Τρίτη 15 Ιανουαρίου 2019
The dilemma of the “ischemic-looking” electrocardiogram: Pulmonary embolism or acute coronary syndrome?
Annals of Cardiac Anaesthesia 2019 22(1):89-91
Pulmonary embolism (PE) may be potentially fatal if not diagnosed and treated in time. Although specific electrocardiogram (ECG) findings often suggest the diagnosis of PE, occasionally, the ECG may mimic that of an acute coronary syndrome (ACS). We report an interesting case of a 45-year-old female presenting with sudden onset chest pain and shortness of breath with widespread ST depression in anterior precordial leads. Although initially treated and referred as a case of ACS, careful analysis of the ECG and subsequent echocardiography and computed tomography imaging confirmed the diagnosis of PE. Intensivists and cardiologists need to be aware that diagnostic dilemma between PE and ACS is not uncommon due to such "ischemic-looking" ECG as well as elevated troponin levels in both conditions. The use of multimodality imaging techniques is helpful in arriving at the correct diagnosis.
http://bit.ly/2QRXgDd
Cardiac output monitoring: Technology and choice
Annals of Cardiac Anaesthesia 2019 22(1):6-17
The accurate quantification of cardiac output (CO) is given vital importance in modern medical practice, especially in high-risk surgical and critically ill patients. CO monitoring together with perioperative protocols to guide intravenous fluid therapy and inotropic support with the aim of improving CO and oxygen delivery has shown to improve perioperative outcomes in high-risk surgical patients. Understanding of the underlying principles of CO measuring devices helps in knowing the limitations of their use and allows more effective and safer utilization. At present, no single CO monitoring device can meet all the clinical requirements considering the limitations of diverse CO monitoring techniques. The evidence for the minimally invasive CO monitoring is conflicting; however, different CO monitoring devices may be used during the clinical course of patients as an integrated approach based on their invasiveness and the need for additional hemodynamic data. These devices add numerical trend information for anesthesiologists and intensivists to use in determining the most appropriate management of their patients and at present, do not completely prohibit but do increasingly limit the use of the pulmonary artery catheter.
http://bit.ly/2VYfQ0b
Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management
Annals of Cardiac Anaesthesia 2019 22(1):1-5
The presence of dynamic left ventricular outflow tract obstruction (LVOTO) can complicate the postoperative course of patients undergoing surgical aortic valve replacement (AVR). The phenomenon of LVOTO is a consequence of an interplay of various pathoanatomic mechanisms. The prevailing cardiovascular milieu dictates the hemodynamic significance of the resultant LVOTO in addition to the anatomical risk factors. A thorough understanding of the predisposing factors, mechanism, and hemodynamic sequel of the obstruction is pivotal in managing these cases. A comprehensive echocardiographic examination aids in risk prediction, diagnosis, severity characterization, and follow-up of management efficacy in the setting of postoperative LVOTO. The armamentarium of management modalities includes conservative (medical) and surgical options. A stepwise approach should be formulated based on the physiological and anatomical substrates predisposing to LVOTO. The index phenomenon occurs more frequently than appreciated and should be considered when the post-AVR patients exhibit hemodynamic instability unresponsive to conventional supportive measures. The present article provides an overview of various peculiarities of this under-recognized phenomenon in the context of the perioperative management of patients undergoing AVR.
http://bit.ly/2QO9JI5
Conversion during off-pump coronary artery bypass graft surgery: A case–control study
Annals of Cardiac Anaesthesia 2019 22(1):18-23
Objectives: Off pump coronary artery bypass (OPCAB) surgery is carried out as an alternative to conventional coronary artery bypass grafting using cardiopulmonary bypass (CPB). At times 'conversion' to CPB may be required to bail out a situation resulting from acute decompensation of the heart. It is reported that such conversion carries significant mortality risk. Since we conduct coronary revascularization by OPCAB technique as the preferred technique, we conducted this study with an aim to identify the markers of adverse outcome during conversion in Indian patients. Design: Case control retrospective study. Setting: Tertiary referral center. Participants: We conducted three thousand two hundred OPAB surgeries in the period between 2013 to16. Ninety patients (3.1%) required conversion to complete the revascularization (Con version group). Twice the number of patients who underwent OPCAB surgery without conver sion were chosen as controls (Control group). Intervention: OPCAB surgery Results: Mortality in the conversion group was 5.56% in contrast to 0.06% in the controls (P = 0.01). The conversion group had higher left ventricular end diastolic pressure, incidence of endarterectomy, and intra-aortic balloon counter pulsation requirement. Female gender was also predictive of conversion. The total chest drain, duration of ventilation, ICU stay and hospital stay were also higher in the conversion group. Conversion was associated with 9.47 times the odds for mortality. Conclusion: Conversion during OPCAB is associated with significantly increased mortality. Female gender, increased left ventricular end diastolic pressure and preoperative requirement of Intra-aortic balloon are markers of increased risk of mortality when converted.
http://bit.ly/2VVkITZ
Quadricuspid aortic valve associated with aortic insufficiency contributors
Annals of Cardiac Anaesthesia 2019 22(1):99-100
A 51-year-old male presented with a wound in his right hand that was suspicious for possible septic emboli of cardiac origin. With transesophageal echocardiography, the patient was found to have a rare quadricuspid aortic valve. This quadricuspid valve can present with variable symptoms and physical exam findings. Due to embryological defects, this pathology is associated with several other anatomical defects that are important to recognize prior to surgical intervention. Transesophaegeal echocardiography remains the gold standard in detection of quadricuspid aortic valve and identification of other possible cardiac lesions.
http://bit.ly/2QPzHes
Rupture of sinus of valsalva – A 15 years single institutional retrospective review: Preoperative heart failure has an impact on post operative outcome?
Annals of Cardiac Anaesthesia 2019 22(1):24-29
Background: We reviewed our experience with ruptured sinus of Valsalva aneurysms (RSOV) to determine a correlation with preexisting heart failure (HF) and coexisting cardiac lesions (aortic regurgitation [AR] and ventricular septal defect [VSD]) to postoperative left ventricular (LV) dysfunction and postoperative outcomes. Materials and Methods: Retrospective review of RSOV cases over 15 years showed that RSOV repair was done in 87 patients. We looked for patients who presented with HF and patients having AR and/or VSDs. Statistical analysis was done to see if the coexisting lesions and preoperative HF were associated with postoperative LV dysfunction. Chi-square test was used on contingency table for statistical analysis. Complications in the postoperative period and prolonged Intensive Care Unit stay were noted. Results: 17% (15/87) presented with HF. Fifty-two patients had moderate to severe AR and 50 patients had VSD. Seventeen patients had postoperative LV dysfunction. The correlation of preoperative HF and coexisting lesions with postoperative LV dysfunction was not statistically significant. Two patients underwent redo surgery for residual RSOV and AR. Two patients had arrhythmias. One patient had cerebrovascular accident. No mortality was seen in the study. Conclusion: Preoperative HF and the presence of VSD and/or AR have no statistical significant correlation with postoperative LV dysfunction. As the outcome of RSOV repair is good, all patients need to undergo early repair to avoid complications.
http://bit.ly/2VVkFrh
Unrecognized double aortic arch in a preterm infant: Diagnostic challenges and perioperative management
Annals of Cardiac Anaesthesia 2019 22(1):83-85
Vascular rings are relatively rare, and are frequently overlooked as a potential cause of neonatal respiratory distress in non specialized centres. This might lead to delay in diagnosis during which the child is subjected to repeated respiratory insults. Procrastination in prompt diagnosis and management can lead to significant comorbidities or even death. We highlight the case report of a preterm infant with an unrecognized double aortic arch who presented with severe respiratory morbidity and the subsequent management.
