Medicine by Sfakianakis Alexandros: 07/27/17

Πέμπτη 27 Ιουλίου 2017

CAR T cells targeting solid tumors: carcinoembryonic antigen (CEA) proves to be a safe target

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Association Between Plasma Proprotein Convertase Subtilisin/Kexin Type 9 and the Presence of Metabolic Syndrome in a Predominantly Rural-Based Sub-Saharan African Population

Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.

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Acquired pachydermatoglyphia: the cutaneous manifestation of pulmonary tumours

Description

A 74-year-old man with active smoking habits presented to the emergency department with a 2-month history of weight loss (20% of previous body mass), dyspnoea and night sweats. Physical examination showed clinical signs of respiratory distress, significant cachexia and thickened velvety palms with pronounced folds (figure 1). The laboratory results revealed leucocytosis of 15 700 cells/µl, thrombocytosis of 547 000/µl and elevated C reactive protein of 6.65 mg/dL. A posteroanterior chest radiograph showed a right pleural effusion and consolidation suggestive of pneumonia.

Figure 1

Thickened velvety palms with pronounced folds consistent with acquired pachydermatoglyphia.

The patient was given antibiotics and submitted to pleural effusion drainage for symptomatic relief. A skin biopsy of the palms was obtained and the histopathological examination identified signs of hyperkeratosis, acanthosis and papillomatosis consistent with acquired pachydermatoglyphia (figure 2).

Figure 2

Skin biopsy consistent with acquired...

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Bacteraemia and liver abscess due to Fusobacterium necrophorum

Fusobacterium necrophorum is the oropharyngeal pathogen usually associated with Lemierre's syndrome, a pharyngeal infection which evolves to sepsis, septic emboli and thrombophlebitis of the adjacent neck vessels. It is an uncommon causative bacteria of a liver abscess, and an extensive workup should, therefore, be performed in order to rule out potential sources of the infection. This case report describes the workup that led to the diagnosis of a colorectal carcinoma, which was deemed to be the source of the Fusobacterium bacteraemia.

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Hypertrophic olivary degeneration

Description

A 30-year-old man underwent MRI of the internal auditory meatus as a routine follow-up after excision of a large left vestibular schwannoma, 2.5 years previously. MRI images showed an incidental finding of left hypertrophic olivary degeneration (figure 1 and figure 2). This phenomenon occurs as a result of Wallerian degeneration of the olivary nucleus secondary to a lesion in the triangle of Guillain and Mollaret, also known as the dento-rubro-olivary pathway (figure 3). The differential diagnoses of hypertrophic olivary degeneration include infarction, infection, neoplasms and demyelination. Differentials can be excluded by the absence contrast enhancement (figure 2).

Figure 1

Axial T2-weighted sequence showing intratumoral haemorrhage within a large left cerebello-pontine angle lesion in keeping with a vestibular schwannoma (panel A). Axial fluid attenuated inversion recovery (FLAIR) image through the posterior fossa after 6 months demonstrating atrophic changes and haemosiderin deposition in the left middle cerebellar peduncle...

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Hiatal hernia mimicking heart problems

Description

A 73-year-old man presented to the emergency department with symptoms of acute coronary syndrome. Findings on examination were dyspnoea, chest tightness and a burning sensation behind the sternum.

On admission, 3 hours after the onset of symptoms, his 12-lead ECG showed a left bundle branch block. Cardiac enzymes revealed only marginally elevated creatine kinase, aspartate transaminase and lactate dehydrogenase levels; however, troponin I (<0.04 ng/mL) was increased to 17 and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) to 1472 pg/mL (73 year normal range: 10–220 pg/mL). Though the consulting cardiologist determined coronary angiography to be unnecessary at the time, the patient was promptly sent to the intensive care unit (ICU) for monitoring and for quick intervention, if needed.

At that time, further information was gathered from the patient and his family. Apparently, the symptoms had started during lunch. The patient had experienced these symptoms several times in the preceding months; this time, however, the...

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Postoperative gluteal compartment syndrome following microsurgical free-flap hand reconstruction: the importance of early recognition and treatment

Compartment syndrome, a surgical emergency, is caused by an increase in pressure within a closed osseofascial space, often due to trauma. This causes a decrease in tissue perfusion and ultimately tissue necrosis and multiorgan failure if not treated in a timely fashion. Gluteal compartment syndrome is a rare variant and often caused by a period of immobilisation secondary to intoxication with alcohol or drugs or during long operations, typically in the supine position. We report on a case of gluteal compartment syndrome developing in a patient postoperatively following a long microsurgical procedure to a hand, which has not been documented before. Although rare, we highlight the clinical course and diagnostic criteria, which are essential for early identification and treatment.

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Adjunctive extracorporeal carbon dioxide removal in refractory status asthmaticus

Status asthmaticus (SA) is a life-threatening disorder. Severe respiratory failure may require extracorporeal membrane oxygenation (ECMO). Previous reports have demonstrated utility of ECMO in SA in various patients with varying success. A 25-year-old man was admitted with status asthmatics and severe hypercapnic respiratory failure. Despite tailored ventilator therapies, such as pressure control ventilation and maximal pharmacological therapy, including general anaesthesia, the patientâ™s condition deteriorated rapidly. Veno-venous ECMO (VV-ECMO) was provided for respiratory support. The patientâ™s clinical condition improved over the following 72âhours and was discharged from the intensive care unit on day 3. This case report demonstrates the successful use of VV-ECMO in a patient with severe respiratory failure due to SA, who failed to respond to maximal therapy. This case adds support to a growing body of literature that shows that ECMO can be used with success for refractory status asthmaticus.

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Intraparotid ductal ectasia: rare cause of parotid swelling

A 41-year-old patient was hospitalised for a chronic right parotid mass. A cervical ultrasound revealed a cystic mass of the parotid. Cervical MRI found a ductal ectasia of the parotid and submandibular glands associated with a retention cyst of the right parotid. He had a right total parotidectomy. Histopathological examination of the lesion revealed a multilocular cystic mass with a diffuse glandular ectasia of salivary ducts. The patient had an uneventful postoperative course without any recurrence of symptoms.

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Gamna-Gandy nodules of the spleen and asplenism in SLE: a novel association?

Description

We present a case of a 53-year-old woman who presented to the emergency room with acute abdominal pain, fever and haemodynamic and respiratory instability and was admitted to the intensive care unit with fulminant septic shock with multiorgan failure. CT imaging of the abdomen showed no gross abnormalities, initial laboratory results are presented in table 1.

