Advances in the Role of Drug-Induced Sleep Endoscopy in Investigating Sleep Apnea

Abstract

Purpose of Review

Our aim is to highlight the current advances and the role of drug-induced sleep endoscopy (DISE) in investigating sleep apnea.

Recent Findings

Since drug-induced sleep is not necessarily identical to natural sleep, proper level of sedation is important. When using propofol, clinically useful determinations of airway obstruction seem to occur at medium sedation, which is most probably achieved with a blood propofol concentration of 3.2 μg/ml. Historically, recommendations were to perform DISE in the worse sleeping position, which is almost always the supine position. In positional dependent obstructive sleep apnea (POSA), evaluation of the upper airway in lateral position becomes more important and can be mimicked by lateral head rotation alone. Simulation bites and systems as the matrix provide higher accuracy to simulate the possible effect of oral appliance therapy (OAT) compared to manual jaw thrust. When evaluating awake examination versus DISE for surgical decision making, a modification was made in 50% after DISE. Multilevel surgery was performed less after preoperative DISE screening (8 versus 59.5%) and surgical success rate was increased (86 versus 51.4%).

Summary

Drug-induced sleep endoscopy can be used for assessment of the upper airway in patients diagnosed with OSA and is essential to determine site-specific treatment and individual patient management. Management of OSA is slowly moving away from CPAP treatment only, and evidence is rising that assessment with DISE changes surgical and non-surgical treatment planning and increases treatment outcome.

http://ift.tt/2vvjDoZ

Mineralization-defects are comparable in fluorotic impacted human teeth and fluorotic mouse incisors

Publication date: November 2017
Source:Archives of Oral Biology, Volume 83
Author(s): Rozita Jalali, Franck Guy, Samaneh Ghazanfari, Don Lyaruu, Leo van Ruijven, Pamela DenBesten, Stefania Martignon, Gina Castiblanco, Antonius L.J.J. Bronckers
ObjectiveFluoride excess of 0.05–0.07mgF/kgbw/day in water or food additives like salt is the principal cause of endemic dental fluorosis. How fluoride causes these defects is not clear yet. Recent studies in rodents suggest that development of enamel fluorosis is associated with insufficient neutralization of protons released during the formation of hypermineralized lines.DesignHere we examined whether hypermineralization could also be assessed by MicroCT in developing molar enamel of humans exposed to fluoride.ResultMicro-CT analysis of hypomineralized enamel from human fluorotic molars graded by the Thylstrup–Fejerskov (TF) Index as III–IV showed weak hypermineralized lines and hypermineralized patches not seen in TF-I/II grade enamel. The mesio-distal sides of these molar teeth were significantly smaller (∼18%, p=0.02) than in TF-I/II teeth.ConclusionThe patterns of changes observed in human fluorotic teeth were similar to those in fluorotic rodent incisors. The data are consistent with the hypothesis that also in developing human teeth fluoride-stimulated local acidification of enamel could be a mechanism for developing fluorotic enamel.



http://ift.tt/2vuVPS5

In Response.

No abstract available

http://ift.tt/2vNM2Jt

In Response: Concerns With Rate of Rise of Carbon Dioxide During Apnea With Buccal Oxygenation.

No abstract available

http://ift.tt/2vv9NDw

The Subtleties of Language as a Reason for Failure to Follow Preoperative Fasting Guidelines: The Differences Between Restricting, Allowing, and Encouraging.

No abstract available

http://ift.tt/2vNVuMT

Core Temperature Monitoring in Obstetric Spinal Anesthesia Using an Ingestible Telemetric Sensor.

BACKGROUND: Perioperative hypothermia may affect maternal and neonatal outcomes after obstetric spinal anesthesia. Core temperature is often poorly monitored during spinal anesthesia, due to the lack of an accurate noninvasive core temperature monitor. The aim of this study was to describe core temperature changes and temperature recovery during spinal anesthesia for elective cesarean delivery. We expected that obstetric spinal anesthesia would be associated with a clinically relevant thermoregulatory insult (core temperature decrease >1.0[degrees]C). METHODS: A descriptive study was conducted in 28 women. An ingestible telemetric temperature sensor was used to record core temperature over time (measured every 10 seconds). The primary outcome was the maximum core temperature decrease after spinal anesthetic injection. The secondary outcomes were lowest absolute core temperature, time to lowest temperature, time to recovery of core temperature, hypothermic exposure (degree-hours below 37.0[degrees]C), and the time-weighted hypothermic exposure (median number of degrees below 37.0[degrees]C per hour). Basic descriptive statistics, median spline smooth, and integration of the area below the 37.0[degrees]C line of the temperature-over-time curve were utilized to analyze the data. RESULTS: Intestinal temperature decreased by a mean (standard deviation) of 1.30[degrees]C (0.31); 99% confidence interval (CI), 1.14 to 1.46 after spinal anesthetic injection. The median (interquartile range [IQR]) time to temperature nadir was 0.96 (0.73-1.32) hours (95% CI, 0.88-1.22). Fourteen of the 28 participants experienced intestinal temperatures below 36.0[degrees]C after spinal injection. Temperature was monitored for a minimum of 8 hours after spinal injection. In 8 of 28 participants, intestinal temperature did not recover to baseline during the monitored period. A median (IQR) of 4.59 (3.38-5.92) hours (95% CI, 3.45-5.90) was required for recovery to baseline intestinal temperature in the remaining 20 patients. Participants experienced a median (IQR) of 1.97 (1.00-2.68) degree-hours of hypothermic exposure (95% CI, 1.23-2.45). The median (IQR) number of degrees below 37.0[degrees]C per hour was 0.45 (0.35-0.60) (95% CI, 0.36-0.58). CONCLUSIONS: During cesarean delivery under spinal anesthesia, women experienced a rapid decrease in core temperature. Using an intestinal telemetric sensor, the perioperative thermal insult and recovery were documented with high resolution. Fifty percent of participants in this study became hypothermic. Although the surgical procedure is typically of short duration, women undergoing spinal anesthesia for cesarean delivery experience significant hypothermic exposure and compromised thermoregulation for several hours. (C) 2017 International Anesthesia Research Society

http://ift.tt/2vuzhkx

Respiratory Outcomes in Preterm Infants: From Infancy Through Adulthood.

No abstract available

http://ift.tt/2vNItms

Reducing Mortality in Acute Kidney Injury.

No abstract available

http://ift.tt/2vvkupC

Cervical mass as the first clinical manifestation of unsuspected metastatic seminoma

The authors reported a case of a 27‐year‐old man with a nontender left neck mass that had grown quite rapidly within few weeks. FNAB and CT were not consistent to establish the definite diagnosis. After excisional biopsy, the histopathological examination and the immunohistochemical study of the specimen revealed a cervical metastasis of seminoma. The patient was treated with chemotherapy with a complete clinical remission. This uncommon case-report can represent a great diagnostic and therapeutic challenge and should be considered in the differential diagnosis of every cervical masses occurring in young males patients.

http://ift.tt/2vrsBp4

Does CT help in predicting preepiglottic space invasion in laryngeal carcinoma?