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Management issues during postinfarction ventricular septal defect and role of perioperative optimization: A case series
Annals of Cardiac Anaesthesia 2019 22(1):30-34
The development of a myocardial infarction ventricular septal rupture is a rare fatal complication, and the surgical repair is the treatment of choice. In most of the scenarios, the operation will be done as an emergency procedure that carries high mortality. Prognosis of these patients depends on prompt echocardiographic diagnosis and the proactive medical and surgical therapy. More recently, various options have been put forward including the timing for surgery, percutaneous closure devices, and the improved outcome with initial stabilization with medical treatment including mechanical support. In this retrospective case series, we are presenting the management of these patients who presented us in different clinical scenarios and trying to identify the risks for the poor outcome and to formulate a strategy to improve the outcome.
http://bit.ly/2VVkDQb
Endovascular approach in chronic aortoiliac disease in patient undergoing coronary artery bypass surgery
Annals of Cardiac Anaesthesia 2019 22(1):96-97
Internal thoracic artery (ITA) is an excellent conduit for coronary artery bypass surgery (CABG). We present a patient with known preoperative aortoiliac disease with anterior collateral pathway who had an indication for elective coronary bypass. The use of ITA in these patients may cause lower limb ischemia. Detecting Winslow's anastomotic pathway before CABG is of utmost importance.
http://bit.ly/2QVfVOM
Comparison of hemodynamic response and postoperative pain score between general anaesthesia with intravenous analgesia versus general anesthesia with caudal analgesia in pediatric patients undergoing open-heart surgery
Annals of Cardiac Anaesthesia 2019 22(1):35-40
Context: Regional anesthesia may attenuate adverse physiological stress responses associated with cardiothoracic surgery. In this study, hemodynamic stress response at the different time of surgical stimuli was compared between patients receiving general anesthesia (GA) along with caudal epidural analgesia with GA with intravenous analgesia in pediatric population undergoing open-heart surgery. Aims: This study aims to compare the hemodynamic response at the different time of surgical stimuli and postoperative pain score, in pediatric patients undergoing open-heart procedures. Settings and Design: We designed a prospective randomized controlled trial to study hemodynamic effects between Group I and Group II. Fifty patients were randomly allocated equally into Group I (GA + caudal epidural) and Group II (GA + intravenous analgesia) by sealed envelope technique. Subjects and Methods: After obtaining approval from Institutional Ethical Committee, this prospective study was conducted in 50 American Society of Anesthesiologist Classes II and III pediatric patients aged between 1 and 12 years posted for cardiac surgery in our institution. Statistical Analysis: ANOVA, two-way ANOVA, and Student's test. Results: The heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure variations were compared between Groups I and II at different time intervals. The variations were found to be significantly higher at the time of skin incision and 2 min after skin incision in Group II as compared to Group I. Pain score was compared between the groups and was found to be significantly lower with Group I (2.5 ± 1.2) as compared to Group II (4.6 ± 1.7), P = (0.004). Conclusions: Caudal analgesia with GA (Group I) was found to have better hemodynamic control and significantly better postoperative pain relief in the first 24 h after awakening.
http://bit.ly/2VS978h
Clinical usage of high-flow oxygenation in postcardiac surgery patients
Annals of Cardiac Anaesthesia 2019 22(1):107-108
http://bit.ly/2QOJnWs
Assessment of ventricular function in patients of atrial septal defect by strain imaging before and after correction
Annals of Cardiac Anaesthesia 2019 22(1):41-46
Background: Atrial septal defect (ASD) is a common congenital heart disease associated with volume overload of Right ventricle (RV) with variable effect on Left ventricle (LV). Two-dimensional (2D) Strain analysis is a new tool for objective analysis of myocardial function. This prospective study evaluated the systolic function of right and left ventricle by conventional 2D echo and strain echo and measured changes in cardiac hemodynamics that occurred in patients of ASD before and after correction. Patients and Methods: 2D echo and strain analysis of each patient before and at 48 hrs, 3 months and 6 months after correction was performed. Routine 2D echo parameters and global longitudinal strain of both ventricles were measured. Result: Improvement in LV ejection fraction (P = 0.0001) and myocardial performance index (MPI) (P < 0.0001) occurred at the end of 6 months, whereas decrease in RV MPI (P < 0.0001) and tricuspid annular plane systolic excursion (P < 0.0001) became statistically significant after 3 months of ASD correction. In comparison to conventional 2D echo, global longitudinal strain of RV decreased significantly only after 48 hours of ASD correction while there was no improvement in left ventricular global longitudinal strain after 6 month of correction. Conclusion: There was improvement in RV function with subtle change in LV function by strain imaging and most of these changes were completed within 6 months of ASD correction and nearly correlated with conventional 2DEchocardiography.
http://bit.ly/2VYfNl1
Bioprosthetic valve thrombosis in carcinoid heart disease
Annals of Cardiac Anaesthesia 2019 22(1):79-82
Tricuspid regurgitation in carcinoid syndrome leads to significant morbidity and mortality that may warrant a tricuspid valve replacement. However, for patients with high serotonin levels and known hypercoagulable risks, the optimum timing for surgery and postoperative anticoagulation approaches remain unclear. High serotonin-triggered hypercoagulability makes prosthetic valves susceptible to thrombosis. Despite appropriate management with a somatostatin analog, some patients continue to have high markers of serotonin that causes platelet aggregation and rapid clot formation. In severely symptomatic patients who require valve surgery, it may not be feasible to postpone surgery until these metabolites are normalized, which may add a substantial risk for postoperative valve thrombosis to an otherwise uneventful procedure. In some, there is a significant need to predict and prevent bioprosthetic valve thrombosis in carcinoid heart disease and to identify best anticoagulation practices across a spectrum of its complex coagulation dynamics and clinical presentation.
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“Vitamin D” as a profile marker for cardiovascular diseases
Annals of Cardiac Anaesthesia 2019 22(1):47-50
Objective: A growing body of research indicates that there exists a correlation between Vit D deficiency and cardiovascular diseases (CVD). In addition to being genetically determined, it is strongly influenced by lifestyle factors. In this study, Vit D and its interrelated factors have been studied as profile marker for identifying the risk of CVD in patients. Methods: The present study includes comparison of a total 200 adults CVD patients with the healthy patients as control, by measuring their serum lipid levels and Vit D concentrations with other CVD risk factors. Results: The average serum Vit D in CVD patients and controls are found to be 22.55±6.2 ng/ml and 37.62±3.2 ng/ml respectively, showing that 63% of CVD patients and 35% of controls are Vit D deficient. Serum lipids levels were considered as marker for patients having CVD which include high levels of total cholesterol, triglycerides, and low-density lipoprotein-cholesterol while low levels of high-density lipoproteins-cholesterol levels. Other risk factors like hypertension, lifestyle, smoking, dietary factors and nutritional status shows significantly correlation for CVD patients compared to controls. Conclusion: Literature supports the relationship between lipid profile and Vit D level by using this as a profile marker for CVD patients. Our study also suggests the same that vitamin D can be used as profile marker for cardiovascular diseases.
http://bit.ly/2VVQpwv
Off-pump coronary bypass grafting in a post-pneumonectomy patient: Challenges and management
Annals of Cardiac Anaesthesia 2019 22(1):86-88
Pulmonary complications are common in cardiac surgical patients. Limited respiratory reserves along with the pain associated with sternotomy add to the morbidity. Patients undergoing cardiac surgery who have had a pneumonectomy done before can be even more challenging to manage perioperatively due to a single-functioning lung. We present a case of a postpneumonectomy patient who underwent off-pump coronary artery bypass grafting. Perioperative optimization of lung function tests was stressed upon including the chest physiotherapy and early mobilization. Preoperative thoracic epidural catheter was inserted for postoperative pain and other proven benefits of thoracic epidural in coronary artery disease patients. We could conclude from our experience that proper optimization of lung function tests and meticulous pain management along with fast-tracking are keys to the management of such patients.