Table 1

Laboratory test results

ParameterValueReference valueUnitCRP96<10mg/LESR7<20mm/hourHb8.07.0–9.2mmol/LHt0.400.32–0.44L/LMCV9582–89fLWBC6.5

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Reversible Holmesa{euro}™ tremor due to spontaneous intracranial hypotension

Holmes' tremor is a low-frequency hand tremor and has varying amplitude at different phases of motion. It is usually unilateral and does not respond satisfactorily to drugs and thus considered irreversible. Structural lesions in the thalamus and brainstem or cerebellum are usually responsible for Holmes' tremor. We present a 23-year-old woman who presented with unilateral Holmes' tremor. She also had hypersomnolence and headache in the sitting posture. Her brain imaging showed brain sagging and deep brain swelling due to spontaneous intracranial hypotension (SIH). She was managed conservatively and had a total clinical and radiological recovery. The brain sagging with the consequent distortion of the midbrain and diencephalon was responsible for this clinical presentation. SIH may be considered as one of the reversible causes of Holmes' tremor.

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Androgenic alopecia: an entity to consider in adolescence

Description

A 15-year-old healthy adolescent girl went to her physician consultation because she was preoccupied with progressive thinning of her hair since 11 years old. In the last year, she noticed an aggravation, with an excessive hair loss. She does not have hirsutism, acne, asthenia, menstrual irregularities or weight variations. In her family history, she reported that her mother had 'excessive hair loss after pregnancy' and her maternal aunt has alopecia of unknown aetiology. At physical examination it was observed diffuse reduction of capillary thickness and density at the frontal scalp area (figure 1) and vertex (figure 2). Rare black dots were present and the pull test was negative. The analytical study including blood count, iron kinetics, thyroid function and hormonal study had no alterations. The pelvic and adrenal gland's ultrasound were normal. At dermatology consultation, scalp biopsy revealed findings compatible with androgenic alopecia. She started treatment...

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Extramacular dome-shaped elevation: a novel finding in a case of high myopia

Description

Dome-shaped macula (DSM) is an elevation at the macula seen in about 5%–10% cases of high myopia, usually within a posterior staphyloma, caused by localised inward scleral and choroidal convexity.1 It may lead to visual deterioration when associated with serous foveal detachment (44% cases).2 3 Herein, we describe a similar but 'Extramacular dome-shaped elevation (EDSE)' associated with a large retinal hole.

A 23-year-old myopic female patient was referred to our clinic for pre refractive surgery fundus screening. She had a history of diminution of vision in the left eye more than the right eye since childhood and was using myopic glasses for the same. Best-corrected visual acuity on Snellen chart was 20/20 in the right eye and 20/200 in the left eye. Lower acuity in the left eye was attributed to anisometropic amblyopia as her refractive error was –6.75 D sphere...

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Sclerosing lymphangitis of the penis associated with marked penile oedema and skin erosions

Sclerosing lymphangitis of the penis is a benign, under-reported condition consisting of a asymptomatic firm cord-like swelling around the coronal sulcus of the penis usually affecting men in the second or third decade of life. Penile oedema and erosions are rarely reported. Clinical signs may be remarkable contrasting with the self-limited character of the disease. We report a new case of sclerosing lymphangitis of the penis occurring in a 59-year-old patient marked by penile swelling and several overlying skin erosions, and discuss the clinical features and the pathogenesis aspects of the disease.

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Directly observed therapy for clozapine with concomitant methadone prescription: a method for improving adherence and outcome

A young male presented with many years of delusions and hallucinations, with concurrent heroin use and subsequent amphetamine uses. There were no depressive or manic symptoms and psychotic symptoms prior to the amphetamine use. After the trials of two atypical antipsychotics and later clozapine due to treatment resistance, adherence and functionality were poor and there was still persistent drug use. As a result, a long acting injectable adjunct was commenced, but only minimal effects were observed. However after initiation of directly observed treatment of clozapine with methadone, there has been functional and clinical response and drug use has ceased.

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Accidental hypothermic cardiac arrest and rapid mediastinal warming with pleural lavage: a survivor after 3.5 hours of manual CPR

A 30-year-old man suffered post-traumatic hypothermic cardiac arrest. On arrival in the emergency department, rectal core temperature was 23°C. Manual cardiopulmonary resuscitation (CPR) was continued as no mechanical chest compression device was available, and active and passive rewarming was undertaken. Bilateral thoracostomies confirmed good lung inflation. Defibrillation and intravenous epinephrine were discontinued until core temperature was elevated above 30°C. Extracorporeal rewarming was unavailable. When no increase in rectal temperature was achieved after 90 min, an alternative oesophageal probe confirmed mediastinal temperature as 23°C. Bilateral chest drain insertion, followed by microwave-heated saline pleural lavage, rapidly raised the oesophageal temperature above 30°C with subsequent successful defibrillation, initially to pulseless electrical activity and finally return of spontaneous circulation 3.5 hours after the commencement of CPR. The patient recovered fully and was discharged without neurological deficit. Rapid mediastinal warming with pleural lavage should be considered in units with no access to extracorporeal rewarming service.

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Disseminated tuberculosis in relatively asymptomatic young woman

Description

A previously healthy 20-year-old woman presented to the emergency department with a history of one episode of generalised tonic–clonic seizure. No history of fever or constitutional symptoms. At admission, she was haemodynamically stable and Glasgow Coma Scale was 8, with no focal neurological deficits. For the workup of seizures, MRI brain (figure 1) was done which revealed multiple ring-enhancing lesions in bilateral temporal, frontal and right parietal lobes. Cerebrospinal fluid examination showed normal cell count with high protein (84 mg/dL) and normal glucose levels (43 mg/dL), and high adenosine deaminase (9.3 U/L) level. Chest X-ray showed (figure 2A) miliary mottling which was confirmed by contrast-enhanced CT (CECT) chest (figure 2B and C). CECT abdomen (figure 3A and B) revealed thick-walled multiloculated collection (7.3x8.4x14.2 cm) with thick internal septations in the left lumbar and iliac fossa region. Pelvic collections were drained with an image-guided pig tail insertion and...

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A perforated caecal volvulus in the foramen of Winslow

The aim of this report is to discuss with high-quality images, a case of a caecal volvulus herniating through the foramen of Winslow with signs of perforation.

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IPL vs PDL in treatment of facial erythema: A split-face study

Summary

Background

Lasers and noncoherent intense pulse light sources effectively treat vascular lesions. Intense pulsed light (IPL), a nonablative treatment for photorejuvenation, uses a flashlamp which emits noncoherent light between 400 and 1400 nm. The light may be filtered to target a specific chromophore. The pulsed dye laser (PDL), at 595 nm, has been the historical standard of care in the treatment of facial erythema. We sought to determine whether IPL may be used in lieu of PDL in reducing facial erythema.

Objectives

To determine whether IPL may be used to treat facial erythema with equal efficacy as PDL used at nonpurpuric settings.

Methods

Prospective investigation of a cohort of 15 subjects with unwanted bilateral facial erythema. Subjects presented for two treatments with an IPL (BBL™ BroadBand Light; Sciton, Palo Alto, CA) to one half of the face and PDL (Cynergy™; Cynosure, Westford, MA) to the other half.

Results

Patients with facial erythema may be successfully treated with IPL or PDL.