Evaluating preepiglottic space involvement in laryngeal cancer by CT may lead misinterpretation. We sought to understand the causes of misinterpretation in evaluating the preepiglottic space by CT and assessed the effects of misinterpretation in treatment plans of patients with laryngeal squamous cell carcinomas.

http://ift.tt/2wCQVT8

Correlation of soft palate length with velum obstruction and severity of obstructive sleep apnea syndrome

Our aim in this study was to analyze whether soft palate length and velum obstruction during sleep are correlated and to determine the effects of related parameters on obstructive sleep apnea syndrome (OSAS) severity. We used computed tomography to measure soft palate length and drug-induced sleep endoscopy (DISE) to evaluate velum obstruction severity. Patients also underwent polysomnography (PSG) for evaluation of OSAS severity.

http://ift.tt/2vrE7kb

Clinical course of incidental parathyroidectomy: Single center experience

Thyroidectomy is a very common surgical procedure. Regardless of surgeon experience, incidental parathyroidectomy is a complication of thyroidectomy. The aim of this study was to identify the clinical course of incidental parathyroidectomies after thyroidectomy.

http://ift.tt/2wCuNZr

Successful long-term extracorporeal membrane oxygenation for invasive pulmonary aspergillosis: a case report

Extracorporeal membrane oxygenation is an established life-saving procedure for severe acute respiratory failure due to various causes. In general, the duration of extracorporeal membrane oxygenation ranges fr...

http://ift.tt/2wQug5t

Erosión ósea del canal carotídeo. Síndrome de Gradénigo

Publication date: Available online 10 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Aina Brunet-Garcia, M. Virginia Barrios-Crispi, Marta Faubel-Serra




http://ift.tt/2vMTXH3

Evaluación de la capacidad formativa del libro del residente de Otorrinolaringología español (FORMIR) como portafolio electrónico

Publication date: Available online 10 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Juan Manuel Maza Solano, Gustavo Benavente Bermudo, Francisco José Estrada Molina, Jesús Ambrosiani Fernández, Serafín Sánchez Gómez
Introducción y objetivosEvaluar la capacidad formativa del libro del residente español como portafolio electrónico para alcanzar los objetivos de aprendizaje de los MIR de Otorrinolaringología (ORL).MétodosSe realizó una investigación cualitativa multimétodo de características tranversal, temporal y de orientación retrospectiva sobre los MIR de ORL mediante un cuestionario estructurado y una entrevista semiestructurada, sobre la aplicación informática web FORMIR.ResultadosParticiparon el 56,5% de los MIR de ORL de alguno de los 63 hospitales españoles acreditados para impartir formación en ORL entre 2009 y 2012. Los resultados obtenidos demostraron que los MIR de ORL que utilizaban el portafolio electrónico eran capaces de autoguiar mejor su aprendizaje, conocían mejor sus objetivos de aprendizaje, cumplían más eficientemente el programa de formación, identificaban más claramente las causas de sus carencias en el aprendizaje y consideraban que FORMIR como portafolio electrónico constituía una herramienta formativa idónea para sustituir al libro del residente en formato papel.ConclusionesLos MIR de ORL apreciaban de forma muy relevante las prestaciones formativas de FORMIR como portafolio electrónico, especialmente su interfaz, el feedback numérico y automático sobre la adquisición de competencias, su capacidad de almacenamiento de evidencias y su capacidad de visualizarse como logbook de la Unión Europea de Médicos Especialistas o como un curriculum vitae estándar. Este feedback automático facilita el aprendizaje autoguiado. Todo esto hace de FORMIR una herramienta formativa y evaluativa que supera las prestaciones y aceptación de instrumentos similares puestos a disposición de los residentes, que no dudan en proponerlo como el libro del residente más idóneo para facilitar su formación especializada.Backgroundand objectives We have evaluated the training capacity of the Spanish resident training book as an electronic portfolio to achieve the learning objectives of otorhinolaryngology (ENT) residents.MethodsA multi-method qualitative investigation with transversal characteristics, temporal and retrospective guidance was performed on Spanish ENT residents using a structured questionnaire, a semi-structured interview, and a computer application on the FORMIR website.ResultsA 56.5% of ENT-residents specialising in one of the 63 accredited Spanish hospitals between 2009-2012 participated in the study. The results obtained show that the ENT residents who used the e-portfolio were better able to implement self-guided study, were more aware of their learning objectives, fulfilled the training programme more efficiently, identified the causes of learning gaps more clearly, and considered FORMIR in e-portfolio format to be an ideal training tool to replace the resident training book in paper format.ConclusionsThe ENT residents greatly appreciated the training benefits of FORMIR as an e-portfolio, especially its simple and intuitive interface, the ease and comfort with which they could record their activities, the automatic and numeric feedback on the acquisition of their competencies (which facilitates self-guided learning), its storage capacity for evidence, and its ability to be used as UEMS logbook as well as a standard curriculum vitae. All these features make FORMIR a training and evaluation tool that outperforms similar instruments available to ENT residents. They do not hesitate to identify it as the ideal resident training book for facilitating their specialised training.



http://ift.tt/2vuIoBS

Arteria lusoria: A rare cause of tracheal compression

Publication date: Available online 10 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Ana Nóbrega-Pinto, Isabel Carvalho, Cecília Almeida-Sousa




http://ift.tt/2vMMR5l

Seudotumor inflamatorio subglótico en un niño de 3 años

Publication date: Available online 10 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Javier Cervera Escario, Sara Sirvent Cerdá, Saturnino Santos Santos, Adolfo Sequeiros González




http://ift.tt/2uy9Mxt

Primary tuberculosis of the nasal septum: The non-ulcerated form presenting as septal thickening