http://bit.ly/2QRQc9U
Practice patterns of left-sided double-lumen tube: Does it match recommendation from literature – A single-centre observational pilot study
Annals of Cardiac Anaesthesia 2019 22(1):51-55
Context: Choosing appropriate-size double-lumen tube (DLT) has always been a challenge as it depends on existing guidelines based on gender, height, tracheal diameter (TD), or personal experience. However, there are no Indian data to match these recommendations. Aim: To find out whether the size of DLT used correlates with height, weight, TD, or left main stem bronchus diameter (LMBD). We also documented clinical consequences of any of our current practice. Setting and Design: Single-center observational pilot study. Subjects and Methods: Prospective, observational study of 41 patients requiring one-lung ventilation with left-side DLT. The choice of DLT was entirely on the discretion of anesthesiologist in charge of the case. Data were collected for TD, LMBD, height, weight, age, sex, and amount of air used in the tracheal and bronchial cuff. Any intraoperative complications and difficulty in isolation were also noted. Statistical Analysis: The statistical analysis was done with the National Council of Statistical Software version 11. Results: Average TD and LMBD were 16.5 ± 0.9 and 10.7 ± 0.8 mm for males and 14.2 ± 1.1 and 9.4 ± 1.1 mm for females, respectively. There was a weak correlation between DLT size and height (R2 = 0.0694), TD (R2 = 0.3396), and LMBD (R2 = 0.2382) in the case of males. For females, the correlation between DLT size and height (R2 = 0.2656), TD (R2 = 0.5302), and LMBD (R2 = 0.5003) was slightly better. Conclusion: Although there was a weak correlation between DLT size and height, TD, and LMBD, the overall intraoperative outcome and lung isolation were good.
http://bit.ly/2VYKfLM
Perioperative management of intramyocardial hydatid cyst with off-pump technique
Annals of Cardiac Anaesthesia 2019 22(1):92-95
Cardiac echinococcosis is a rare disease. Depending on the location of hydatid cyst in the heart, clinical presentation can be an asymptomatic case or lethal stroke, arrhythmias, valvular dysfunction, cardiac tamponade, cardiac failure, shock, and even death. Treatment of choice for cardiac hydatid cysts is surgical excision, even in an asymptomatic patient. We present a case report of an asymptomatic case of off-pump removal of intramyocardial hydatid cyst. A 21-year-old male presented asymptomatically and was diagnosed with a hydatid cyst incidentally during a regular checkup. Echocardiography and cardiac computed tomography angiography images demonstrated an intramyocardial hydatid cyst on the lateral aspect of the left ventricle with slight extension over the anterior and posterior regions. Important aspects of diagnosis and management specific to cardiac hydatid cyst along with the review of literature have been discussed.
http://bit.ly/2QR4OpT
A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor
Annals of Cardiac Anaesthesia 2019 22(1):56-66
Context: Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India. Aims: The aim of this survey is to gather information on variations during the conduct of CPB in India. Settings and Design: This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists. Subjects and Methods: Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices. Results: The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes. Conclusions: There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.
http://bit.ly/2VVQ8cX
Massive subcutaneous emphysema after off-pump coronary bypass surgery
Annals of Cardiac Anaesthesia 2019 22(1):97-98
Subcutaneous emphysema is a condition when air gets accumulated into the tissues under the skin and in the soft tissues of the chest wall or neck but can also spread to other parts of the body. It generally causes minimal symptoms and nonlethal; sometimes, it may be severe and life-threatening if deeper tissues of the thoracic outlet and chest are involved. It is essential to know the mechanisms of subcutaneous emphysema after cardiac surgery.
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Descriptive statistics and normality tests for statistical data
Annals of Cardiac Anaesthesia 2019 22(1):67-72
Descriptive statistics are an important part of biomedical research which is used to describe the basic features of the data in the study. They provide simple summaries about the sample and the measures. Measures of the central tendency and dispersion are used to describe the quantitative data. For the continuous data, test of the normality is an important step for deciding the measures of central tendency and statistical methods for data analysis. When our data follow normal distribution, parametric tests otherwise nonparametric methods are used to compare the groups. There are different methods used to test the normality of data, including numerical and visual methods, and each method has its own advantages and disadvantages. In the present study, we have discussed the summary measures and methods used to test the normality of the data.
http://bit.ly/2VVQro7
Diagnostik der Sepsis – Teil 2: Erregeridentifikation
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 38-48
DOI: 10.1055/a-0756-4651
Im Rahmen der Sepsis und des septischen Schocks spielen, trotz der zunehmenden Verbreitung von neuen molekularbiologischen Verfahren, der kulturelle Erregernachweis und die Resistenztestung weiterhin die entscheidende Rolle in der antimikrobiellen Therapie auf der Intensivstation. Hierbei kann der Erregernachweis für die antimikrobielle Therapie einerseits direkt aus dem Patientenblut, andererseits aber auch aus diversen anderen Probenmaterialien (respiratorische Sekrete, Punktat, intraoperative Abstriche etc.) geführt werden. Ein Nachteil konventioneller kultureller Verfahren im Kontext kritisch kranker Patienten ist die zeitliche Latenz bis zum Erregernachweis bzw. zum Ergebnis der Resistenztestung. Molekularbiologische Verfahren wie Techniken der Erregerdiagnostik und Resistenztestung, die auf Polymerase Chain Reaction (PCR) oder vor allem Next-Generation Sequencing (NGS) basieren, versprechen hier zwar kürzere Umlaufzeiten, sind aber aktuell noch kein klinischer Standard. Trotzdem besitzen diese Verfahren das Potenzial, einen Paradigmenwechsel in der Erregerdiagnostik herbeizuführen.
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Georg Thieme Verlag KG Stuttgart · New York
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Sechs-Monats-Outcome nach restriktivem oder liberalem Transfusionsregime in der Herzchirurgie
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 4-4
DOI: 10.1055/a-0817-3208
Georg Thieme Verlag KG Stuttgart · New York
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Sepsis-Update: Definition und Epidemiologie
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 10-20
DOI: 10.1055/a-0625-5492
Sepsis ist eine häufige Erkrankung auf den Intensivstationen weltweit, die mit einer relevanten Morbidität und Mortalität einhergeht. Bis heute gibt es keine spezifische Therapie der Sepsis – allein die frühe Diagnosestellung und schnellstmögliche therapeutische Intervention können das Outcome der Patienten verbessern. Daher ist eine Definition des Krankheitsbildes der Sepsis mit hoher diagnostischer Sensitivität und Spezifität unabdingbar.
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Georg Thieme Verlag KG Stuttgart · New York
Article in Thieme eJournals:
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Ketamin: weniger Nebenwirkungen bei langsamer Infusion?
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 5-6
DOI: 10.1055/a-0817-2141
Georg Thieme Verlag KG Stuttgart · New York
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DGEM-Leitlinie: Klinische Ernährung in der Intensivmedizin – Kurzversion
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 63-73
DOI: 10.1055/a-0805-4118
Fragestellung Variationen in der klinischen Ernährungstherapie können die Prognose kritisch kranker Patienten beeinflussen. Hier präsentieren wir die Kurzversion der aktualisierten, konsensbasierten S2k-Leitlinie „Klinische Ernährung in der Intensivmedizin" der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Kooperation mit 7 anderen nationalen Fachgesellschaften. Als Zielpopulation der Leitlinie wurden kritisch kranke, erwachsene Patienten, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden, definiert. Methodik Die früheren Leitlinien der DGEM wurden in Einklang mit den aktuellen Richtlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) als S2k-Leitlinie aktualisiert. Als Grundlage für die Empfehlungen wurde die Evidenz von randomisiert-kontrollierten Studien, Metaanalysen und Beobachtungsstudien mit angemessener Fallzahl und hoher methodologischer Qualität (bis Mai 2018) sowie aktuell gültige Leitlinien internationaler Fachgesellschaften herangezogen und kommentiert. Die Empfehlungsstärke ist rein sprachlich beschrieben. Jede Empfehlung wurde mittels Delphi-Verfahren abschließend bewertet und konsentiert. Ergebnisse In der vorliegenden Kurzversion werden alle 69 Empfehlungen für essenzielle, praxisrelevante Bestandteile der klinischen Ernährung der Zielpopulation zusammenfassend dargestellt. Ein spezifischer Fokus ist die Adjustierung der Ernährung gemäß den Phasen der kritischen Erkrankung sowie gemäß der individuellen Toleranz gegenüber exogener Substratzufuhr. Unter anderem werden Empfehlungen zur Beurteilung des Ernährungszustandes, zur Indikation für eine klinische Ernährungstherapie, zum Zeitpunkt des Beginns, zum Applikationsweg, zur Menge und Zusammensetzung der Ernährungssubstrate (Makro- und Mikronährstoffe) sowie zu speziellen Aspekten der Ernährung bei adipösen kritisch kranken Patienten und Patienten mit extrakorporalen Unterstützungsverfahren gegeben. Schlussfolgerung Die Kurzversion der Leitlinie gibt eine prägnante Übersicht über alle 69 aktualisierten Handlungsempfehlungen zur enteralen und parenteralen Ernährung erwachsener kritisch kranker Patienten, die an mind. einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden. Die Gültigkeit der Leitlinie beträgt voraussichtlich 5 Jahre (2018 – 2023).