Conclusions

Intense pulsed light and pulsed dye laser with nonpurpuric settings were equally effective in reducing facial erythema.

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Surgical considerations and safety of cochlear implantation in otitis media with effusion

Publication date: Available online 26 July 2017
Source:Auris Nasus Larynx
Author(s): Rasit Cevizci, Alper Dilci, Fatih Celenk, Recep Karamert, Yildirim Bayazit
ObjectiveTo evaluate the effects of otitis media with effusion on surgical parameters, patient safety, perioperative and postoperative complications.MethodsTotal 890 children who underwent cochlear implantation between 2006 and 2015 were included. The ages ranged from 12 months to 63 months (mean: 32 months). The patients were divided into two groups according to the presence or absence of otitis media with effusion; otitis media with effusion group and non-otitis media group.ResultsOf 890 children, 105 had otitis media with effusion prior to surgery. In non-otitis media with group, there were 785 children. The average duration of surgery was 60min (ranged from 28 to 75min) in non-otitis media group, and 90min (ranged from 50 to 135min) in otitis media with effusion group (p<0.05). Granulation tissue and edematous middle ear and mastoid mucosa were observed in all cases of otitis media with effusion during the surgery. There was no significant difference between the complications of groups with or without otitis media with effusion (p>0.05). In 5 of 105 patients, there was a ventilation tube inserted before cochlear implantation, which did not change the outcome of implantation.ConclusionThere is no need for surgical treatment for otitis media with effusion before implantation since otitis media with effusion does not increase the risks associated with cochlear implantation. Operation duration is longer in the presence of otitis media with effusion. However, otitis media with effusion leads to intraoperative difficulties like longer operation duration, bleeding, visualization of the round window membrane, cleansing the middle ear granulations as well as mastoid and petrous air cells.

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Endoscopic contralateral transmaxillary approach for pterygoid process osteotomy in total maxillectomy: A technical case report

Publication date: Available online 26 July 2017
Source:Auris Nasus Larynx
Author(s): Toyoyuki Hanazawa, Kazuki Yamasaki, Hideaki Chazono, Yoshitaka Okamoto
An approach for total maxillectomy with endoscopic transection of the pterygoid process via the contralateral maxillary sinus is described. In total maxillectomy, the resection of the pterygoid process of the sphenoid is a key step for successful resection. However, a conventional craniofacial approach requires extensive incision in the face, elevation of the lateral cheek flap. Even after elevation of the lateral cheek flap, visualization of this region is not good. An endoscopic approach through the contralateral maxillary sinus improved visualization of the pterygoid process, and osteotomy using a diamond-drilling bar was successfully performed. This technique has the potential to widen the indication for total maxillectomy in malignant neoplasms of the maxillary sinus.

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Management of perioperative laryngospasm by French paediatric anaesthetists

Editor—Perioperative laryngospasm is a life-threating emergency in paediatric patients. A recent multicentre study of children undergoing surgery¹ found a high rate of severe critical events during the perioperative period (5.2%), with an incidence of respiratory critical events of 3.1%. Laryngospasm was one of most frequent respiratory complications (0.2–6.7%). Its effective management requires appropriate diagnosis, followed by prompt and aggressive management. The use of a structured algorithm would lead to earlier recognition and better management.² We undertook a survey in order to explore the practical management of laryngospasm by French paediatric anaesthetists.

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Electroencephalography and delirium in the postoperative period

Abstract

Delirium commonly manifests in the postoperative period as a clinical syndrome resulting from acute brain dysfunction or encephalopathy. Delirium is characterized by acute and often fluctuating changes in attention and cognition. Emergence delirium typically presents and resolves within minutes to hours after termination of general anaesthesia. Postoperative delirium hours to days after an invasive procedure can herald poor outcomes. Easily recognized when patients are hyperactive or agitated, delirium often evades diagnosis as it most frequently presents with hypoactivity and somnolence. EEG offers objective measurements to complement clinical assessment of this complex fluctuating disorder. Although EEG features of delirium in the postoperative period remain incompletely characterized, a shift of EEG power into low frequencies is a typical finding shared among encephalopathies that manifest with delirium. In aggregate, existing data suggest that serial or continuous EEG in the postoperative period facilitates monitoring of delirium development and severity and assists in detecting epileptic aetiologies. Future studies are needed to clarify the precise EEG features that can reliably predict or diagnose delirium in the postoperative period, and to provide mechanistic insights into this pathologically diverse neurological disorder.

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Abstracts for Spring BJA Research Forum meeting, Royal College of Anaesthetists, London, 5th and 6th April 2017

(The authors of all the following abstracts have confirmed that their research received ethics committee approval or was conducted under the Animal (Scientific Procedures) Act (1986) or equivalent.)

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Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics

Abstract

Background: Despite evidence of high activity, the number of surgical procedures performed in UK hospitals, their cost and subsequent mortality remain unclear.Methods: Time-trend ecological study using hospital episode data from England, Scotland, Wales and Northern Ireland. The primary outcome was the number of in-hospital procedures, grouped using three increasingly specific categories of surgery. Secondary outcomes were all-cause mortality, length of hospital stay and healthcare costs according to standard National Health Service tariffs.Results: Between April 1, 2009 and March 31, 2014, 39 631 801 surgical patient episodes were recorded. There was an annual average of 7 926 360 procedures (inclusive category), 5 104 165 procedures (intermediate category) and 1 526 421 procedures (restrictive category). This equates to 12 537, 8073 and 2414 procedures per 100 000 population per year, respectively. On average there were 85 181 deaths (1.1%) within 30 days of a procedure each year, rising to 178 040 deaths (2.3%) after 90 days. Approximately 62.8% of all procedures were day cases. Median length of stay for in-patient procedures was 1.7 (1.3–2.0) days. The total cost of surgery over the 5 yr period was £54.6 billion ($104.4 billion), representing an average annual cost of £10.9 billion (inclusive), £9.5 billion (intermediate) and £5.6 billion (restrictive). For each category, the number of procedures increased each year, while mortality decreased. One-third of all mortalities in national death registers occurred within 90 days of a procedure (inclusive category).Conclusions: The number of surgical procedures in the UK varies widely according to definition. The number of procedures is slowly increasing whilst the number of deaths is decreasing.

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How powerful is failure to rescue as a global metric? Not as powerful as a commitment to measurement

In a much-discussed study published in 2009, Dr Ghaferi and colleagues¹ revived the concept, originally described in the early 1990s by Jeffrey Silber and colleagues,² of 'failure to rescue'. Ghaferi and colleagues¹ used a prospective, multicentre clinical registry organized by the American College of Surgeons (ACS-NSQIP) to rank hospitals by mortality quintiles. They then evaluated adverse events and noted that across the different mortality quintiles the risk of an adverse event was remarkably consistent. What differed with respect to mortality was not so much the likelihood of a complication, but the ability of a hospital to 'save' a patient who experienced a complication. Hospitals in the lowest mortality quintile had very similar rates of both minor and major complications to those in the highest mortality quintile, yet had half the rates of death. They concluded that 'failure to rescue' patients with complications in the higher mortality quintiles represented an opportunity for improvement; it was not the complications per se that killed patients, but the inability to quickly recognize and respond to their deterioration.