Publication date: Available online 10 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Neeraj Aggarwal, Mainak Dutta, Ramanuj Sinha




http://ift.tt/2vMDqD5

Télédermatologie unissant deux hôpitaux : deux ans d’expérience

Publication date: Available online 10 August 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): C. Bertin, A. Diakite, B. Carton, C. Wozniak, S. Nathanson, S. Monnier, C. Sin, M.-A. Dommergues, J. Parigot, F. Moreau, M.-L. Sigal, P. Foucaud, A. Greder, E. Mahé
IntroductionLa télédermatologie est en plein essor. La pénurie de dermatologues rend difficile l'accès de certaines structures hospitalières à des avis dermatologiques. Nous présentons notre expérience unissant un centre expert, le service de dermatologie du centre hospitalier Victor-Dupouy d'Argenteuil, à toutes les structures médicales rattachées au centre hospitalier André-Mignot (CHV) de Versailles : 2 unités sanitaires de centres pénitentiaires (UCSA), les services traditionnels et les urgences.Matériel et méthodesLa télédermatologie, sous la forme de télé-expertises, a été déployée aux UCSA du CHV en novembre 2013. Cette expertise s'est ensuite étendue en juin 2014 au service de médecine interne et du CHV, et en décembre 2014 à l'ensemble des services du CHV y compris les urgences. Les règles de télédermatologie et éthiques ont été respectées. Si tous dossiers pouvaient être déposés par les UCSA, seuls les dossiers urgents ou difficiles pouvaient être déposés par les autres services du CHV.RésultatsEn 26 mois, 347 requêtes ont été déposées, 231 par les centres pénitentiaires et 116 par le CHV. Aucun refus de patient d'utiliser la télé-expertise n'a été exprimé. La qualité des informations et photographies était considérée comme bonne ou excellente dans plus de 95 % des cas. La réponse était donnée dans les 3heures dans plus de 50 % des cas et dans tous les cas dans les 24heures (jours ouvrables). L'analyse des pathologies diagnostiquées illustre la grande diversité des pathologies rencontrées en dermatologie, avec des spécificités propres aux différentes structures.ConclusionL'exemple détaillé ici illustre la possibilité de développer une telle plate-forme inter-hospitalière. Elle ne répond pas encore aux demandes adressées aux dermatologues par des patients ou par d'autres dermatologues. Son acceptabilité a été considérée comme excellente par les patients (aucun refus), par les demandeurs et par le centre expert.BackgroundTeledermatology is currently booming. Due to the shortage of dermatologists in hospitals access to dermatological consultations is very limited in some hospitals. We present our experience of collaboration between an expert center, the dermatology department of the Victor-Dupouy Hospital Centre in Argenteuil, and all medical structures under the André-Mignot Hospital in Versailles (CHV), including 2 prison medical centers (UCSA), traditional departments and emergency department.Patients and methodsTeledermatology, developed in the form of tele-expertise, began at the UCSA in November 2013. This expertise was then extended in June 2014 to the Internal Medicine department of CHV, and in December 2014 to all departments, including the emergency department. The rules and ethics of teledermatology were strictly adhered to. While UCSA could file all expertise dossiers, only urgent or difficult cases could be filed by other CHV departments.ResultsIn 26 months, 347 expertise requests were filed: 231 by prisons and 116 by the other departments of the CHV. No patients refused teledermatology. The quality of information and photographs was considered good or excellent in over 95% of cases. A response was given within 3hours in more than 50% of cases and in all cases within 24hours (on working days). Analysis of diseases diagnosed illustrates the wide variety of conditions encountered in dermatology, with different structures having their own specific features.ConclusionOur example illustrates the possibility of developing such an inter-hospital platform. However, it does not yet cater for requests made by patients to dermatologists, by dermatologists to dermatologists, or by dermatologists to the hospital teledermatology department. Acceptability was considered excellent by patients (with no refusals), physicians at the CHV, and the expert center.



http://ift.tt/2wPEGSN

Predictors of survival in head and neck mucosal melanoma

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): Matthew Q. Schmidt, John David, Emi J. Yoshida, Kevin Scher, Alain Mita, Stephen L. Shiao, Allen S. Ho, Zachary S. Zumsteg
ObjectivesTo evaluate hospital-based data of head and neck mucosal melanoma patients in order to identify predictors of survival.Materials and methodsThe National Cancer Data Base was used to identify 1368 patients with head and neck mucosal melanoma diagnosed between the years of 2004 and 2012. The Kaplan-Meier method was utilized to estimate overall survival, and multivariate Cox regression analyses were performed to assess the impact of covariates on survival after adjusting for confounding variables.ResultsMedian follow-up was 55.2months. Median survival of all patients was 29.3months, and the 5-year survival was 27.4%. After adjusting for other prognostic factors in multivariate analysis, paranasal sinus location [hazard ratio (HR)=1.54, 95% Confidence Interval (CI)=1.30–1.82, P<0.001)] and the use of radiotherapy alone for definitive local treatment (HR=2.27, 95% CI=1.72–2.98, P<0.001) were associated with worse survival. Similar results were seen in the subgroup of patients with complete clinical staging information. In terms of patterns of care, the use of combined surgery and radiotherapy as the primary local treatment modality has significant increased from 2004 and 2012 (P=0.03).ConclusionOutcomes in mucosal melanoma of the head and neck remain suboptimal, despite increased use of multimodality local therapy, likely due to the high risk of distant metastases. Mucosal melanomas arising from the paranasal sinuses have particularly poor prognosis. Novel therapeutic paradigms for head and neck mucosal melanoma, incorporating systemic therapies to decrease the risk of distant relapse, should be pursued in clinical trials.



http://ift.tt/2fyMo08

Incidence of facial nerve sacrifice in parotidectomy for primary and metastatic malignancies

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): Brian Swendseid, Shawn Li, Jason Thuener, Rod Rezaee, Pierre Lavertu, Nicole Fowler, Chad Zender
IntroductionThe parotid gland may become involved by primary parotid malignancies and secondarily by metastases from other primary sites. Surgical resection of these tumors can be technically challenging due to the intimate relationship of the parotid gland and the facial nerve. The primary aim of this project was to determine the incidence of facial nerve sacrifice in parotidectomy for primary and secondary malignancies of the parotid.MethodsA retrospective chart review of was performed. Patients who received parotidectomy with final pathology consistent with a malignant neoplasm were included. The primary outcome studied was necessity for facial nerve sacrifice. Co-variates included preoperative facial nerve function, preoperative pain, superficial versus total parotidectomy and pathologic diagnosis. Univariate analysis was performed using student t-test to determine odds ratios.ResultsWe identified 75 patients who had a parotidectomy for a malignant process in our review. 30 patients had facial nerve sacrifice: 14 total and 16 partial sacrifices. Patients were more likely to require facial nerve sacrifice when they presented with preoperative facial nerve dysfunction [100% vs 19.6%, p=0.0006, OR 154.3, CI (8.66–2750.9)], pre-op pain [76.5% vs. 29.3%, p=0.001, OR 7.84, CI (2.23–27.50)], and required excision of both superficial and deep lobes of the parotid gland [64.9% vs 15.8%, p=0.0001, OR 9.85, CI (3.27–29.66)].ConclusionOur data illustrates that many patients with normal facial nerve function, even in the setting of malignancy, can have their facial nerve preserved. Pain, deep lobe involvement and preoperative facial nerve dysfunction are associated with an increased risk of needing at least partial facial nerve sacrifice in the setting of parotid gland malignancies.



http://ift.tt/2hRTbCN

A Comparison of Two Endoscopic Posterior Cordotomy Techniques: Laser Cordotomy vs Diathermy Assisted Cordotomy

Abstract

Objectives

To compare respiratory function, swallowing and voice quality of bilateral abductor vocal fold paralysis (BAVFP) patients undergoing laser and diathermy assisted posterior cordotomy.