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Georg Thieme Verlag KG Stuttgart · New York
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ICU: Lactoferrin gegen nosokomiale Infektionen?
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 6-7
DOI: 10.1055/a-0817-2154
Georg Thieme Verlag KG Stuttgart · New York
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Diagnostik der Sepsis – Teil 1: allgemeine Diagnostik und Fokussuche-/sanierung
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 22-36
DOI: 10.1055/a-0625-5507
Die Sepsis ist ein medizinischer Notfall mit weiterhin hoher Sterblichkeit. Die Surviving Sepsis Campaign (SSC) gibt für die Diagnostik und die Gabe eines adäquaten Breitspektrumantibiotikums ein Zeitfenster von max. 1 h nach Stellen der Verdachtsdiagnose „Sepsis" vor. Aktuell wird dieses sog. 1 h-Maßnahmenbündel kritisch diskutiert. Als Kernaspekt der Fokussuche orientiert sich die Art der Bildgebung am vermuteten Fokus und dem Patientenkollektiv. Bei kritisch kranken Patienten ist die kontrastmittelverstärkte Computertomografie häufig Mittel der Wahl. Die Erregerdetektion erfolgt meist kulturbasiert. Daher sind mikrobiologische Proben aus einfach zugänglichen Kompartimenten, mindestens aber die Entnahme von 2 Blutkultursets, obligat und sollten vor der Gabe eines Antibiotikums erfolgen. Von herausragender Bedeutung sind vor allem intraoperative Abstriche aus sonst sterilen Kompartimenten. Suspekte Katheter (z. B. zentralvenöse Katheter, Dialysekatheter) oder potenziell infizierte implantierte Medizinprodukte (z. B. Schrittmacher, Defibrillatoren) sollten – wenn vertretbar – zügig entfernt und einer mikrobiologischen Aufarbeitung zugeführt werden. Generell sollten alle notwendigen Maßnahmen zur Fokussanierung/-kontrolle so schnell wie medizinisch/logistisch möglich, mindestens aber innerhalb von 6(– 12)h nach Beginn der Sepsis, erfolgt sein. Es existiert bislang kein spezifischer Biomarker für das Krankheitsbild der Sepsis. Biomarker wie das Procalcitonin (PCT) und das C-reaktive Protein (CRP) spielen im Kontext der Sepsis beim infektiologischen Management und Therapiemonitoring auf der Intensivstation eine wichtige Rolle. Vielversprechende Biomarker wie das midregionale Pro-Adrenomedullin (MR-proADM) oder das Presepsin werden außerhalb von Studien noch nicht in der klinischen Routine eingesetzt. Als Marker von Mikrozirkulationsstörungen und eines gestörten Metabolismus spielt das Laktat (bzw. die Laktat-Clearance) als prognostischer Parameter der Sepsis eine große Rolle.
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Georg Thieme Verlag KG Stuttgart · New York
Article in Thieme eJournals:
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Sepsis – weiter eine große Herausforderung!
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 8-9
DOI: 10.1055/a-0808-1194
Georg Thieme Verlag KG Stuttgart · New York
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http://bit.ly/2Fgkpy0
Sepsis-Update: evidenzbasierte Therapie
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 50-62
DOI: 10.1055/a-0625-5521
Sepsis und septischer Schock stellen medizinische Notfälle dar, die einer kompetenten Früherkennung und eines entsprechenden sofortigen, zielgerichteten Managements bedürfen. Die Therapie der Sepsis und des septischen Schocks hat sich während der letzten Jahre kontinuierlich weiterentwickelt. Dieser Beitrag gibt einen Überblick über die aktuelle Evidenz der Therapie der Sepsis und des septischen Schocks und deren Umsetzung in die klinische Praxis.
[...]
Georg Thieme Verlag KG Stuttgart · New York
Article in Thieme eJournals:
Table of contents | Abstract | Full text
http://bit.ly/2FfPkdx
Heute aus der Gynäkologie: Neugeborenenreanimation und Notsectio
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 74-78
DOI: 10.1055/s-0042-101628
Georg Thieme Verlag KG Stuttgart · New York
Article in Thieme eJournals:
Table of contents | Full text
http://bit.ly/2Ff93Kx
ICU: welches Antibiotikum bei vancomycinresistenten Enterokokken (VRE)?
Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54: 4-5
DOI: 10.1055/a-0817-2987
Georg Thieme Verlag KG Stuttgart · New York
Article in Thieme eJournals:
Table of contents | Full text
http://bit.ly/2FgkqC4
EAACI position paper: Comparing insect hypersensitivity induced by bite, sting, inhalation or ingestion in human beings and animals
Abstract
Adverse reactions to insects occur in both human and veterinary patients. Systematic comparison may lead to improved recommendations for prevention and treatment in all species. In this position paper, we summarize the current knowledge on insect allergy induced via stings, bites, inhalation or ingestion, and compare reactions in companion animals to those in people. With few exceptions, the situation in human insect allergy is better documented than in animals. We focus on a review of recent literature, and give overviews of the epidemiology and clinical signs. We discuss allergen sources and allergenic molecules to the extent described, and aspects of diagnosis, prophylaxis, management and therapy.
This article is protected by copyright. All rights reserved.
http://bit.ly/2M9yUEc
Mobile health tools for the management of chronic respiratory diseases
Abstract
Background
The market of mobile health (mHealth) technology is rapidly evolving, making new mobile technologies potentially available for health care systems. Patient empowerment through self‐monitoring of symptoms, shared decision making with the physician and easily accessible education are important features extending the reach of mHealth technology beyond traditional care.
Methods
Two digital distribution platforms (Apple App Store and Google Play Store) were searched for currently available mobile applications (apps) for patients with chronic respiratory diseases (CRDs). A new index (score ranging from 0‐10) was developed to assess the potential of apps as a tool to empower patients through mobile technology (based on self‐monitoring, personalized feedback and patient education app features).
Results
One hundred and twelve apps were retained for analysis and could be classified in 5 categories: Asthma (n=71), COPD (n=15), Asthma and COPD (n=15), Rhinitis and Asthma (n=5) and Rhinosinusitis (n=6). Eighty percent were developed by medical technology companies compared to 18% by medical doctors and 2% by pharmaceutical companies. Two‐thirds of apps allow disease self‐monitoring whereas over half of apps provide patient feedback through graphs. Sixty percent of apps contain easily accessible patient education material. Only sixteen percent of apps reach a score of ≥7 on the newly designed patient empowerment index.
Conclusions
A variety of apps are available for patients with CRDs of which only few were developed by or jointly with medical doctors. The majority of these apps include self‐monitoring tools but only few also provide personalized feedback, which is needed to adopt these apps into daily care.
This article is protected by copyright. All rights reserved.
http://bit.ly/2sv7L5S
Expression of immunoregulatory molecules PD-L1 and PD-1 in oral cancer and precancerous lesions: A cohort study of Japanese patients
Publication date: January 2019
Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 1
Author(s): Atsumu Kouketsu, Ikuro Sato, Mariko Oikawa, Yoshinaka Shimizu, Hiroki Saito, Tetsu Takahashi, Hiroyuki Kumamoto
Abstract
Objective
An association of the programmed cell death-1 (PD-1) and its ligand PD-L1 with various types of malignant tumors has been established. This study aimed to investigate the role of the PD-L1/PD-1 pathway in oral squamous cell carcinoma (OSCC) and oral epithelial precursor lesions (OEPL).
Materials and methods
We examined 106 OSCC and 79 OEPL specimens for PD-L1 and PD-1 expression by immunohistochemistry. The results were compared with clinicopathological features of OSCC patients.