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Simulated emergency cricothyroid incision length

Editor—The revised 2015 Difficult Airway Society (DAS) guidelines for the 'unanticipated difficult airway' include a standardized approach to performance of emergency front-of-neck access in the 'can't intubate, can't oxygenate' (CICO) scenario.¹ We have subsequently changed how we educate colleagues in the management of a CICO scenario using the surgical technique as part of our airway update days and on the Aintree Difficult Airway Management course.

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Delirium, what’s in a name?

Delirium has been known since ancient times. Hippocrates [460–370 Before Common Era (BCE)] may have been the first to describe the syndrome that he called 'phrenitis', marked by confusion and restlessness that fluctuated unpredictably and that was associated with physical illness.¹ Many other names have been used, including acute mental status change, confusional state, confusion, acute brain dysfunction, brain failure, encephalopathy, postoperative psychosis and acute organic syndrome.¹ Of these, the term delirium (derived from the Latin word delirare, deviate from a straight track) has gained acceptance. Besides a more uniform terminology, an important recent achievement includes publication of criteria to define delirium. Although criticized,² ³ the criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5) have become standard.⁴ According to these criteria, a patient can be considered delirious when all items listed in Table 1 are present at the same time.⁴ In essence, this means that a patient has acutely developed disturbed attention with other cognitive deficits, which is not solely due to underlying dementia and is caused by a physical condition. Table 1Criteria for delirium according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)⁴

A. A disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).
D. The disturbances in Criteria A and C are not better explained by another pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple aetiologies.

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Topics for the national audit projects of the Royal College of Anaesthetists

Editor—Moppett and colleagues¹ provide a very fair assessment of the value of the national audit projects (NAPs) performed in the UK during the last decade. However, I would question their statement that the choice of topics for the third and fourth projects performed by the Royal College of Anesthetists (NAP3 and NAP4) was 'in part serendipitous, as a result of the coincidence of the desires of the specialist societies (Pain and Difficult Airway) and the Royal College of Anaesthetists'. The subjects for both audits were discussed at meetings of College Council and, as a member of that group at the time, I remember no input from any society.

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Postoperative delirium portends descent to dementia

Many elderly patients worry that their thinking will be impaired after surgery. Concerns include acute confusion in the days to weeks following surgery, as well as persistent cognitive deficits lasting months to years.¹ Both postoperative delirium (POD) and delayed neurocognitive recovery lasting months after surgery are common in older adults, but reports of non-resolving cognitive decline or neurocognitive disorders (NCDs) are inconsistent.² ³ The acute onset inattention and disorganized thinking characteristic of POD often manifest between one and four days after surgery.⁴ Delayed neurocognitive recovery is a subtle NCD that typically lasts weeks to months following surgery. Although transient, both disorders can significantly impact recovery. Patients with POD have increased morbidity and mortality, longer Intensive Care Unit (ICU) stays, decreases in quality of life and are likely to be vulnerable to delayed neurocognitive recovery.⁵ ⁶ While the pathophysiology of delirium remains unclear, it has been linked with NCDs and dementia in non-surgical patients,⁷ and several studies have suggested that POD may be a risk factor for non-resolving minor and even major NCD (or incident dementia).⁸ ⁹ In this issue of the British Journal of Anaesthesia, the retrospective cohort studies by Sauër and colleagues¹⁰ and Sprung and colleagues¹¹ investigate the association between POD and persistent NCDs; the conflicting results highlight the difficulties in studying postoperative cognition.

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In This Issue

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Post-anaesthesia care unit delirium: incidence, risk factors and associated adverse outcomes

Delirium is a sudden disturbance in attention and orientation to the environment that develops over a short period of time and tends to fluctuate in severity during the course of the day.¹ The acute confusional state of delirium occurs in 50–80% of critically ill patients and postoperatively (from the day after surgery onwards) in up to 54% of elective major non-cardiac surgical patients.¹ It incurs a huge societal burden, because of, in part, a result of its association with increased morbidity and mortality; each additional day of delirium has been independently associated with a 10% increased risk of death.² Increased morbidity contributes to prolonged hospital length of stay and significant financial implications: delirium is estimated to total $4–16 billion annually.³ Its association with long-term neuropsychological and cognitive deficits^4–7 mandates a better understanding of the pathogenesis of delirium⁸ and the mechanisms underlying the prolonged disruption of cognitive processing.⁹ Despite these apparent strong associations, it remains unclear whether delirium identified in the post-anaesthetic care unit (PACU) or recovery unit is associated with similar outcomes. For anaesthetists, this is a critical question that remains unanswered. Indeed at least some of these events are of limited duration and hence it could be assumed they would be associated with less severe consequences. In this context, PACU delirium is differentiated from postoperative delirium as the latter occurs from the day after surgery onwards whereas the former occurs in the PACU on the day of surgery.

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Approach affects injectate spread in ultrasound-guided thoracic paravertebral block: a cadaveric trial

Editor—Ultrasound-guided thoracic paravertebral block has made much progress, and various approaches have been developed in the past decade.¹ However, the differences in local anaesthetic distribution patterns are unknown. We adopted two patterns of injections, namely the intercostal approach (IC approach)² and the paralaminar in-plane approach (PL approach),³ ⁴ and compared their injectate spreading patterns in three Thiel-embalmed human cadavers using a dye injection method.⁵ ⁶ For the IC approach, a 6–13 MHz linear array transducer was placed at the T4, T5 and T9 intercostal levels to visualize the transverse process. An 18-gauge Tuohy needle was inserted from lateral to medial beside the probe to penetrate the internal intercostal membrane next to the tip of the transverse process. For the PL approach, the needle was inserted from medial to lateral using a 5–8 MHz microconvex array transducer to visualize the lateral edge of the vertebral lamina at the T6, T7 and T10 levels. We investigated five injections by the IC approach and four injections by the PL approach using 10 ml of dye of various colours. One injection in each group included real-time, direct observation of the distribution pattern after dissection via a pre-inserted catheter 2.5 cm beyond the needle tip. Paravertebral spread was confirmed in all procedures. In the IC approach group, dye covered the respective intercostal space and the adjacent paravertebral space (PVS) (Fig. 1A), consistent with previous reports.⁷ The injected dye in the PL approach group covered the more longitudinal and medial PVS rather than the lateral intercostal space (Fig. 1B).⁸ Real-time dye injections from the catheter showed that in the IC approach dye first spread to the respective intercostal level following PVS whereas in the PL approach dye first covered the area around the sympathetic trunk followed by the intercostal area.

