐risk GIM, or malignant. The primary outcome was the proportion of patients with premalignant or malignant gastric findings who had high‐risk clinical indications for endoscopy relative to those with benign results.
Results
A total of 3699 patients underwent endoscopy to evaluate upper gastrointestinal symptoms. There were 373 (10.1%) patients with GIM of which 278 had high‐risk GIM. One hundred and sixty (4.3%) patients were diagnosed with gastric cancer. High‐risk indications for upper endoscopy predicted gastric cancer (OR 1.8 [95% CI 1.3‐2.6]) but not GIM (OR 1.0 [0.8‐1.3]) or high‐risk GIM (OR 0.9 [0.7‐1.2]). Hispanic or Asian patients and patients >50 years old were more likely to have GIM, high‐risk GIM, and cancer.
Conclusions
Performance of upper endoscopy for high‐risk indications is inadequate to detect GIM and marginal for malignancy. At risk patients should undergo upper endoscopy for both low‐ and high‐risk symptoms. Screening certain populations deserve additional study and may, in fact, be cost‐effective.
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Is injury to the inferior alveolar nerve still common during orthognathic surgery? Manual twist technique for sagittal split ramus osteotomy
The osteotomy in a bilateral sagittal split ramus osteotomy (BSSRO) is made in close proximity to the inferior alveolar nerve (IAN), so direct damage to the nerve and irreversible neurosensory deficit may result. The aim of this study was to compare the incidence of injury to the nerve when a conventional osteotomy using an osteotome was made, with that after manual twist splitting. We retrospectively reviewed the casenotes of 769 consecutive patients who had bilateral SSRO either alone or with a simultaneous maxillary procedure by a single surgeon from May 2009 − October 2016.
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Interventions for infantile haemangiomas of the skin: abridged Cochrane systematic review including GRADE assessments
Summary
Infantile haemangiomas (IH) are soft swellings of the skin that occur in 3‐10% of infants. When haemangiomas occur in high‐risk areas or when complications develop, active intervention is necessary. This is an update of a Cochrane Review assessing the interventions for the management of IH in children. We searched for randomized controlled trials in CENTRAL, MEDLINE, Embase, LILACS, AMED, PsycINFO, CINAHL and six trials registers to February 2017. We included 28 trials (1728 participants) assessing 12 interventions. We downgraded evidence from high to moderate/low for issues related to risk of bias and imprecision. Oral propranolol (3 mg/kg/day) probably improves clinician‐assessed clearance compared to placebo (risk ratio (RR) 16·61, 95% confidence interval (CI) 4·22 to 65·34; moderate quality of evidence (QoE)); we found no evidence of a difference in terms of serious adverse events (RR 1·05, 95% CI 0·33 to 3·39; low QoE). We found the chance of reduction of redness may be improved with topical timolol maleate (0·5% gel applied twice daily) when compared to placebo (RR 8·11, 95% CI 1·09 to 60·09; low QoE). We found no instances of bradycardia or hypotension for this comparison. Our key results indicate that oral propranolol and topical timolol maleate are more beneficial than placebo in terms of clearance or other measures of resolution, or both, without an increase in harms.
This article is protected by copyright. All rights reserved.
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Psoriasis in a cohort of patients with common variable immunodeficiency
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults. CVID is characterized by reduced serum levels of IgG, IgA, and/or IgM, recurrent bacterial infections, autoimmune and inflammatory diseases and malignancies. According to literature, autoimmune diseases occur in 20–30% of CVID patients. Dermatological involvement has occasionally been reported in CVID and includes alopecia totalis, lichen planus, and vitiligo. Data regarding the frequency and features of psoriasis in CVID are scant.
This article is protected by copyright. All rights reserved.