Results
In OSCC and OEPL specimens, PD-L1 expression was detected predominantly in epithelial or carcinoma cells, whereas PD-1 expression was found mainly in infiltrating or stromal lymphocytes. Seventy-two OSCC (67.9%) and 21 OEPL (26.6%) specimens were positive for PD-L1, and 73 OSCC (68.9%) and 23 OEPL (29.2%) specimens were positive for PD-1. PD-L1 and PD-1 expression levels were significantly different between OEPL and OSCC specimens (P < 0.001). There were significant positive correlations between PD-L1 and PD-1 expression in OEPL and OSCC specimens (P < 0.001). PD-L1 and PD-1 immunoreactivity was significantly associated with tumor size (P < 0.05). PD-L1 and PD-1 immunoreactivity in cases with advanced TNM staging was significantly higher than that in low staging cases (P < 0.01). There were significant correlations between PD-L1 and PD-1 expression in OSCC specimens and pathological variables such as stromal lymphocytic reaction (P < 0.05) and invasion depth (P < 0.01).
Conclusion
PD-L1 and PD-1 immunohistochemical status may be related to carcinogenesis, tumor progression, and prognosis in oral epithelial lesions. Agents targeting PD-1 and PD-L1 might be useful for OSCC treatment.
http://bit.ly/2ANrQc6
Editorial Board
Publication date: January 2019
Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 1
Author(s):
http://bit.ly/2T1qv8N
EACMFS Awards
Publication date: January 2019
Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 1
Author(s):
http://bit.ly/2AM6rzY
Announcements
Publication date: January 2019
Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 1
Author(s):
http://bit.ly/2T3jDr6
Revisiting age‐related admission following tonsillectomy in the pediatric population
Objectives/Hypothesis
The objectives of this study were to examine patient outcomes using a 36‐month age cutoff as a strict admission criterion following tonsillectomy, and review the safety and determine the plausibility of same‐day discharge of children under 3 years old following tonsillectomy.
Study Design
Retrospective chart review.
Methods
A chart review of patients aged 24 to 42 months undergoing tonsillectomy over a 3‐year period was conducted. Patients were stratified into <36 months and ≥ 36 months cohorts. Data collected included demographics, medical/sleep history, inpatient records, 30‐day emergency department visits, and readmission data. Bivariate comparisons were made using χ2 and Wilcoxon tests for categorical and continuous variables.
Results
Between July 2014 and July 2017, 427 patients aged 24 to 42 months underwent tonsillectomy at our institution. Thirty‐day emergency department visit, readmission, and greater‐than‐expected length of stay rates were 3.0% versus 3.7% (P = .75), 1.0 versus 1.8% (P = .61), and 4.7% versus 4.5% (P = 1.00) between the younger and older cohorts, respectively, with no difference in complication rates identified based on age.
Conclusions
No significant difference in adverse outcomes was appreciated based on a cutoff of 36 months of age at a tertiary center over 3 years. There should continue to be ongoing studies addressing strict age‐related admission criteria.
Level of Evidence
4 Laryngoscope, 2019
http://bit.ly/2RuZ0rl
Retrograde parotidectomy under local anesthesia for benign, malignant, and inflammatory lesions
Publication date: Available online 14 January 2019
Source: American Journal of Otolaryngology
Author(s): Michael Chang, Alanna Coughran, Yu-Jin Lee, Jeremy Collins, Davud Sirjani
Abstract
Objective
To report the patient selection, surgical technique, and outcomes of parotidectomy using local anesthesia under monitored anesthesia care (MAC).
Methods
A retrospective chart review was performed for patients undergoing parotidectomy under local anesthesia at an academic head and neck surgery center.
Results
Six patients deemed high risk for general anesthesia (GA) due to medical comorbidities or with a strong preference to avoid GA underwent parotidectomy using local anesthesia and MAC. Parotidectomy was performed for several indications, including benign tumors, malignant tumors, and chronic sialadenitis. Mean age of patients was 78.0 ± 7.9 years, and all had an American Society of Anesthesia score ≥ 2 and Charlson comorbidity index ≥4. Mean operative time was 102.8 ± 38.3 min, comparable to that of parotidectomy under general anesthesia. No major complications occurred. Minor complications included three cases of temporary postoperative facial nerve weakness limited to 1–2 lower division branches. At most recent follow up (10 to 48 months), all patients were medically stable and disease free.
Conclusion
In carefully selected patients, parotidectomy under local anesthesia is a viable treatment alternative that can be offered to patients. Successful outcomes require preoperative counseling, meticulous technique, and close collaboration with anesthesia colleagues.
http://bit.ly/2ClLegi
Audiological outcomes in Pediatric patients with congenital aural atresia implanted with transcutaneous active bone conduction hearing implant
Publication date: Available online 14 January 2019
Source: International Journal of Pediatric Otorhinolaryngology
Author(s): Zernotti ME, Chiaraviglio MM, Mauricio SB, P.A. Tabernero, Zernotti M, M.F. Di Gregorio
Abstract
Objectives
The objective of this study is to evaluate the safety and efficacy of the transcutaneous Bone Conduction Implant, the Bonebridge, in patients with congenital aural atresia.
Methods
Audiometry, speech recognition test and free field audiometry were performed. Word recognition scores and speech perception was evaluated using Spanish phonetically-balanced disyllables word list.
Results
Fourteen subjects were implanted with the Bonebridge (seven bilateral placements). The study cohort comprised seven males and seven females aged from 3 to 17 years (mean age 9.76yrs). All patients accepted and benefited from the implanted Bonebridge system. The pre-operative PTA4 was 66.4 dB (64.2-68.6, 95-%CI) and improved after activation to 19.2 dB (16.9-21.5, 95%-CI), resulting in a mean functional gain of 48 dB. Regarding speech discrimination, the pre-operative outcomes of the disyllabic measurements were 34.3% and for monosyllables 27.4%. Following activation the speech discrimination improved to 98.6% and 97.9%, respectively. No infections or adverse device related effects occurred in patient group.
Conclusion
We have concluded that the Bonebridge implant is an innovative solution for patients with conductive or mixed hearing loss and unilateral loss suffering from congenital atresia. Different surgical techniques may be used for implant placement, based on the patient's anatomy. Studies show improved functional gain, better speech perception, and lower rates of percutaneous complications associated with this implant.
http://bit.ly/2SQXGvv
Auditory brainstem implantation in children with hearing loss: effect on speech production
Publication date: Available online 14 January 2019
Source: International Journal of Pediatric Otorhinolaryngology
Author(s): Jolien Faes, Steven Gillis
Abstract
Auditory brainstem implantation (ABI) is a recent technique in children's hearing restoration. Up till now the focus in the literature has mainly been the perceptual outcomes after implantation, whereas the effect of ABI on spoken language is still an almost unexplored area of research. This study presents a one-year follow-up of the volubility of two children with ABI. The volubility of signed and oral productions is investigated and oral productions are examined in more detail. Results show clear developmental trends in both children, indicating a beneficial effect of ABI on spoken language development.
http://bit.ly/2AN0937
Early life undernutrition reprograms CD4+ T-cell glycolysis and epigenetics to facilitate asthma
Publication date: Available online 15 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Xi Chen, Hui Lin, Daping Yang, Wei Xu, Guangwei Liu, Xinmei Liu, Jianzhong Sheng, Hefeng Huang
Abstract
Background
Exposure to early life undernutrition is closely related to higher risks of adverse immunologic outcomes in adulthood. Although it has been suggested that asthma has its origins in early life, its underlying mechanisms remain largely unknown.
Objective
We characterized the impacts of early life undernutrition on T lymphocytes, which play a pivotal role in immune diseases, and we investigated whether this contributes to susceptibility to asthma in adulthood.
Methods
Pregnant mice were fed a protein restriction diet (PRD) to establish an early life undernutrition model. Naïve CD4+ T cells (CD4+CD62LhiCD44-) from offspring were used throughout the study. Type 2 T helper (Th2) differentiation was examined by FACS and ELISA under Th2-polarized conditions in vitro and by ovalbumin (OVA)-induced experimental asthma in vivo. T-cell metabolism was measured with a Seahorse XF96 Analyzer. DNA methylation levels were measured by bisulfite sequencing.