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Predicting postoperative brain function from the blood: is there a role for biomarkers?

Loss of consciousness upon exposure to general anaesthetics reflects the powerful influence of these drugs on brain physiology. While this phenomenon is usually transient and rapidly resolves upon discontinuation of drug administration, an overwhelming number of both clinical and experimental observations suggest that even relatively short periods of anaesthesia can trigger a myriad of biochemical pathways which, in turn, can give rise to temporary or even lasting changes in neurobehavioural and cognitive function after emergence from anaesthesia.¹ Most of these functional alterations have been described as postoperative delirium or impaired cognitive performance and, therefore, have negative connotations. It is nevertheless important to note that exposure to anaesthetics can also improve both cognition and mood in some specific clinical states, such as in major depressive disorders. This context-dependent impact of anaesthetics on neuronal function probably reflects the major context-dependent modulatory influence of these drugs on neuronal plasticity.¹

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Mind the gap when performing emergency front-of-neck access

Editor—Plan D of the Difficult Airway Society guidelines¹ on managing the can't intubate can't oxygenate (CICO) scenario states that a 6.0 mm cuffed tracheal tube should be railroaded over the bougie when performing scalpel cricothyroidotomy. During our departmental CICO training sessions, conducted on sheep larynxes, we have noticed that candidates have difficulties railroading the tube over the bougie (Frova Intubating Introducer, Cook Medical Ltd. Limerick, Ireland) when using a 6 mm cuffed tracheal tube. This appears to be caused by the tip of the tube catching on the airway as it is being advanced, because of the large gap between the bougie and the tube (Fig. 1A). We noted that when using a smaller 5 mm tube, railroading appeared to be easier, perhaps because the gap between the bougie and the tube is smaller (Fig. 1B). The resistance to advancing the tube over the bougie was almost negligible when using a size 5 mm Melker cuffed emergency cricothyrotomy catheter (Cook Medical Ltd, Limerick, Ireland), as this tube has a tapered tip that fits snugly over the bougie (Fig. 1C).

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Using a worldwide in-app survey to explore sugammadex usage patterns: a prospective observational study

Editor—Via encapsulation, sugammadex can rapidly and completely reverse even profound neuromuscular block induced by rocuronium or vecuronium, which is not possible to achieve with cholinesterase inhibitors.^1–4 Although approved for use in Europe in 2008⁵ and available for several years elsewhere,⁶ the United States Food and Drug Administration (US FDA) delayed approval due to concerns regarding potential hypersensitivity reactions and effects on coagulation tests,⁷ which were ultimately satisfied.^8–10 We are interested in better understanding global experience with sugammadex and the impact, if any, of pharmacoeconomics on post-marketing policies. The present data were analysed from an ongoing, Institutional Review Board (IRB)-approved (Emory University, Atlanta, GA, USA, IRB# 00082571) study of a globally utilized anaesthesia calculator app for the Android platform ('Anesthesiologist')¹¹ ¹² fitted with a module capable of collecting survey data and app analytics.¹³ We used this tool to deploy a survey assessing global patterns of clinical practice and experience with sugammadex.

http://ift.tt/2eRSfNJ

The Princes of Serendip

Editor—We thank Professor Wildsmith¹ for his interest in our editorial² and for clarifying aspects of the process around NAP3.³

http://ift.tt/2h7oYzr

Availability of critical care services in Taiwan under National Health Insurance

Editor—Since the implementation of Taiwan's National Health Insurance (NHI) programme in 1995, use of health-care services has significantly increased.¹ This is also true for the use of mechanical ventilation and extracorporeal membrane oxygenation.² ³ In contrast, information is limited about use of intensive care unit (ICU) beds.⁴ We conducted this study to investigate the availability of the critical care service in Taiwan under the NHI programme.

http://ift.tt/2h7vztq

Abstracts from the BJA Research Forum Glasgow, November 10–11, 2016

Ultrasound-guided central venous catheterization in the prone position

Editor—Central venous catheterization for patients positioned prone poses challenges to the anaesthesiologist, such as anatomical restrictions in head and neck position, lack of anatomical landmark points to approach, and difficult right internal jugular vein (RIJV) needle advancement with the left hand. Here we present an approach for RIJV catheterization in a patient positioned prone using in-plane needle ultrasound guidance.

http://ift.tt/2h7Hck2

Association between delirium and cognitive change after cardiac surgery

Abstract

Background. Previous studies provide inconsistent data on whether postoperative delirium (POD) is a risk factor for postoperative cognitive decline (POCD). We thus investigated the relationship between POD and cognitive change after cardiac surgery and assessed the relationship between preoperative cognitive domain scores and POD.Methods. Postoperative delirium was assessed with the Confusion Assessment Method (CAM) adapted for the intensive care unit and the conventional CAM accompanied by chart review. Cognitive function was assessed with a neuropsychological test battery before elective cardiac surgery and 1 month and 1 yr afterwards. Cognitive change was calculated using the Reliable Change Index (RCI). Multiple linear regression was used to adjust for confounding.Results. Of the 184 patients who completed baseline assessment, 23 (12.5%) developed POD. At 1 month, the decline in cognitive performance was worse in patients with POD [median composite RCI −1.00, interquartile range (IQR) −1.67 to 0.28] than in patients without POD (RCI −0.04, IQR −0.70 to 0.63, P=0.02). At 1 yr, both groups showed cognitive improvement on average compared with baseline (POD patients median composite RCI 0.25, IQR −0.42 to 1.31, vs non-POD patients RCI 0.92, IQR 0.18–1.53; P=0.08). Correction for differences in age and level of education did not change the results. Patients with POD performed less well than patients without POD on the preoperative Trailmaking test part A (P=0.03).Conclusions. Postoperative delirium is independently associated with cognitive decline 1 month after surgery, but cognitive performance generally recovers in 1 yr. Patients with a predisposition to POD can be identified before surgery by worse performance in an attention task.Clinical trial registration. NCT00293592.

http://ift.tt/2eSNdAK

Epstein-Barr virus-positive ileal carcinomas associated with Crohn’s disease

http://ift.tt/2v3VCqX

Engraftment and Repopulation Potential of Late Gestation Fetal Rat Hepatocytes.