Design

Prospective study.

Setting

Tertiary academic hospital.

Participants

Thirty patients were included in the study (Group 1 and 2, 15 patients each). Mean age was 53±14.27 years with a range of 31-78 years (12 (40%) male, 18 (60%) female).

Main outcome measures

Sufficient airway, complications, FEV1, FEV1/FVC, PEF, voice quality VAS, fundamental frequency, jitter, shimmer, NHR, APQ and PPQ scores.

Results

A sufficient laryngeal airway was achieved in all patients. Six patients (20%) developed postoperative granulation tissue (two in group 1 and four in group 2).

There was a statistically significant improvement in FEV1, FEV1/FVC and PEF measurements at the postoperative sixth month compared to preoperative measurements in both of the groups (p<0.05).

Preoperative median voice quality VAS scores in groups 1 and 2 were 8 (IQR=1) and 8 (IQR=3) respectively. Postoperative sixth month voice quality VAS scores in groups 1 and 2 were 6 (IQR=1) and 6 (IQR=0) respectively. Postoperative VAS scores were significantly lower in both groups (p<0.05).

The postoperative changes in fundamental frequency, NHR, jitter, shimmer, APQ and PPQ were not statistically significant in both of the groups (p>0.05).

Conclusions

Laser and diathermy assisted posterior cordotomy are both minimaly invasive, effective techniques with a long-term sufficient laryngeal airway. Despite lower quality of voice VAS scores, objective acoustic outcomes were not significantly lower in both of the groups.

This article is protected by copyright. All rights reserved.

http://ift.tt/2vqdc8f

The SIGN 104 guideline (2014) for topical antibiotic prophylaxis during grommet insertion: misguided?

Abstract

We write to express both concern and surprise at the updated SIGN (Scottish Intercollegiate guidelines network) guideline 104 (2014) for antibiotic prophylaxis [1]. The original SIGN guideline 104 (2008)[2] recommended the use of a single dose of prophylactic topical antibiotic during grommet insertion based on 3 RCT's one of which showed no difference in outcome in the use of antibiotic and saline drops. Two of the 3 studies used Ciprofloxacin and Ofloxacin, neither of which is licensed for use in the United Kingdom.

This article is protected by copyright. All rights reserved.

http://ift.tt/2wAWTnH

Comparison of robotic and coblation tongue base resection for obstructive sleep apnea

Abstract

Objectives

To compare the efficacy and safety of transoral robotic surgery (TORS) with endoscope-guided coblation tongue base resection.

Design

Retrospective case-control study.

Setting

University-based tertiary care medical center.

Participants

OSA patients who underwent endoscope-guided tongue base coblation resection or TORS in combination with lateral pharyngoplasty at a single institution in South Korea between April 2013 and December 2016 were investigated. Forty-five patients who had moderate to severe OSA with tongue base collapse and a minimum follow-up period of 6 months with postoperative polysomnography (PSG) were enrolled in this study.

Main outcome measures

All patients underwent pre- and postoperative (at least 4 months after surgery) overnight PSG. Available information on results of the PSG, Epworth Sleepiness Scale, and complications of the TORS and coblation groups were compared.

Results

Postoperative PSG studies showed improved sleep quality for most patients. The mean postoperative apnea-hypopnea index (AHI) was reduced significantly from 45.0 to 17.0 events/h (p < 0.0001) in the TORS group and from 45.6 to 16.2 events/h (p < 0.0001) in the coblation group. The mean rates of improvement (AHI reduction > 50%) were 75.0% in TORS patients and 62.1% in coblation patients; the difference was not significant. Less frequent postoperative morbidity, including bleeding, taste dysfunction, and foreign body sensation, were recorded in TORS patients.

Conclusions

Both the coblation and TORS groups showed similar surgical outcomes, TORS achieved PSG results non-inferior to and complication rates comparable to coblation.

This article is protected by copyright. All rights reserved.

http://ift.tt/2vq26A5

Unresectable squamous cell carcinoma of upper trachea with long-term survival after concurrent chemoradiotherapy

Upper tracheal malignancies are rare, and long-term survival is even rarer, especially among the unresectable malignancies. A 66-year-old chronic smoker was diagnosed as a locally advanced, non-metastatic squamous cell carcinoma of the upper trachea. Being unresectable, he was treated with six cycles of concurrent weekly cisplatin and three-dimensional conformal radiotherapy to a dose of 60 Gy in 30 fractions over 6 weeks. Follow-up imaging at 6 and 12 months revealed no disease. Our patient is presently 36 months post-treatment and is disease free without tracheal necrosis, fistula or radiation pneumonitis but developed hypothyroidism and is presently euthyroid. Concurrent chemoradiotherapy appears safe up to 3 years at least without any necrosis and is effective in controlling local disease. Meticulous planning obviates the need for higher technology like motion management techniques or intensity-modulated radiotherapy.

http://ift.tt/2vpm9P8

Paraneoplastic mucous membrane pemphigoid with ocular and laryngeal involvement

A 73-year-old woman was treated 8 years previously for synchronous breast and uterine neoplasms. She presented with a severe sore throat, odynophagia, dysphonia, dyspnoea, ocular irritation and weight loss over the last 3 months. Physical examination revealed ulcerations in the oral cavity, posterior pharyngeal wall and supraglottic larynx, nasal crusting, bilateral conjunctivitis and three cutaneous blisters. A diagnosis of anti-laminin 5 mucous membrane pemphigoid was retained, based on skin biopsy, direct immunofluorescence and immunoprecipitation. A positron emission tomography (PET)-CT detected multiple adenopathies. Cytology revealed adenocarcinoma with an immunocytology compatible with a breast origin and this was considered as a late metastatic recurrence of her previous breast cancer. A treatment of prednisone, dapsone and hormonotherapy was introduced, but intravenous immunoglobulin and rituximab were added due to new mucosal lesions. Despite treatment, a posterior laryngeal scar and bilateral symblepharon were developed. After 3 years, the patient is still alive and reports a satisfactory quality of life.