Results
PRD CD4+ T cells displayed increased activation and proliferation and were prone to differentiate into Th2 cells both in vitro and in vivo, leading to susceptibility to experimental asthma. Mechanistically, early life undernutrition upregulated mTORC1- dependent glycolysis and induced conserved noncoding DNA sequence 1 (CNS1) DNA hypomethylation in Th2 cytokine locus of CD4+ T cells. Glycolysis blockades undermined increased Th2 skewing and alleviated experimental asthma in PRD mice.
Conclusion
Early life undernutrition induced mTORC1-dependent glycolysis upregulation and Th2 cytokine locus hypomethylation in CD4+ T cells, resulting in increased T-cell activation, proliferation and Th2 skewing and further susceptibility to experimental asthma.
Graphical abstract
http://bit.ly/2CixoLq
Sublingual immunotherapy with the SQ tree SLIT-tablet is highly effective and well tolerated: results from a randomized, double-blind, placebo-controlled phase III trial
Publication date: Available online 15 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Tilo Biedermann, Piotr Kuna, Petr Panzner, Erkka Valovirta, Morgan Andersson, Frederic de Blay, Dorthe Thrane, Sanja Hald Jacobsen, Brian Sonne Stage, Lone Winther
Abstract
Background
The SQ tree SLIT-tablet (ALK) is developed for treatment of tree pollen induced allergic rhinoconjunctivitis (ARC).
Objective
The aim of this pivotal phase III trial was to demonstrate efficacy and safety of the SQ tree SLIT-tablet.
Methods
This was a randomized, double-blind, placebo-controlled trial with 634 subjects (12-65 years) with moderate-severe ARC despite use of symptom-relieving medication. Eligible subjects were randomized 1:1 to active or placebo. The primary endpoint was the average daily ARC total combined score (TCS) during the birch pollen season (BPS) analyzed for subjects with diary data during the BPS. Secondary endpoints included average daily symptom score (DSS) during the BPS, average TCS and DSS during the tree pollen season (TPS), and average daily medication score (DMS) in the BPS and TPS.
Results
The primary and key secondary endpoints demonstrated statistically significant and clinically relevant effects of the SQ tree SLIT-tablet compared to placebo were found. For the BPS, absolute (relative) differences to placebo were: 3.02 (40%) for TCS, 1.32 (37%) for DSS and 1.58 (49%) for DMS (all p<0.0001). For the TPS, absolute (relative) differences to placebo were: 2.27 (37%) for TCS, 0.99 (33%) for DSS and 1.20 (47%) for DMS (all p<0.0001). Treatment was well tolerated. The most frequently reported treatment-related AEs were mild or moderate local reactions related to the sublingual administration.
Conclusion
The trial demonstrated efficacy and safety of the SQ tree SLIT-tablet compared to placebo during the BPS and TPS in adolescents and adults with birch pollen induced ARC.
Graphical abstract
http://bit.ly/2RqAqrD
Complexities in analyzing human basophil responses to auto-antibodies to IgE or FcεRI
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Stephen J. Galli
http://bit.ly/2RscbcH
Inhibitory checkpoint receptors control CD8+ resident memory T cells to prevent skin allergy
Publication date: Available online 15 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Pia Gamradt, Léo Laoubi, Audrey Nosbaum, Virginie Mutez, Vanina Lenief, Sophie Grande, Daniel Redoulès, Anne-Marie Schmitt, Jean-François Nicolas, Marc Vocanson
Abstract
Background
Tissue-resident memory T cells (Trm) are detrimental in numerous chronic inflammatory diseases, including allergic contact dermatitis (ACD).
Objectives
To analyze the contribution of Trm to the chronicity and severity of ACD and to define the local parameters regulating their development and functions.
Methods
We used an experimental model of ACD, i.e. contact hypersensitivity (CHS) to 2,4-dinitrofluorobenzene (DNFB) which is mediated by CD8+T cells.
Results
Our data show that early effector T cells accumulated in the skin during the acute CHS reaction and gave rise to epidermal CD8+ Trm expressing a specific set of immune checkpoint receptors (ICR), such as PD-1 and Tim-3. Those Trm remained in the epidermis for several weeks and mediated the eczema exacerbations, which developed upon allergen re-exposure without the contribution of circulating specific T cells. Furthermore, allergen-induced Trm reactivation was constrained, since treatment with ICR antagonists dramatically enhanced the magnitude and severity of eczema exacerbations. Finally, we show that the persistence of the allergen in the epidermis for long periods of time was responsible for both the development and maintenance of epidermal Trm as well as the sustained expression of ICR.
Conclusion
Although CD8+Trm cells are key for the pathophysiology of ACD, intrinsic mechanisms control their reactivation to prevent damaging immunopathology. Developing strategies targeting the reactivation of skin Trm in situ via their ICR should open new perspectives for the treatment of ACD.
Graphical abstract
http://bit.ly/2CqTY4z
A monoallelic activating mutation in RAC2 resulting in a combined immunodeficiency
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Vassilios Lougaris, Janet Chou, Abdallah Beano, Jacqueline G. Wallace, Manuela Baronio, Luisa Gazzurelli, Tiziana Lorenzini, Daniele Moratto, Giovanna Tabellini, Silvia Parolini, Michael Seleman, Kelsey Stafstrom, Haiming Xu, Chad Harris, Raif S. Geha, Alessandro Plebani
http://bit.ly/2RqwOpv
Association between rhinovirus species and nasopharyngeal microbiota in infants with severe bronchiolitis
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Laura Toivonen, Carlos A. Camargo, James E. Gern, Yury A. Bochkov, Jonathan M. Mansbach, Pedro A. Piedra, Kohei Hasegawa
http://bit.ly/2ClAm23
IL-21 promotes allergic airway inflammation by driving apoptosis of FoxP3+ regulatory T cells
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Luigi Tortola, Helga Pawelski, Sanchaita Sriwal Sonar, Franziska Ampenberger, Michael Kurrer, Manfred Kopf
Abstract
Background
IL-21 is a key player of adaptive immunity with well-established roles in B and cytotoxic T cell responses. IL-21 has been implicated in promotion of effector CD4+ T cells and inhibition of FoxP3+ regulatory T cells (Tregs), but the mechanism and functional relevance of these findings remain controversial.
Objective
We sought to understand the mechanisms by which IL-21 controls effector CD4+ cell responses and Treg homeostasis.
Methods
We used IL-21R-deficient mice to study the impact of IL-21 on T cell responses in models of asthma and colitis. We used mixed bone marrow chimeras and adoptive transfers of naïve CD4+ T cells and Tregs into lymphopenic mice to assess cell intrinsic effects of IL-21. Using various in vitro T cell assays we characterized the mechanism of IL-21-mediated inhibition of Tregs.
Results
We show that IL-21 production by Th2 and Tfh/ex-Tfh cells promotes asthma by inhibiting Tregs. Il21r–/– mice displayed reduced generation of Th2 cells and increased Tregs. In mixed chimeras, we demonstrate that IL-21 promotes Th2 responses indirectly via inhibition of Tregs. Depleting Tregs in Il21r–/– mice restored Th2 generation and eosinophilia. Furthermore, IL-21 inhibited Treg generation in colitic mice. Using competitive transfers of Il21r+/+ and Il21r–/– CD4+ cells, we show that IL-21 directly inhibited expansion of differentiated Tregs, but was dispensable for Th1/Th17 effectors. We show that IL-21 sensitizes Tregs to apoptosis by interfering with the expression of Bcl-2 family genes.
Conclusion
IL-21 directly promotes apoptosis of Tregs and therefore indirectly sustains generation of inflammatory T helper cells and related effector responses.
http://bit.ly/2CqZNzk
Early decreases in blood eosinophil levels with reslizumab
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Pascal Chanez, Mirna McDonald, Margaret Garin, Kevin Murphy
http://bit.ly/2Rqu8YS
Prevalence of Eosinophilic Colitis and the Diagnoses Associated with Colonic Eosinophilia
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): Lauren A. DiTommaso, Chen E. Rosenberg, Michael D. Eby, Amy Tasco, Margaret H. Collins, John L. Lyles, Philip E. Putnam, Vincent A. Mukkada, Marc E. Rothenberg
http://bit.ly/2CmaanO
Anaphylaxis After Vaccination Reported To The Vaccine Adverse Event Reporting System, 1990–2016
Publication date: Available online 14 January 2019
Source: Journal of Allergy and Clinical Immunology
Author(s): John R. Su, Pedro L. Moro, Carmen Ng, Paige W. Lewis, Maria A. Said, Maria V. Cano
Abstract
Background
Anaphylaxis, a rare, potentially life-threatening hypersensitivity reaction, can occur after vaccination.