Background: The limited availability of donor organs has led to a search for alternatives to liver transplantation to restore liver function and bridge patients to transplantation. We have shown that the proliferation of late gestation (embryonic day 19; ED19) fetal rat hepatocytes is mitogen-independent, and that mechanisms regulating of mRNA translation, cell cycle progression and gene expression differ from those of adult rat hepatocytes. In the present study, we investigated whether E19 fetal hepatocytes can engraft and repopulate an injured adult liver. Methods: Fetal hepatocytes were isolated using a monoclonal antibody against a hepatic surface protein, leucine amino peptidase (LAP). LAP+ and LAP- fractions were analyzed by immunofluorescence and microarray. Immunopurified E19 liver cells from DPPIV+ rats were transplanted via splenic injection into partial hepatectomized DPPIV- rats that had been pretreated with mitomycin C. Results: More than a third of LAP+ fetal hepatocytes expressed ductal markers. Transcriptomic analysis revealed that these dual expressing cells represent a population of less well differentiated hepatocytes. Upon transplantation, LAP+ late gestation fetal hepatocytes formed hepatic, endothelial and ductal colonies within 1 month. By 10 months, colonies derived from LAP+ cells increased so that up to 35% of the liver was repopulated by donor-derived cells. Conclusions: Late gestation fetal hepatocytes, despite being far along in the differentiation process, possess the capacity for extensive liver repopulation. This is likely related to the unexpected presence of a significant proportion of hepatocyte marker-positive cells maintaining a less well differentiated phenotype. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Mounting Clinical Evidence with Tacrolimus Generic Products.

No abstract available

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Fatal Septic Shock Triggered by Donor Transmitted Varicella Zoster Virus Reinfection 3 Days After Lung Transplantation.

No abstract available

http://ift.tt/2eS5VIt

Methods in Allergy/Immunology: Food Challenges

Publication date: Available online 27 July 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Barbara K. Ballmer-Weber, Kirsten Beyer
Since there is no in vitro test, which can accurately predict the clinical relevance of a sensitization to food, the oral food challenge still remains the most reliable procedure to confirm or exclude food allergy and to assess the development of tolerance in children with potentially transient food allergies such as to cow's milk, hen's egg, wheat or soy. Although in the last few years component-resolved diagnostic has improved the food allergy diagnostics, especially in peanut and tree nut allergy, the majority of patients still need to undergo oral food challenge. The following paper will describe in whom and how to perform an oral food challenge as well as its interpretation of the results with a focus on suspected IgE-mediated food allergy.

http://ift.tt/2uCb1hy

Erratum to: A Modeling Study of the Responses of the Lateral Superior Olive to Ipsilateral Sinusoidally Amplitude-Modulated Tones

http://ift.tt/2tNLByL

Erratum to: A Modeling Study of the Responses of the Lateral Superior Olive to Ipsilateral Sinusoidally Amplitude-Modulated Tones

http://ift.tt/2tNLByL

Toni-Haid-Reisestipendium für neurootologische Forschung der Arbeitsgemeinschaft Deutschsprachiger Audiologen, Neurootologen und Otologen

http://ift.tt/2uGEa9F

Will we ever have better glucocorticoids?

Publication date: Available online 27 July 2017
Source:Clinical Immunology
Author(s): Frank Buttgereit, Johannes W.J. Bijlsma, Cindy Strehl
Glucocorticoids are cost-effective drugs with potent anti-inflammatory and immunosuppressive effects. They are used successfully to treat many disorders, including rheumatoid arthritis, polymyalgia rheumatic and other rheumatic diseases. However, these drugs also have the potential to cause adverse effects, particularly if high doses are used for prolonged periods. Therefore, continuous efforts are being made to implement recommendations for optimal dosing of glucocorticoids, monitoring for potential adverse events, adverse event prevention and management. Apart from this, novel and interesting work is underway to develop innovative glucocorticoids or glucocorticoid receptor ligands in order to improve the therapeutic balance. This article briefly mentions a recent publication discussing the question under which conditions long-term treatment with glucocorticoids has an acceptably low level of harm, and focuses then on two current approaches to minimize glucocorticoid adverse effects while keeping or even enhancing their anti-inflammatory efficacy, liposomal glucocorticoids and dissociated agonists of the glucocorticoid receptor.

http://ift.tt/2tNpgRV

Therapy of ulcus cruris of venous and mixed venous arterial origin with autologous, adult, native progenitor cells from subcutaneous adipose tissue: a prospective clinical pilot study

Abstract

Background

The stromal vascular fraction (SVF) of adipose tissue consists of cellular subpopulations with distinct regenerative potential.

Objective

To investigate the regenerative capacities of autologous SVF cells in the treatment of chronic leg ulcers of venous (VLU) and arterial-venous (AVLU) origin.

Methods

Multimorbid ulcer patients received a singular topical treatment with 9-15x10⁶ SVF cells, separated from abdominal lipoaspirates by digestion with collagenase and dispase and applied immediately after isolation. The primary endpoints were the change in wound size 12 weeks after treatment and evaluation of adverse events. Secondary endpoints included the time to complete wound epithelialization and change in pain levels. Postoperative wound treatment modalities and treatment of comorbidities were not intensified compared with preoperative management. Follow-up period was at least 6 months.

Results

Sixteen elderly ulcer patients (7 with VLU, 9 with AVLU) were treated as described. All VLU patients (median ulcer size: 48.25 cm²) and 4 of 9 AVLU patients showed complete epithelialization of the ulcers within 71 to 174 days. In 3 patients with large ulcerations on both legs, ulcerations on the non-treated, contralateral leg also epithelialized. Patients reported a considerable rapid decrease in pain intensity by 2.5 points on average on a visual scale from 1 to 5 within the first two weeks after treatment. The patients were followed-up for 9-44 months (median: 30 months). No severe side effects were observed.

Conclusions

The use of SVF cells presents an effective, minimally invasive option for the treatment of VLU and AVLU even in multimorbid patients. In patients with larger predominantly ischemic AVLU and comorbidities, one-time application of the used amounts of SVF cells was not sufficient in the majority of cases.

http://ift.tt/2tNfQpk

Safety and Efficacy of Dual Wavelength Laser (1064 nm + 595 nm) for Treatment of Non-treated Port-Wine Stains

Abstract

Background

Patients with port-wine stain (PWS) suffer physically and psychologically because of the high incidence (0.3%–0.5%) of the disease. Pulsed dye laser (PDL) at 595 nm is the gold standard of the treatment for PWS. Nevertheless, clinicians intend to determine whether the dual wavelength laser (DWL) (595 nm PDL + 1064 nm Nd:YAG) is an adequate choice in the treatment of non-treated PWS. This study is the first prospective within-patient controlled research seeking to investigate the safety and efficacy of DWL for the treatment of non-treated PWS.

Methods

A total of 61 patients with non-treated flat facial PWS, who were treated using the Cynergy laser system in our clinic, were included in this study. Each PWS lesion was divided into 2 adjacent test treatment sites of similar size and color. The 2 sites were randomly assigned to PDL or DWL treatment in a blinded manner of participants. In each case, 2 sets of treatment parameters were used: 1) 595 nm PDL and 2) 595 nm PDL+1064 nm Nd:YAG. Both had a 10 mm spot size, an epidermal cooling system, and 1 sec interpulse interval between 2 pulses. Clinical efficacy and safety outcomes were evaluated by visual assessment 2 months after treatment.

Results

Comparison by visual evaluation suggests that the responses of non-treated PWS to treatment by PDL and DWL were not significantly different. Moreover, 3 patients developed scarring after DWL treatment.