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A Case of Acute Pemphigus Vulgaris Relapses Associated with Cocaine Use and Review of the Literature
Abstract
Pemphigus is a bullous autoimmune disease that affects the skin and mucous membranes. It is very difficult to establish the etiology and the triggering factors that influence reactivations in pemphigus vulgaris (PV). The case of a 33-year-old male with chronic history of intranasal cocaine consumption is presented in this report. We present the clinical case of the patient, followed for a total of 86 weeks, with ten relapses secondary to probable cocaine use. The patient was admitted to the emergency department after presenting polymorphic dermatosis characterized by blisters, vesicles, and excoriations extending from the oral cavity to the thorax, and to the inguinal and genital regions, affecting approximately 35 % of the body surface area with a score of 56 on the Pemphigus Skin Disorder Index. Skin biopsies were compatible with PV diagnosis. The patient had clinical improvement with a combination of methylprednisolone 500 mg intravenously (IV) and cyclophosphamide 500 mg IV every 15 days, along with prednisone 50 mg orally (PO) q24 h and mycophenolic acid 500 mg PO q6 h. Persistent cocaine use is highly likely to be the factor triggering lesion reactivation and responsible for the torpid evolution. We cannot definitively conclude whether the change from azathioprine to mycophenolic acid after the tenth relapse was the adjuvant medication responsible for the end of the consolidation phase and complete remission on therapy. This case study could potentially serve as a guide for management of patients who continuously persist with cocaine use, leading to a clinical picture refractory to multiple therapeutic schemes.
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Periostin deletion suppresses late-phase response in mouse experimental allergic conjunctivitis
Publication date: Available online 9 November 2018
Source: Allergology International
Author(s): Yosuke Asada, Mikiko Okano, Waka Ishida, Satoshi Iwamoto, Ken Fukuda, Toshiaki Hirakata, Norihiro Tada, Atsuki Fukushima, Nobuyuki Ebihara, Akira Kudo, Akira Matsuda
Abstract
Background
To investigate the potential roles of periostin (POSTN), an extracellular matrix preferentially expressed in Th2-skewed conditions in the pathophysiology of allergic conjunctivitis.
Methods
The roles of POSTN in ragweed-induced experimental allergic conjunctivitis (RW-EAC) were evaluated using both POSTN-knockout (KO) and congenic BALB/c wild-type mice. Histological analysis was carried out to enumerate eosinophils/basophils in the conjunctival tissue. Th2 cytokine expression was evaluated by quantitative polymerase chain reaction (Q-PCR), and microarray analysis was performed to elucidate genes differentially expressed in POSTN-KO and wild-type mice in the RW-EAC model.
Results
Upregulation of POSTN expression and eosinophil infiltration was observed in subconjunctival tissue of RW-EAC in the wild-type mice. The number of infiltrating eosinophils in the conjunctivae of RW-EAC was diminished in POSTN-KO mice compared to wild-type mice. Q-PCR analysis of conjunctival tissue showed induction of Th2 cytokine (Ccl5, Il4, Il5, Il13) expression in the RW-EAC and attenuated Ccl5, Il4, Il13 mRNA expression in the conjunctivae of the RW-EAC using POSTN-KO mice. Microarray analysis and immunohistochemical analysis showed diminished basophil marker (Mcpt8) expression and reduced numbers of infiltrating basophils in the conjunctivae of RW-EAC in POSTN-KO mice.
Conclusions
POSTN expression in conjunctival tissue plays an indispensable role in the late-phase reaction of the RW-EAC model by facilitating eosinophil/basophil infiltration and augmenting Th2 cytokine expression.
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Contents
Publication date: December 2018
Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 135, Issue 6
Author(s):
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Editorial Board
Publication date: December 2018
Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 135, Issue 6
Author(s):
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Endoscopic lateralization of the vocal fold
Publication date: Available online 9 November 2018
Source: European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): C. Fabre, C.A. Righini, P.F. Castellanos, I. Atallah
Abstract
Vocal fold paralysis in adduction can result in significant breathing difficulties. Techniques such as vocal fold lateralization and/or arytenoidopexy help to improve respiratory function in this setting. These techniques require open approach or specific instruments. The authors describe an original vocal fold lateralization technique performed exclusively via an endoscopic approach. This technique helps to enlarge the glottic aperture, while preserving laryngeal architecture, and permanently improves respiratory function in patients with vocal fold paralysis in adduction.
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Clinicopathological analysis of oral diffuse large B‐cell lymphoma, NOS: a systematic review
Abstract
Background
Diffuse large B‐cell lymphoma, NOS (DLBCL NOS) is the commonest extranodal non‐Hodgkin lymphoma diagnosed in the oral and maxillofacial region. However, few studies are currently available and its prognostic determinants still remain undefined.
Purpose
To analyse the available data on oral DLBCL NOS and to describe its clinicopathological features, identifying potential prognostic factors.
Methods
An electronic systematic search was performed using multiple databases with a specific search strategy in April 2018. All reports describing DLBCL NOS involving the oral cavity and jaw bones with sufficient clinicopathological information were assessed.