http://ift.tt/2wBeX0P

Isolated intraductal variant of hepatocellular carcinoma

Description

A 70-year-old male teetotaller, with a history of chronic obstructive lung disease and hypertension, presented to the emergency department with a 2-day history of right upper quadrant pain and melaena. Investigations revealed total bilirubin 6.8 mg/dL, aspartate and alanine transaminases 88 and 122 IU/L, respectively, alkaline phosphatase 338 IU/L and gamma-glutamyl transpeptidase 223 IU/L. Tests for chronic hepatitis B, hepatitis C and HIV were negative. Serum alpha-fetoprotein was 22.8 ng/mL, whereas carcino-embryonic antigen (CEA), CA 19–9, prostate specific antigen and chromogranin levels were normal. Contrast CT of the abdomen revealed fatty liver with moderate dilation of bilateral intrahepatic biliary radicles (figure 1A) and dilated common bile duct (CBD) with hyperdense contents, without identifiable mass lesions in the liver or biliary tree. Upper gastrointestinal endoscopy revealed haemobilia, and cholangiogram showed normal calibre CBD with filling defects. Endoscopic intraductal ultrasound revealed focal thickening of segment three hepatic duct, and Spyglass cholangioscopy confirmed a...

http://ift.tt/2vqbZho

Bilateral painful tic convulsif

'Painful tic convulsif' (PTC) describes the coexistence of hemifacial spasm and trigeminal neuralgia. In this report, we describe a unique presentation of bilateral PTC in a man with bilateral hemifacial spasm and trigeminal neuralgia secondary to neurovascular conflict of all four cranial nerves. Following failed medical and radiofrequency therapy, microvascular decompression of three of the four involved nerves was performed, where the offending vessels were mobilised and Teflon used to prevent conflict recurrence. He continues to respond to Botox for right hemifacial spasm. Since surgery, he remains pain free bilaterally and spasm free on the left.

http://ift.tt/2wAWS39

Lenalidomide-associated arterial thrombosis in a patient with JAK2 positive atypical myeloproliferative neoplasm

Description

A 71-year-old woman, with a recent diagnosis of JAK2 positive atypical myeloproliferative neoplasm, presented to the emergency room (ER) for bilateral foot pain and purplish discolouration of her toes (figure 1). She started her first cancer treatment 3 weeks ago using lenalidomide with prednisone 20 mg daily. Venous thromboprophylaxis was not prescribed then due to anaemia and history of intracranial haemorrhage. ER work up included simple X-rays of her feet that were normal. Lower extremity ultrasound did not show any deep vein thrombosis, so she was discharged home. The patient did not have atrial fibrillation or hyperviscosity. No history of arterial thrombosis or smoking. Two weeks later, she was re-evaluated by her haematologist, and a hospital admission was arranged given worsening symptoms. Her physical exam now showed the purplish discolouration has progressed over both feet, associated with some toes turning black (figure 2). She had strong lower extremity...

http://ift.tt/2vpWx4F

Right hepatic artery 'caterpillar hump and dual cystic arteries: relevance of critical view of safety in a 'straightforward cholecystectomy

Description

A 60-year-old woman with unremarkable medical history, underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. A four-port technique was performed. Initial exploration of Calot's triangle was carried out by upward traction of the fundus and lateral retraction of the Hartmann's pouch; after dissection of the peritoneum medially at the level of the infundibulum, two tubular structures entering the gallbladder were visible, as usually expected. However, to obtain a 'critical view of safety',1 dissection was continued by opening up the lateral aspect of the peritoneum; hepatobiliary triangle was dissected free of areolar tissue and the bottom of the gallbladder was dissected off the lower part of the liver bed. At this stage, an anatomical variation became evident (figure 1): the right hepatic artery made a 'caterpillar-like' loop inside Calot's triangle and two short cystic arteries reached the gallbladder. According to a recent review, among clinically...

http://ift.tt/2wAV0Y6

Therapeutic options for bleeding oesophageal varices: cyanoacrylate and balloon-occluded retrograde obliteration (BRTO)

A 56-year-old male with cirrhosis presented with acute bleeding from cardiofundal gastroesophageal varices (GOV) and was treated with endoscopic cyanoacrylate glue. Glue therapy achieved stabilisation of the patient in the emergent setting. Three months later, the patient suffered rebleeding. At that time, he underwent retreatment with balloon-occluded retrograde obliteration (BRTO), with no recurrence at a follow-up of 14 months.

Available treatments for bleeding GOV include methods to (a) directly obstruct the varices (endoscopic variceal ligation , sclerotherapy and cyanoacrylate glue, BRTO) or to (b) decrease portal pressure (surgical portacaval shunts; transportal intrahepatic portosystemic shunt). No precise guidelines are available regarding when to use which modality, and few centres have experience with all of them. This case report illustrates a setting in which both options of cyanoacrylate glue therapy and BRTO were used for acute gastric variceal bleeding.

http://ift.tt/2vqpP3q

Cytomegalovirus-related transverse myelitis in an immunocompetent host: a subacute onset of an immune-mediated disease?

We report a case of transverse myelitis in an immunocompetent host with an atypical long onset of symptoms. A 56-year-old man was admitted to the hospital reporting 5 months of progressive ascending lower extremity weakness and numbness, inability to walk, bowel incontinence,urinary retention and several episodes of nausea and vomiting. MRI showed moderate spinal swelling and multiple hyperintense signal changes on cervical levels C2–C5 and thoracic levels T1–T3. Cerebrospinal fluid (CSF) showed pleocytosis and was positive for anti-cytomegalovirus (CMV) IgG intrathecal antibodies, but the CSF PCR for CMV was negative. The diagnosis of immune-mediated CMV-related transverse myelitis was established and the patient was treated with methylprednisolone and valgancyclovir. The patient had poor recovery and remained paraplegic at discharge.

http://ift.tt/2fyL2m6

Portal vein aneurysm in thalassaemia

Arterial aneurysms are more common than visceral venous aneurysms. Portal vein aneurysms being the most common type of visceral venous aneurysms. Here, we present an 18-year-old young woman with thalassaemia major, who presented with headache, palpitation, shortness of breath and a recent increase in blood transfusion rate. On clinical examination, she had hepatosplenomegaly. Ultrasonography revealed hepatosplenomegaly with fusiform dilatation of extrahepatic portal vein, which was confirmed to be portal vein aneurysm on contrast enhanced CT. Though portal vein aneurysms were previously thought to be rare, recently they are increasingly diagnosed with the use of cross-sectional imaging. Recognition of this finding can help to avoid potential confusion with other periportal cystic masses of different aetiologies, especially on sonography.

http://ift.tt/2hRuw1b

Acute myeloid leukaemia masquerading as a primary CNS tumour

In children with newly diagnosed acute myeloid leukaemia (AML), myeloid sarcomas (MS) of the central nervous system (CNS) are rare. Since MS involving the CNS are potentially curable, timely recognition is paramount. Establishing a diagnosis may be problematic as they can easily mimic primary CNS neoplasms. We report the case of a 5-year-old boy with AML with t(8;21)(q22;q22) rearrangement who presented with a massive intracranial MS and rapid clinical deterioration suggestive of a meningioma or a primitive neuroectodermal tumour. The peripheral smear showed blasts with Auer rods. Urgent chemotherapy was started for AML with presumptive CNS MS. The mass resolved with chemotherapy, and treatment was consolidated with radiotherapy. Although exceedingly rare, this case highlights the potential for MS to present similarly to a primary CNS tumour. MS should be part of the differential diagnosis as part of a CNS mass, particularly if the complete blood count is abnormal.