Conclusion

Compared with PDL, DWL exhibits a higher risk of potential scarring and has no advantage in efficacy of treating non-treated PWS.

http://ift.tt/2u29jlV

Are checkpoint inhibitors a valuable option for metastatic or unresectable vulvar and vaginal melanomas?

Abstract

Immune checkpoint inhibitors might be therapeutic options for unresectable or metastatic melanomas of the vulva and vagina but data available in the literature in these melanomas are very limited ¹²³⁴. The aim of this retrospective study was to investigate the effect of anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and anti-programmed death 1 (PD-1) antibodies in patients treated in our Skin Cancer Department for unresectable or metastatic vulvar or vaginal melanoma since 2013.

http://ift.tt/2tNkhAy

Severity assessments used for inclusion criteria and baseline severity evaluation in atopic dermatitis clinical trials: a systematic review

Abstract

Background

Numerous inclusion criteria and baseline severity assessments are used in clinical trials of atopic dermatitis (AD), which may limit comparison of results.

Objective

We sought to characterize the inclusion criteria and baseline severity assessments used in randomized controlled trials (RCT) of AD internationally.

Methods

We performed a systematic review of RCT with a pharmacological intervention from 2007-2016. Cochrane Library, EMBASE, GREAT, LILACS, MEDLINE and Scopus were searched. Two authors independently performed study selection and data extraction.

Results

Overall, 212 RCT met inclusion/exclusion criteria. Target population and inclusion criteria based on AD severity were not documented in 78 (36.8%) and 25 (18.7%) studies, respectively. Thirty and 58 severity assessments were used for inclusion criteria and baseline severity, respectively, with only 60.3% concordance between their use. Global assessments were most frequently used for both inclusion criteria and baseline severity assessment in North America (39.5% and 32.1%), while SCORing AD (SCORAD) or objective SCORAD index was most frequently used in Europe (23.5% and 23.0%) and Asia (34.2% and 43.5%). Minimum and maximum thresholds of severity assessments were inconsistently used between studies for inclusion criteria, even within similar target populations. SCORAD, global assessments and body surface area were most frequently used for both inclusion criteria and baseline severity assessment. IGA was particularly used in trials of topical agents.

Conclusions

There was considerable variability and poor documentation of inclusion criteria and baseline severity assessments in RCT for AD. These differences may limit interpretation of a study and comparison of results between studies.

http://ift.tt/2u1YQXP

The diagnosis and management of male genital lichen sclerosus: a retrospective review of 301 patients

Abstract

Introduction

Male genital lichen sclerosus (MGLSc) is an acquired, chronic, inflammatory skin disease that is associated with significant morbidity and squamous cell carcinoma of the penis (PSCC). However, some clinical, diagnostic and management controversies endure, including the relationship with penile intraepithelial neoplasia (PeIN).

Objectives

To clarify clinical presentations, diagnostic approaches, histological findings, response to treatment and the relationship with PeIN.

Methods

Retrospective review of patients with a diagnosis of MGLSc who attended a specialist male genital dermatoses clinic.

Results

301 patients were identified; 260 had isolated MGLSc, and 41 both MGLSc and PeIN. Referrals were made from the local Urology and Andrology departments (128), primary care (89), GUM (54), other dermatology departments (28), and other specialties (2). In isolated MGLSc, 94.6% were diagnosed clinically with 93.5% accuracy (based on data from subsequent circumcisions). In combined MGLSc/PeIN, 85.4% were diagnosed following diagnostic biopsy and 14.6% retrospectively after circumcision. In isolated MGLSc, 50% were treated topically, and 50% required surgery. In MGLSc/PeIN, 78% required surgical interventions. In isolated MGLSc, 92.2% achieved resolution of symptoms, 3.5% were awaiting procedures, and 4.8% were receiving ongoing topical therapy. In MGLSc/PeIN, 90.2% achieved clearance, 2.4% were waiting surgery, and 7.3% were treated topically. Only 2.7% reported ongoing symptoms, all in patients treated surgically. None progressed to PSCC.

Discussion

MGLSc is generally a disease of the uncircumcised; the majority of cases of MGLSc are accurately diagnosed clinically; suspected PeIN or PSCC requires histological confirmation; circumcision histology can be non-specific; most men are either cured by topical treatment with ultrapotent corticosteroid (53.1%) or by circumcision (46.9%); surgical intervention is required in most cases of concomitant MGLSc and PeIN; the majority of patients with MGLSc alone or with MGLSc and PeIN remit with this approach; effective management appears to negate the risk of malignant transformation to PSCC.

http://ift.tt/2tNmCvp

Current approach of skin lesions suspected of malignancy in general practice in the Netherlands: A quantitative overview

Abstract

Background

The role of general practitioners (GPs) in skin cancer care is increasing. Previous, hospital-based studies suggest that GPs might not have the capabilities to gain responsibility concerning skin cancer care.

Objectives

To evaluate the current approach of GPs towards skin lesions suspected of malignancy in the Netherlands.

Methods

In three general practices, all consultations in 2015 concerning skin lesions suspected of malignancy were identified and reviewed. Patients demographics, circumstances of consultation, evaluation of skin lesion(s), presumed diagnosis, diagnostic accuracy and policy were evaluated.

Results

Five hundred and eighty consultations were identified. Patient took initiative for encounter in 90%. Case-finding occurred in 2%. Diagnostic tools were used in 22%; dermoscopy was used in 8% and a diagnostic excision in 10%. The GP diagnosed a benign lesion in 69%. Therapeutic interventions were applied in 31% and a wait-and-see policy in 40%. The diagnosis after referral was a benign tumour in 39% of the cases, a malignancy in 29% and a premalignant lesion in 17%. The positive predictive value (PPV) of the presumed benign, malignant, and premalignant diagnoses was 86%, 54% and 18%, respectively.

Conclusions

Most lesions that are presented to the GP with a suspicion of a malignancy, appear to be benign lesions. In the examined practices, the diagnosis of the GP is mainly based on clinical examination and little use is made of available diagnostic tools. The use of a diagnostic tool like a biopsy, might prevent unnecessary referrals.

http://ift.tt/2u29fTd

Is mitotic rate still useful in the management of patients with thin melanoma?

Abstract

Background

T1 melanoma substaging was recently modified by the American Joint Committee on Cancer (AJCC). Although sentinel lymph node (SLN) positivity is the most important prognostic factor in melanoma, there is a lack of consensus on whether SLN biopsy should be performed in patients with thin melanoma (≤1 mm).

Objective

The main aim of this study was to investigate predictors of SLN positivity in patients with thin melanoma, with a special emphasis on mitotic rate. A secondary aim was to evaluate survival in this group of patients.

Materials and Methods

Retrospective multicenter observational study with analysis of age, sex, tumor location, thickness, mitotic rate, regression, and microscopic satellites. Predictive factors were identified using a classification and regression tree (CART) approach. Melanoma-specific survival according to SLN status was estimated using Kaplan-Meier curves.