Results
Sixty‐three publications were included in the study, comprising 122 cases. Oral DLBCL NOS was found predominantly in elderly males (61.5%), and most often presented as an asymptomatic swelling of the gingiva. Patients commonly were HIV‐negative (36.1%), with few reports describing EBV‐positive cases (4 cases/3.3%). Only 8 cases presented B‐symptoms and most cases were classified as stage I or II (48.4%). CHOP therapy was the main treatment option (24.5%) and the overall 5‐year survival rate achieved 83%. Males and advanced Ann‐Arbor stage patients presented significantly lower survival rates in the univariate analysis, but no significance was found in the multivariate model.
Conclusion
Oral DLBCL NOS is an aggressive malignancy, but with a high survival rate.
This article is protected by copyright. All rights reserved.
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Programme des cas cliniques de l’ADF
Publication date: Available online 10 November 2018
Source: Annales de Dermatologie et de Vénéréologie
Author(s):
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Place des laboratoires de génétique, d’anatomie pathologique et d’immunologie dans la prise en charge des maladies rares dermatologiques
Publication date: Available online 9 November 2018
Source: Annales de Dermatologie et de Vénéréologie
Author(s): D. Vidaud, C. Silve, S. Leclerc-Mercier, S. Hüe, S. Ingen-Housz-Oro, C. Bodemer
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Giant nonfunctioning adrenal tumors: two case reports and review of the literature
There are an estimated 1–2 cases per million per year of adrenocortical carcinoma in the USA. It represents a rare and aggressive malignancy; it is the second most aggressive endocrine malignant disease after ...
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Evaluation of a clinical preventive treatment using Er,Cr:YSGG (2780 nm) laser on the susceptibility of enamel to erosive challenge
Abstract
The purpose of this in vitro study was to evaluate the effect of a clinical preventive treatment using Er,Cr:YSGG laser irradiation on bovine enamel susceptibility after erosive challenge. Twelve sound bovine incisors were used and twenty-four enamel specimens were prepared in total. Two experimental groups (n = 12) were assigned as follows: Group 1 was the control group and in Group 2, the enamel specimens were irradiated with an Er,Cr:YSGG (2780 nm) laser system for 20 s, with average output power of 0.25 W, pulse repetition rate at 20 Hz without water or air flow and the pulse duration was fixed at 140 μsec. The tip diameter was 600 μm, the tip to tissue distance was 1 mm, the speed of handpiece movement was 2 mm/s, the power density was 88.34 W/cm2, and the fluence was 31.25 J/cm2. The specimens were submitted to erosive challenge using a common soft drink. Surface microhardness changes, surface roughness changes, and surface loss were evaluated after erosive challenge. The data were statistically analyzed using one-way ANOVA and Tukey's post-hoc test at a level of significance a = 0.05. Er,Cr:YSGG laser-treated enamel exhibited significantly less decrease in surface microhardness and significant less surface loss compared to control enamel after the erosive challenge (p < 0.05). The experimental groups did not show significant differences in surface roughness increase after the erosive challenge (p > 0.05). Er,Cr:YSGG laser treatment may be promising for the limitation of enamel erosive tooth wear induced by excessive consumption of soft drinks. Clinical studies are needed to clarify whether this protective effect is clinically significant.