http://ift.tt/2fxjUDU

Transvaginal postpartum manual removal of a prolapsed submucous leiomyoma, initially diagnosed hybrid predominantly intramural

We present a rare case of a large infarcted submucous fibroid removed manually after a normal vaginal delivery. This patient was known to have a large postero-fundal hybrid predominantly intramural uterine fibroid, measuring 11 x 10 cm in diameter and diagnosed 2 years prior to last conception. Thirty-five days postpartum, she presented with severe lower abdominal pain and foul smell per vaginum. Abdominal examination revealed a very tender bulky uterus at 24 weeks size, and vaginal examination revealed a big fleshy smelly mass with friable surface just bulging from a dilated cervix. Examination under anaesthesia revealed a very foul smelly large pedunculated submucous fibroid that was felt through a dilated cervix. It was deliverable vaginally, so the submucous leiomyoma was removed manually, a procedure similar to manual removal of placenta. Histopathology examination confirmed an infarcted massive fibroid.

http://ift.tt/2hQCYho

Anterior cervical osteophytosis as a cause of dyspnoea and stridor

Description

A 77-year-old man with no history of respiratory disease presented with a 12-hour history of dyspnoea, stridor, non-productive cough and rhinorrhoea. He denied other symptoms such as dysphagia and dysphonia. Physical examination showed diminished vesicular breath sounds and stridor, although there were no vocal cord abnormalities in the laryngoscopic evaluation. The laboratory results and the posteroanterior chest radiograph revealed no significant abnormalities.

In order to exclude an airway obstruction, a cervical radiograph was obtained. The exam showed anterior osteophytosis involving the lower segment of the cervical spine (figure 1). A CT scan confirmed the diagnosis, revealing a tracheal narrowing due to anterior osteophytosis between C5 and C7 associated with thickening of adjacent soft tissues (figure 2).

Figure 1

Cervical radiograph showing extensive osteophytosis in the anterior aspects of the lower cervical vertebrae.

Figure 2

Cervical CT scan...

http://ift.tt/2fy8rEg

Mechanical thrombectomy for repeated cerebral tumor embolism from a thoracic sarcomatoid carcinoma

Cerebral embolism originating from intracardiac tumors represents a rare cause of stroke and has been documented in both adult and pediatric populations. We present a patient recently diagnosed with a right pulmonary hilum tumor, invading the pulmonary veins and the left atrium. Two consecutive episodes of large cerebral vessel occlusion in separate vascular territories occurred in the same day and were treated by mechanical thrombectomy. Embolic material retrieved on both occasions contained tumor fragments with peripheral endothelialization. To our knowledge, this is the first report with histological confirmation of cerebral embolism from an invasive extracardiac tumor.

http://ift.tt/2hRmMfO

Insulin-mediated lipohypertrophy: an uncommon cause of diabetic ketoacidosis

Description

A 15-year-old boy with a 3-year history of type 1 diabetes mellitus was referred to endocrinology clinic for the management of uncontrolled blood glucose levels. His present treatment plan comprised subcutaneous basal-bolus insulin regimen. He was taking regular insulin before the three major meals and insulin glargine at the bedtime. His body mass index (BMI) was 14.8 kg/m² and HbA1c level 14.9%, suggesting uncontrolled hyperglycaemia for a long time.

On examination, he was found to have remarkably prominent bilateral lipohypertrophic areas on the lower abdomen (figure 1), large enough to be noticeable even through the clothing.

Figure 1

Showing prominent bulge on either side of the lower abdomen (side view).

His injection practices revealed that he was self-administering insulin over the abdomen with the syringe of needle size 6 mm, apparently leading to intramuscular injection in a thin-built person.1 Furthermore,...

http://ift.tt/2fz55Rz

Aluminium phosphide poisoning with severe cardiac dysfunction and the role of digoxin

Aluminium phosphide (ALP) is a common cause of suicidal poisoning in India where it is easily available and commonly known as 'rice tablet'. In rural areas of India, it is still used to protect rice and stored grains from rodents and pests.¹ There is no specific antidote for phosphide poisoning and treatment involves meticulous supportive care. Ingestion can lead to severe cardiac suppression and cardiogenic shock. For patients poisoned with ALP who continue to have refractory shock with persistent myocardial suppression despite the use of adrenergic inotropic agents, the addition of digoxin may be beneficial. We present a case where digoxin was utilised with beneficial patient outcomes.

http://ift.tt/2hQVgin

Postcardiac injury syndrome and stroke following permanent pacemaker insertion

An 80-year-old woman initially presented with an episode of pleuritic chest pain 10 days after implantation of a dual chamber permanent pacemaker. She returned to hospital a day later with vomiting and fever. She was found to have new atrial fibrillation in addition to right-sided weakness and dysarthria. An infarct in the left anterior inferior cerebellar artery territory was later confirmed on CT. She continued to have recurrent febrile episodes associated with vomiting and dyspnoea. Extensive investigations for infection were negative, and her symptoms were initially attributed to aspiration pneumonia. The patient gradually deteriorated despite antibiotics and became progressively short of breath, with development of large pleural and pericardial effusions. A diagnosis of postcardiac injury syndrome was made after exclusion of other differentials. The patient recovered well after pleurocentesis, pericardiocentesis and a pericardial window, with resolution of symptoms without further medical therapy.

http://ift.tt/2fz50gJ

Sternal cleft malformation in a newborn

Description

We present the video case report (see online ) of a term newborn with complete sternal cleft and skin defect 2 cm in diameter, without other associated anomaly, including skeletal (figure 1). She was born by elective C-section due to breech presentation. There was no prenatal diagnosis. The baby was in good general condition. The chest X-ray did not reveal any other thoracic malformation. The echocardiogram showed a small patent ductus arteriosus and a patent foramen ovale in a structurally normal heart.

Figure 1

Chest X-ray demonstrates no skeletal abnormality on first day of life.