Results

We analyzed 203 patients with a melanoma ≤1 mm. Using the new AJCC staging criteria, the CART algorithm identified a 7.5% likelihood of SLN positivity in T1a patients. In the case of T1b melanoma, there was a 14.3% likelihood of SLN positivity in patients with a mitotic rate >1 mitosis/mm² and a 3.2% likelihood in those with ≤1 mitoses/mm². None of the patients with T1b disease who had ≤1 mitoses/mm² and regression had SLN positivity.

In T1b patients, 5-year melanoma-specific survival was 98.7% in the SLN-negative group and 75% in the SLN-positive group (P=0.05). When stratified by mitotic rate, survival was 100% for patients with a mitotic rate of ≤1 mitoses/mm² and 91.4% for those with >1 mitosis/mm² (P=0.022). There were no deaths in the T1a subgroup.

Conclusions

SLN metastasis was less common in patients with T1b melanoma who had a mitotic rate of ≤1 mitoses/mm². Performance of SLN biopsy should be carefully considered in this subgroup of patients, particularly considering the good prognosis.

http://ift.tt/2tNfOhc

Skin hydration, microrelief and greasiness of normal skin in Antarctica

Abstract

Background

The skin is the primary defence of the human body against external factors from physical, chemical, mechanical, and biologic origin. Climatic factors together with low temperature and sun radiation affect the skin. The effect of climatic conditions in Antarctica on healthy skin has not been previously addressed.

Objectives

The aim of this study was to evaluate the changes in the skin hydration, greasiness, and microrelief due to the extreme climatic environmental factors during the stay of the members of the Bulgarian Antarctic expedition.

Material and methods

Fifty nine Caucasian healthy subjects, 42 male and 17 female with mean age 50,9 years (27-68) were enrolled. The study was performed in five consecutive years from 2011 to 2016 at the Bulgarian Antarctic base camp at Livingston island. The study protocol consisted of two parts: study A: duration of 15 days with measurement of skin physiology parameters on a daily basis; study B: 5 measurements at baseline and at days 14, 30, 45 and 50 upon arrival in Antarctica. We measured three biophysical parameters related to skin physiology at cheek skin by an impedance measuring device.

Results

No statistically significant difference between parameters at the different measurement points. There is a variation in skin hydration reaching its lower point at day 11 and then returning to values similar to baseline. Initially an increase in skin greasiness was witnessed with a sharp depression at day 11 and final values at day 15 resembling the ones at baseline. An increase, although not statistically significant, in skin roughness was observed in the first 15 days of the study. Study B showed no statistically significant variances between values of the three parameters.

Conclusion

Our studies show the pioneer results of the effect of Antarctic climate on human skin physiology.

http://ift.tt/2u1Q1NN

Prevalence of Hearing Loss Among Children 9 to 11 Years Old

This Dutch population-based cohort study describes the prevalence of sensorineural hearing loss among children 9 to 11 years old and examines potential associations between purported risk factors and sensorineural hearing loss in early childhood.

http://ift.tt/2vMjeyp

Exercise-Induced Vertigo in Vestibular Schwannoma

This case report describes a man in his 60s with a right intracanalicular vestibular schwannoma who presented with persistent motion-induced vertigo.

http://ift.tt/2uBG3WU

Variations in the Prevalence of Hearing Loss in Children

Epidemiologic estimates of the prevalence of childhood hearing loss (HL) are important to public health and policy for a host of reasons. On the public health front, estimating the disease and disability burden of HL influences priorities in health care and research, determines whether prevention strategies are effective, and tracks longitudinal progression vs new onset of HL in the population. On a policy level, knowing the prevalence of HL in children helps policymakers allocate resources needed in the schools to rehabilitate and accommodate children and adolescents with HL, as mandated by the Individuals with Disability Education Act part C, and contributes to understanding the overall societal cost as children with HL grow into adulthood. However, epidemiological studies have reported large differences in the prevalence of childhood HL over time, from approximately 1 in 1000 to 19.5%.

http://ift.tt/2vMFCay

Prevalence of Hearing Loss in US Children and Adolescents

This analysis of NHANES data aims to further characterize changes in prevalence of hearing loss and noise exposures in the US pediatric population over time.

http://ift.tt/2uBG1yg

Fluorodeoxyglucose-positron emission tomography/computed tomography imaging features of colloid adenocarcinoma of the lung: a case report

Colloid adenocarcinoma of the lung is a rare subtype of variants of invasive adenocarcinomas. We report the appearance of this unusual entity on 18F-fluorodeoxyglucose positron emission tomography/computed tomogr...

http://ift.tt/2vMhRzq

Role of eculizumab in a pediatric refractory gemcitabine-induced thrombotic microangiopathy: a case report

The incidence of gemcitabine-induced hemolytic uremic syndrome has already been described in adults. Several approaches have been employed in the treatment of gemcitabine-induced hemolytic uremic syndrome with...

http://ift.tt/2uBdfOp

Impact of Perioperative Physical Activity on Postoperative Pulmonary Complications and Quality of Life Among Esophageal Cancer Patients

Condition: Esophageal Neoplasms
Intervention:
Sponsor: Samsung Medical Center
Recruiting - verified July 2017

http://ift.tt/2uFt7gW

Metformin Hydrochloride in Mitigating Side Effects of Radioactive Iodine Treatment in Patients With Differentiated Thyroid Cancer

Condition: Thyroid
Interventions: Drug: Metformin Hydrochloride; Other: Radioactive Iodine; Other: Placebo
Sponsor: Sidney Kimmel Cancer Center at Thomas Jefferson University
Recruiting - verified July 2017

http://ift.tt/2v1707v

Update on Quinolone Allergy

Abstract

Purpose of Review

Quinolones are a group of synthetic antibiotics widely use as first-line treatment for many infections. There has been an increase in the incidence of hypersensitivity reactions to quinolones in recent years, likely due to increased prescription. The purpose of this review is to summarize the clinical pictures, the methods used for diagnosing and the management of allergic reactions to quinolones.

Recent Findings

Allergic reactions to quinolones can be immediate or delayed, being anaphylaxis and maculopapular exanthema respectively the most frequent clinical entities. A precise diagnosis is particularly difficult since clinical history is often unreliable, skin tests can induce false-positive results, and commercial in vitro test are not well validated. Therefore, drug provocation testing is considered the gold standard to establish diagnosis, which is not a risk-free procedure. Cross-reactivity between quinolones is difficult to predict due to the small number of patients included in the few published studies. Moreover, hypersensitivity to quinolones has also been associated with beta-lactam and neuromuscular blocking agent allergies, although further studies are needed to understand the underlying mechanisms. Avoidance of the culprit quinolone is indicated in patients with a diagnosis of hypersensitivity to these drugs. When quinolone treatment is the only therapeutic option available, desensitization is necessary.