Objective
Describe reports of anaphylaxis after vaccination to the Vaccine Adverse Event Reporting System (VAERS) during 1990–2016.
Methods
We identified domestic reports of anaphylaxis within VAERS using a combination of Medical Dictionary for Regulatory Activity queries and Preferred Terms. We performed descriptive analysis, including history of hypersensitivity (e.g., anaphylaxis, respiratory allergies, drug allergies), and vaccines given. We reviewed all serious reports, and all non-serious reports with available medical records, to determine if they met the Brighton Collaboration case definition (BCCD) for anaphylaxis or were diagnosed by a physician.
Results
During the analytic period, VAERS received 467,960 total reports; 828 met BCCD for or were physician-diagnosed as anaphylaxis: 654 (79%) were classified as serious, and 669 (81%) had medical records available. Of 478 reports in children aged <19 years, 65% were male; childhood vaccines were most commonly reported. Of 350 reports in persons aged ≥19 years, 80% were female, and influenza vaccines were most frequently reported. Overall, 41% of reports described persons with no history of hypersensitivity. We identified 8 deaths, 4 among persons with no history of hypersensitivity.
Conclusion
Anaphylaxis after vaccination is rare in the United States, and can occur among persons with no history of hypersensitivity. Most persons recover fully with treatment, but serious complications, including death, can occur.
http://bit.ly/2RwICGI
Journal of Nursing and Midwifery Sciences, a publication of Mazandaran University of Medical Sciences, is a peer-reviewed online journal with Quarterly print on demand compilation of issues published. The journal's full text is available online at: http://www.jnmsjournal.org. The journal allows free access (Open Access) to its contents and permits authors to self-archive final accepted version of the articles on any OAI-compliant institutional / subject-based repository.
| ORIGINAL ARTICLES | ||
  | The effect of concurrent endurance and resistance training on cardio-respiratory capacity and cardiovascular risk markers among sedentary overweight or obese post-menopausal women | p. 123 |
| Anahita Shabani, Ramin Shabani, Setila Dalili, Afagh Hassanzadeh Rad DOI:10.4103/JNMS.JNMS_34_18 Context: Exercise training has been inversely associated with cardiovascular risk factors. However, the clinical trials examining the effect of exercise training on reducing cardiovascular risk factors have produced conflicting results. Aims: We aimed to assess the effect of concurrent exercise training on cardiorespiratory capacity and cardio-vascular risk factors among sedentary overweight or obese post-menopausal women. Settings and Design: This randomized controlled trial was done in 2016. Materials and Methods: This study was conducted on 22 healthy post-menopausal overweight and obese females, which randomly divided into concurrent endurance and resistance (ER) exercise (n = 12) and control (n = 10) groups. The participants did not have any history of any serious medical condition or using drugs. Demographic questionnaire was completed, vital signs and biochemical tests were measured, and Rockport one-mile submaximal exercise test for assessing maximal oxygen consumption (VO2max) was performed before and after the study. Statistical Analysis Used: Mean, standard deviation, and paired and independent t-test were used for statistical analysis. Results: The data from the ER groups showed that the body mass index (BMI), heart rate (HR), systolic and diastolic blood pressure, triglyceride, high-sensitivity C-reactive protein (CRP) decreased, high-density lipoprotein, and VO2max increased significantly, during the 8 weeks (P < 0.05). Moreover, no changes were found in the cardiovascular risk factors of women who did not exercise (P > 0.05). Conclusion: Concurrent ER training can be a suitable exercise program for improving plasma lipid profile as well as reducing body composition, high-sensitivity CRP, and increasing VO2max in postmenopausal women. | ||
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| The effect of staff training on the amount of sound pollution in the intensive care unit | p. 130 | |
| Kobra Zamani, Hossein Ali Asgharnia, Jamshid Yazdani, Zohreh Taraghi DOI:10.4103/JNMS.JNMS_38_18 Context: Sound pollution is a common problem in intensive care units (ICUs) with unfavorable consequences.Aims: The aim of the current study was to determine the effect of staff training on the amount of sound pollution in the ICU. Setting and Design: This quasi-experimental study was conducted in the ICU of Rouhani Hospital in Babol. Materials and Methods: Level of equivalent (leq) sound was measured in three work shifts for 2 weeks, before and after training, in 2 workdays and a holiday, using a systematic network stationing method. The sample size was determined based on the days of measurement, work-shift, and measuring stations (6 × 3 × 10 = 180). Indirect training was performed. A 2-week opportunity was given to study materials. Statistical Analysis Used:Data were analyzed using paired t-test and RMANOVA. Results: Following the training, the mean leq in all stations (ten stations) decreased from 67.21 to 62.11 dB (P = 0.002). Conclusion: Although the amount of sound pollution decreased significantly after training, it was still higher than standard. To achieve the desired level of sound, continuous monitoring of sound at intervals of 6 months, along with structural engineering and equipment, is suggested. | ||
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 | The effect of relaxation exercises on emotions of primigravida women in famenin | p. 134 |
| Farzaneh Soltani, Samerah Ghlichkhani, Arezoo Shayan, Parisa Parsa, Ghodratollah Roshanaei DOI:10.4103/JNMS.JNMS_32_18 Context: Recognizing effective interventions for improving women's positive emotion can improve mental health and self-confidence in anxious women, at least during pregnancy. Aim: This study aimed to investigate the effect of relaxation training on positive and negative emotions of primigravida women. Setting and Design: In this randomized quasi-experimental study, 100 primigravida women with gestational age of 28–32 weeks, who were referred to the prenatal care centers in Famenin City (Hamadan, Iran), were randomly assigned into two groups of intervention and control, using randomized blocking. Methods and Material: All the pregnant women completed the positive and negative affect schedule questionnaire. In the intervention group, eight sessions were held twice a week with emphasis on relaxation techniques. The control group received routine prenatal care.Statistical Analysis Used: Descriptive statistics, independent and paired t-tests were used to compare the difference between and within two groups. Results: The mean score of positive emotion increased from 31.92 ± 6.39 to 34.12 ± 5.41 after intervention (P = 0.034). In contrast, the mean score of positive emotion in the control group reduced from 33.62 ± 6.58 to 26.92 ± 6.35 after the intervention (P < 0.001). In addition, there was a significant difference between the mean scores of positive emotion in the two groups after the intervention (P < 0.001). The mean score of negative emotion reduced from 24.12 ± 7.06 to 17.18 ± 5.95 in the intervention group (P < 0.001). On the other hand, the mean score of negative emotion in the control group increased from 22.08 ± 6.85 to 28.42 ± 7.24 after the intervention (P < 0.001). There was a significant difference between the mean scores of negative emotion in the two groups after the intervention (P < 0.001). The mean score of positive emotion of the women increased after the intervention (from 31.92 ± 6.39 to 34.12 ± 5.41) (P = 0.034). In contrast, the mean score of positive emotion of the women in the control group reduced after the intervention (from 33.62 ± 6.58 to 26.92 ± 6.35) (P < 0.001). Also, the mean score of negative emotion reduced in the intervention group (from 24.12 ± 7.06 to 17.18 ± 5.95). On the other hand, the mean score of negative emotion of the women in the control group significantly increased after the intervention (from 22.08 ± 6.85 to 28.42 ± 7.24).Conclusion: Research findings suggest that relaxation training may increase positive emotion and reduced negative emotion in pregnant women. It is recommended that relaxation techniques are used in prenatal care centers as a simple and available health intervention in pregnancy. | ||
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| Qualitative needs assessment: Iranian parents' perspectives in sexuality education of their children | p. 140 | |