Sternal cleft is a rare congenital malformation due to a partial or total failure of sternal fusion early in the embryological development.1 The sternal defect seems to be more easily identified when associated with a cardiac anomaly, because of the repeated scans for other malformations....

http://ift.tt/2hQUNNf

Autoimmune gastrointestinal dysmotility due to small cell lung cancer

The diagnosis of autoimmune gastrointestinal dysmotility requires a high level of clinical suspicion when standard work-up is unrevealing. We report the case of a 56-year-old male patient with history of tobacco use and a subacute presentation of weight loss, vomiting and cerebellar ataxia. The discovery of paraneoplastic type 1 antineuronal nuclear antibodies and neuronal acetylcholine receptor antibodies led to further directed imaging and diagnostic studies in spite of prior negative chest imaging. Bronchoscopy with endobronchial ultrasound was used to confirm a diagnosis of small cell lung cancer and paraneoplastic syndrome as the cause of the presenting upper gastrointestinal symptoms.

http://ift.tt/2fxC88u

Valsalva haemorrhagic retinopathy in pregnancy after yoga

A 35-year-old pregnant Caucasian woman at 27 weeks gestation presented with sudden onset painless loss of vision and a large floater in her left eye while doing yoga. She was found to have a dense vitreous haemorrhage with a small preretinal haemorrhage. Ultrasound imaging confirmed the haemorrhage and showed no other retinal damage. She was diagnosed with valsalva haemorrhagic retinopathy and was treated conservatively. After 5 months of follow-up, this woman had had a normal delivery and her haemorrhages and vision loss had resolved.

http://ift.tt/2hRw63p

Isolated clival metastasis: a rare presentation of renal cell carcinoma

Renal cell carcinoma accounts for 3% of all adult malignancies. Usual sites of metastasis are lymph nodes, lungs, bone, liver and brain. We describe a patient who presented with complaints of holocranial headache and diplopia. MRI of the head showed a clival-based lesion with associated bony erosion. With suspicion of a metastatic lesion, an ultrasonogram of the abdomen was done which showed a left renal mass that enhanced on contrast-enhanced CT. There were no other metastatic foci. Patient underwent radiotherapy for the clival lesion. This case report emphasises on the evaluation of clival lesion with cranial neuropathies for a possibility of a renal primary tumour.

http://ift.tt/2fz4OOx

Family with clots: antithrombin deficiency

Description

A 44-year-old African-American woman presented to the emergency department with chest pain and shortness of breath of 12 hours prior to presentation. Her medical history includes antithrombin deficiency, recurrent deep venous thrombosis (DVT), recurrent pulmonary emboli, poorly controlled hypertension, diabetes mellitus, asthma, inferior vena cava filter placement, pulmonary hypertension and bipolar disorder. Her surgical history includes bilateral pulmonary thromboendarterectomy 3 months prior to presentation. She reported non-compliance to Coumadin. She smokes half a pack per day for the last 25 years. Family history is positive for multiple early deaths secondary to thromboembolic complications.

Physical examination showed tachycardia with heart rate of 105 beats per minute. Chest examination was significant for bilateral rales at the lung bases. ECG showed sinus tachycardia, cardiac troponins were negative and international normalised ratio was 1.08. Venous duplex of the lower extremities showed chronic DVT.

Chest CT scan with contrast showed an occlusion of the left...

http://ift.tt/2hRO3yN

Hypercapnia-induced cerebral oedema in a patient with COPD exacerbation: a rare and under-recognised entity

Description

A 56-year-old Caucasian woman with severe chronic obstructive pulmonary disease (COPD) on home oxygen presented with a severe exacerbation. Vitals included a blood pressure of 111/73 mm Hg, a pulse of 102/minute, respiratory rate of 13/minute and O₂ saturation of 84% on oxygen of 2–3 L/minute by nasal cannula. She was lethargic, confused and was wheezing. She was placed on bi-level positive airway pressure (BiPAP) but her mentation continued to deteriorate. White cell counts were normal. Chest X-ray showed hyperinflated lungs but no infiltrates. Arterial blood gases revealed severe hypercapnic respiratory acidosis with a pH of 7.26, pCO₂ of 100.1 mm Hg, pO₂ of 187 mm Hg and bicarbonate of 47 mmol/L. In spite of BiPAP, her acidosis worsened with a pCO₂ of 131 mm Hg. She was intubated for acute hypercapnic respiratory failure. Although her deteriorating mentation correlated with CO₂ narcosis, it was judicious to perform neuroimaging like cerebral CT to rule out other causes...

http://ift.tt/2fyBV52

Stabbing pain in the throat after teeth cleaning

Description 

A previously healthy, 25-year-old woman presented to the emergency department with mild stabbing pain and foreign body feeling in her throat after cleaning her interdental spaces with a pin, which she accidentally swallowed. Physical examination, including enoral inspection, showed no abnormalities. An anterior–posterior and lateral cervical radiograph was performed (figures 1 and 2).

Figure 1

Anterior–posterior (A) and lateral (B) cervical radiographs. L, left; R, right.

Figure 2

Anterior–posterior (A) and lateral (B) cervical radiographs. A transversely located pin is shown at the level of the epiglottis above the hyoid bone. C, cervival vertebra; Th, thoracic vertebra.

Radiographically, the pin was identified in the laryngopharynx and therefore laryngoscopy was performed. The pin was found transversely sticking into the epiglottic vallecula. Extraction was possible without anaesthesia using a forceps. No pain, bleeding or infection was reported...

http://ift.tt/2hQVd6b

Massive ascites, pelvic mass, elevated CA-125 and weight loss: think outside the 'ovaries'

A 44-year-old woman presented with 3 months' history of painless progressive abdominal distension and weight loss of more than 15 kg. Clinically a pelviabdominal mass with ascites was detected. CT scan of the pelvis and abdomen showed a subserosal leiomyoma with huge amount of ascites. Cancer Antigen (CA)-125 was 546 kU/L. Exploratory laparotomy with myomectomy was done and this was followed by dramatic improvement postoperatively.

http://ift.tt/2fyBPuc

Determinants of Patient Delay in Doctor Consultation in Oeso-gastric Cancers

Conditions:   Oesophageal Carcinoma;   Gastric Adenocarcinoma
Intervention:   Other: Questionnaire
Sponsors:   University Hospital, Lille;   University of Lille Nord de France
Recruiting - verified August 2017

http://ift.tt/2uNlvrg

Nivolumab Plus Ipilimumab in Thyroid Cancer

Condition:   Thyroid Cancer
Interventions:   Drug: Nivolumab;   Drug: Ipilimumab
Sponsors:   Dana-Farber Cancer Institute;   Bristol-Myers Squibb
Not yet recruiting - verified August 2017

http://ift.tt/2uuJKPE

TCR-engineered T Cells in NSCLC and HNSCC Patients (ACTengine)

Conditions:   Solid Tumor;   Cancer;   Head and Neck Squamous Cell Carcinoma;   Squamous Cell Non-small Cell Lung Cancer
Interventions:   Biological: IMA201 T-Cells;   Diagnostic Test: IMA201_Detect;   Diagnostic Test: ACT-HLA;   Drug: Fludarabine;   Drug: Cyclophosphamide;   Biological: Recombinant human interleukin-2
Sponsors:   Immatics US, Inc.;   M.D. Anderson Cancer Center
Not yet recruiting - verified August 2017

http://ift.tt/2uNCh9K

Radiolabelled CCK-2/Gastrin Receptor Analogue for Personalized Theranostic Strategy in Advanced MTC