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Ethnic and Age Disparities in Outcomes among Liver Transplant Waitlist Candidates
Background Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population. Methods All adult, liver-only white and AA LT waitlist candidates (1/1/2003-10/1/2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger (age
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Pretransplant cancer in kidney recipients in relation to recurrent and de novo cancer incidence posttransplantation and implications for graft and patient survival
Background Whether kidney transplant recipients who were treated for a malignant tumor prior to transplantation are at an increased risk of developing a tumor post transplantation has not been adequately quantified and characterized. Methods We studied more than 270 000 patients on whom pre and posttransplant malignancy data were reported to the Collaborative Transplant Study. More than 4000 of these patients were treated for pretransplant malignancy. The posttransplant tumor incidence in these patients was compared to that in recipients without a pretransplant tumor. Cox regression considering multiple confounders was applied. Results Significant increases in posttransplant tumor incidence with HR ranging from 2.10 to 5.47 (all P
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Steatosis in Liver Transplantation: Current Limitations and Future Strategies
In parallel with the pandemic of obesity and diabetes, the prevalence of nonalcoholic fatty liver disease (NAFLD) has progressively increased. Non-alcoholic steatohepatitis (NASH), a subtype of NAFLD has also augmented considerably being currently cirrhosis due to NASH the second indication for liver transplantation in USA. Innovative treatments for NASH have shown promising results in phase-2 studies and are being presently evaluated in phase-3 trials. On the other hand, the high mortality on the liver transplant wait list and the organ shortage has obligated the transplant centres to consider suboptimal grafts, such as steatotic livers for transplantation. Fatty livers are vulnerable to preservation injury resulting in a higher rate of primary non-function, early allograft dysfunction and post-transplant vascular and biliary complications. Macrosteatosis of more than 30% in fact is an independent risk factor for graft loss. Therefore, it needs to be considered into the risk assessment scores. Growing evidence supports that moderate and severe macrosteatotic grafts can be successfully used for liver transplantation with careful recipient selection. Protective strategies, such as machine-based perfusion have been developed in experimental setting to minimize preservation related injury and are now on the verge to move into the clinical implementation. This review focuses on the current and potential future treatment of NASH and the clinical practice in fatty liver transplantation, highlights its limitations and optimal allocation, and summarizes the advances of experimental protective strategies, and their potential for clinical application to increase the acceptance and improve the outcomes after liver transplantation with high-grade steatotic livers. Authors contributed equally to this paper, Ivan Linares MD, Matyas Hamar MD. Correspondence author: Markus Selzner, MD, Associate Professor of Surgery, University of Toronto, General Surgery & Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB 178, Toronto, ON M5G 2N2, Phone: 416-340-4800 ext. 5884 Fax: 416-340-5321, e-mail: markus.selzner@uhn.ca Authorship: -Ivan Linares participated in performance of research, research design and writing the paper (lin85ij@outlook.com) -Matyas Hamar participated in performance of research, research design and writing the paper (mahamar@gmail.com) -Nazia Selzner participated in research design and writing the paper (Nazia.Selzner@uhn.ca) -Markus Selzner participated in research design and writing the paper (Markus.Selzner@uhn.ca) Disclosure: The authors of this manuscript have no conflicts of interest to disclose as described by the Transplantation Journal. Funding: None Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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Impact of Donor Hepatectomy Time during Organ Procurement in Donation after Circulatory Death Liver Transplantation: The United Kingdom Experience
Background No data exists to evaluate how hepatectomy time (HT), in the context of donation after cardiac death (DCD) procurement, impacts on short and long-term outcomes following liver transplantation (LT). In this study we analyse the impact of the time from aortic perfusion to end of hepatectomy on outcomes following DCD LT in the UK. Methods An analysis of 1112 DCD donor LT across all UK transplant centres between 2001 and 2015 was performed, using data from the UK Transplant Registry. Donors were all Maastricht Category III. Graft survival after transplantation was estimated using Kaplan-Meier method and logistic regression to identify risk factors for PNF and short and long-term graft survival after LT. Results Incidence of PNF was 4% (40) and in multivariate analysis only CIT >8 hrs. (HR 2.186 (1.113-4.294, p=0.023) and HT > 60 mins (HR 3.669 (1.363-9.873, p=0.01) were correlated with PNF. Overall 90-day, 1 year, 3 year and 5 year graft survival in DCD LT was 91.2%, 86.5%, 80.9% and 77.7% (compared to a DBD cohort in the same period (n=7221) 94%, 91%, 86.6%, and 82.6% respectively (p 60mins, donor age >45 yrs., CIT> 8 hours and recipient previous abdominal surgery. Conclusions There is a negative impact of prolonged HT on outcomes on DCD LT and although HT > 60 mins is not a contraindication for utilisation it should be part of a multifactorial assessment with established prognostic donor factors such as age (>45yrs) and CIT (>8hrs) for an appropriately selected recipient. No conflicts of interest Correspondence: Mr. Shahid Farid, Consultant Transplant Surgeon, Department of Transplantation, St James University Hospital, Beckett Street, Leeds, United Kingdom, LS9 7TF. s.farid@nhs.net Authorship Page: SG Farid: Participated in research design, performance of the research, statistical analysis, writing and final review of the paper. MS Attia: Participated in research design and final review of the paper. D Vijayanand: Participated in research design, writing and final review of the paper. V Upasani: Participated in research design, performance of the research, statistical analysis, writing and final review of the paper. S Willis: Participated in research design, performance of the research, statistical analysis, writing and final review of the paper. A Barlow: Participated in the writing and final review of the paper. E Hidalgo: Participated in research design, performance of the research, writing and final review of the paper. N Ahmad: Participated in research design, performance of the research, statistical analysis, writing and final review of the paper. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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