| Jila Ganji, Mohammad Hassan Emamian, Raziyeh Maasoumi, Afsanah Keramat, Effat Merghati-Khoei DOI:10.4103/JNMS.JNMS_42_18 Context: Parental education in sexuality plays a vital role in children's lives. Aims: The purpose of this study was to explore Iranian parents' perspectives about the needs of children sexuality education. Setting and Design: This qualitative study was done in 2016. Materials and Methods: In this qualitative inquiry, seven sessions of community group interview and focus group discussions were conducted with the parents of Ghaemshahr, Iran, using purposive sampling (n = 39, 27 mothers and 12 fathers). Statistical Analysis Used:We employed thematic analysis method to extract our findings. Results: The findings were categorized into three essential needs: (1) parents' preparedness, (2) efficacious parental management, and (3) supportive environments. The sub-theme describing the theme 1 includes "the need for adequate knowledge to answer the sexual questions and the child's sexual curiosity" and "the need for awareness about the time of beginning an appropriate sexuality education for children." Moreover, the sub-theme describing theme 2 includes "the need for sufficient skills to begin proper and intimate communication," "the need for effective monitoring and care," and "the need for capability in managing the child sexual behavior." Moreover, the sub-theme describing theme 3 includes "the need to receive training from sexual health professionals," "the need for authorized sexuality education programs," "the need for national-wide policy-making and strategy planning in sexuality education," and "the need for a comprehensive and complete educational resource." Conclusion: Our findings suggest that to address the goals in sexuality education for children, parents' need to be prepared in knowledge, and gaining positive attitude and practical skills. To achieve these goals, supportive environments must be provided by policy-makers and health providers with culturally appropriate strategy planning. | ||
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| Strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health: using nominal group technique | p. 147 | |
| Maryam Hajizadevalokolaee, Zohreh Shahhosseini, Soghra Khani, Fereshteh Yazdani, Zeinab Hamzeghardeshi DOI:10.4103/JNMS.JNMS_35_18 Context: The spread of HIV is growing, so that its way of transmission has created worries in the field of sexual and reproductive health, because the wave of transmission has changed from injection to sexual activities.Aims: To evaluate the perspectives of sexual and reproductive health experts and providers on strategies for improving the integrated program of HIV/AIDS with sexual and reproductive health using the nominal group technique (NGT). Setting and Design: Mazandaran University of Medical Sciences, Sari, Iran. NGT. Materials and Methods: It was a semiquantitative/qualitative methodology research through NGT, based on the opinions of 30 experts and sexual and reproductive health providers in the field of health in Mazandaran (2016).Statistical Analysis Used: Semiquantitative/qualitative analysis. Results: In total, 15 cases got the scores of 2–62 as strategies to improve the integrated program of HIV/AIDS with sexual and reproductive health. The highest scores were found in society-centered level and stigma management, and the lowest scores were found in individual-centered level and negotiation skill training. Conclusion: One of the strategies to improve the integrated program of HIV/AIDS was the empowerment of women and men in sexual and reproductive health and stigma management. Based on the results, the NGT is a useful tool for doing researches and prioritizing the programs. Based on the expert opinion, it can be concluded that designing strategies based on individual-, community-, and society-centered approach would be an appropriate approach for improving the integrated program of HIV/AIDS with sexual and reproductive health issues in Iranian society. | ||
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 | Evaluation of occupational hazards for nurses in intensive care units of tertiary care centers | p. 153 |
| Kobra Abdi Zarrini, Akram Sanagoo, Leila Jouybari, Mohammad Ali Vakili, Ali Kavosi DOI:10.4103/JNMS.JNMS_52_18 Context: Nursing is a high-risk occupation, and intensive care units (ICUs) are one of the most sensitive hospital wards. Aim: This study aimed to determine the level of occupational hazards among nurses in the ICUs. Setting and Design: This descriptive-analytical study was conducted on a total of 281 nurses in the ICUs of tertiary care centers in Golestan and Mazandaran Universities of Medical Sciences in 2017. Materials and Methods: Data were collected using a five-dimensional occupational hazard questionnaire. Statistical Analysis Used: Data analysis was performed in SPSS software (version 16) and descriptive and inferential statistics were considered statistically significant (P < 0.05). Results: In this study, 75.1% of the nurses were female and 50.9% of the participants were within the age range of 26–35 years. The total mean and standard deviation of occupational hazards was 3.20 ± 0.66. In addition, the mean values and standard deviations of chemical, ergonomic, biological, psychosocial, and organizational, as well as physical hazards were reported to be 2.43 ± 1.06, 2.6 ± 0.82, 2.63 ± 0.91, 3.38 ± 0.7, and 3.38 ± 0.86, respectively. According to the results, significant differences were observed between occupational hazards and variables of gender, marital status, educational level, and work experience (P = 0.0001). Conclusion: Occupational hazard level was moderate among nurses in the ICUs, and most of the damages were related to the physical dimension. In addition to holding educational workshops in tertiary care centers by the related officials, proper preventive plans must be designed to reduce occupational injuries. | ||
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| Incidence and risk factors of pressure ulcers among general surgery patients | p. 159 | |
| Ensieh Ramezanpour, Amir Emami Zeydi, Mohammad Ali Heidari Gorji, Jamshid Yazdani Charati, Mahmood Moosazadeh, Vida Shafipour DOI:10.4103/JNMS.JNMS_23_17 Context: Pressure ulcers are among the main postoperative complications which isassociated with an increased length of hospitalization. Determining risk factors of postsurgical pressureulcers is crucial for developing prevention and treatment strategies. Aims: This study aimed to investigate the incidence rate of pressure ulcer and related risk factors after general surgery. Settings and Design: This descriptive cross-sectional study was carried out in three hospitals in Mazandaran province in 2016. Materials and Methods: The sample size was 191 surgical patients undergoing general surgery by using census method. Data were collected in pre-, intra-, and post-operative period using demographic and clinical questionnaires and also, through the Braden Scale for Predicting Pressure Ulcer Risk. Statistical Analysis Used: Descriptive statistics, t-test, Chi-square, and univariateand multivariate logistic regression were used to analyze the data. Results: The incidence rate of postoperative pressure ulcers in patients was 17.8% (34 out of 191 patients). Based on the multivariate logistic regression model, significant correlations existed between the incidence of pressure ulcers and the following variables: age over 70 years old (P = 0.003), history of hypertension (P = 0.035), history of heart diseases (P = 0.029), Braden score <15 (P = 0.017), type of surgery (P = 0.003), and type of anesthesia (P = 0.015).Conclusions: Since it is critical to consider the incidence of postoperative pressure ulcers among patients, further measurements are required to identify high-risk people and use preventive protocols by nurses at pre-, intra-, and post-operative levels. Moreover, it requires extra attention in patients over 70 years, those with a history of hypertension and heart diseases, and those undergoing emergency surgery and spinal anesthesia. | ||
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| The relationship between the quality of nursing care and the satisfaction of pregnant mothers | p. 165 | |
| Ali Hatami, Zohreh Saeidlandi, Azam Jahanghiri Mehr, Akram Hemmatipour DOI:10.4103/JNMS.JNMS_44_18 Context: The Health System Development Plan is one of the key steps taken by the eleventh government to promote health services in the country. Aims: The aim of this study was to determine the relationship between the quality of nursing care and the satisfaction of pregnant mothers from the implementation of the health system development plan. Settings and Design: This research was an analytic cross-sectional study. The study population included 163 mothers who were hospitalized before delivery and 18 nurses from maternity sections who were selected by the census method during the 3 months of September 2017–November 2017. Material and Methods: The data collection tool was a demographic data form, quality patient care scale, and a researcher-made questionnaire on the satisfaction of hospitalized mothers in maternity sections of the implementation of the Health System Reform Plan. Statistical Analysis Used: Data were analyzed using descriptive statistics, Mann–Whitney test, and correlation coefficient in SPSS-16 software. Results: The results showed that the quality of care in nurses at the desired level (63%) and the satisfaction of mother maternity sections of the delivery system had a moderate level of implementation of the Health System Development Plan (56.3%). The results of Pearson's correlation test showed that there is a statistically significant relationship between the quality of nursing care and patient satisfaction (P = 0.001). Conclusions: The satisfaction of the mothers participating in the research was that the quality of nursing care was often modest after implementing the Health System Reform Plan. | ||
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