Condition:   Medullary Thyroid Carcinoma
Interventions:   Drug: 111In-CP04;   Drug: 111In-CP04 with co-administration of gelofusine/gelaspan
Sponsors:   Paola Anna Erba;   Jagiellonian University Medical College;   University Hospital Freiburg;   Medical University Innsbruck;   University Medical Centre Ljubljana;   NATIONAL CENTRE FOR NUCLEAR RESEARCH, Poland;   Erasmus Medical Center;   INRASTES, NCSR Demokritos, Athens, Greece
Recruiting - verified August 2017

http://ift.tt/2uvinVL

Phase 2 Study of Imprime PGG & Pembrolizumab in Subjects With Adv SCCHN Who Failed Pembro Monotherapy or Experiencing SD

Condition:   Squamous Cell Carcinoma of the Head and Neck
Interventions:   Biological: Imprime PGG;   Drug: Pembrolizumab
Sponsors:   Biothera;   Merck Sharp & Dohme Corp.
Not yet recruiting - verified August 2017

http://ift.tt/2uMN6sB

A Study of DBPR112 in Patients With Head and Neck Cancer and EGFR Mutated Lung Cancer

Conditions:   Head and Neck Cancer;   NSCLC
Intervention:   Drug: DBPR112
Sponsor:   National Health Research Institutes, Taiwan
Recruiting - verified May 2017

http://ift.tt/2uvoeKu

ATF3-Dependent Regulation of EGR1 in vitro and in vivo

Background/Aims: Activating transcription factor 3 (ATF3) and early growth response protein 1 (EGR1) are reported to interact, but their use as prognostic factors in cancer is discussed controversially. Methods: We measured ATF3 and EGR1 gene expression changes in human mini-organ cultures (MOCs) of healthy nasal epithelia, UM-SCC-22B, and FADU_DD cells after acid reflux exposure. Next, ATF3 and EGR1 gene expression was analysed in tumour tissues and related to the median expression of autologous reference tissue samples. Results: ATF3 and EGR1 mRNA expression was significantly reduced after consecutive exposure of MOCs at pH DD cells, the upregulation of EGR1 was significant after refluxate exposure, but in HN-SCC 22B, no significant changes were detected. The analysis of the HNSCC samples confirmed the heterogeneous data of the literature. Conclusion: The data maintain the hypothesis that ATF3 and EGR1 are involved in the beginning of inflammatory processes. Whether these two transcription factors act as tumour suppressors or promoters is context dependent and warrants analysis in further studies.
ORL 2017;79:239-250

http://ift.tt/2vLVzkh

Sebocytes contribute to skin inflammation by promoting the differentiation of Th17 cells

Abstract

Background

The main function of sebocytes is considered to be the lipid production for moisturizing the skin. However, it became recently apparent that sebocytes release chemokines and cytokines and respond to pro-inflammatory stimuli as well as presence of bacteria.

Objectives

To analyze the functional communication between human sebocytes and T cells.

Methods

Immunofluorescence stainings for CD4 and IL-17 were performed on acne sections and healthy skin. Migration assays and T cell stimulation cultures were performed with supernatants derived from unstimulated or pre-stimulated SZ95 sebocytes. DCs were generated in presence of SZ95 supernatant and subsequently used in mixed leukocyte reactions.

Results

We could show that CD4+IL-17+ T cells accumulate around the pilosebaceous unit and are in close contact with sebocytes in acne lesions. By using SZ95 sebocyte supernatant, we demonstrate a chemotactic effect of sebocytes on neutrophils, monocytes and T cells in a CXCL-8 dependent manner. Furthermore, sebocyte supernatant induces the differentiation of CD4⁺CD45RA⁺ naïve T cells into Th17 cells via the secretion of IL-6, TGF-β and, most importantly, IL-1β. No direct effects of sebocytes on the function of CD4⁺CD45RO⁺ memory T cells were detected. Moreover, sebocytes functionally interact with Propionibacterium acnes in the maturation of dendritic cells leading to antigen presenting cells that preferentially prime Th17 cells.

Conclusions

Our study provides evidence that human sebocytes actively participate in inflammatory processes in the skin by recruiting and communicating with immune cells. This interaction leads to the generation of Th17 cells that might contribute not only to the pathogenesis of acne vulgaris, but to several inflammatory skin diseases.

This article is protected by copyright. All rights reserved.

http://ift.tt/2vVuYC0

Genomic and clinical evidence uncovers the enterohepatic species Helicobacter valdiviensis as a potential human intestinal pathogen

Abstract

Background

Helicobacter valdiviensis is a recently described enterohepatic species isolated from wild bird's fecal samples. Currently, its pathogenic potential and clinical significance are unknown mainly due to the lack of whole-genome sequences to compare with other helicobacters and the absence of specific screenings to determine its prevalence in humans.

Materials and Methods

The species type strain (WBE14^T) was whole-genome-sequenced, and comparative analyses were carried out including the genomes from other Helicobacter species to determine the exact phylogenetic position of H. valdiviensis and to study the presence and evolution of virulence determinants. In parallel, stools from diarrheic patients and healthy individuals were screened by PCR to assess the clinical incidence of H. valdiviensis.

Results

Helicobacter valdiviensis belongs to a monophyletic clade conformed by H. canadensis, H. pullorum, H. winghamensis, H. rodentium, and H. apodemus. Its predicted genome size is 2 176 246 bp., with 30% of G+C content and 2064 annotated protein-coding genes. The patterns of virulence factors in H. valdiviensis were similar to other enterohepatic species, but evidence of horizontal gene transfer from Campylobacter species was detected for key genes like those coding for the CDT subunits. Positive PCR results confirmed the presence of H. valdiviensis in 2 of 254 (0.78%) stools of patients with acute diarrhea while not a single sample was positive in healthy individuals.

Conclusions

Horizontal gene transfer has contributed to shape the gene repertory of H. valdiviensis, which codes for virulence factors conserved in other pathogens that are well-known human pathogens. Additionally, the detection of H. valdiviensisDNA in diarrheic patients supports its role as a potential emergent intestinal pathogen. Further, sampling efforts are needed to uncover the clinical relevance of this species, which should be accomplished by the isolation of H. valdiviensis from ill humans and the obtention of whole genomes from clinical isolates.

http://ift.tt/2vVqJGh

Upfront immunohistochemistry improves specificity of Helicobacter pylori diagnosis. A French pathology laboratory point of view

Abstract

Background

There is no consensus about the histopathologic methods to detect Helicobacter pylori in gastric biopsies to date. We aimed to question about the value of upfront anti-H. pylori immunohistochemistry in this field.

Material and Methods

We led a retrospective study about the rate of H. pylori-positive gastric biopsies before and after the implementation of upfront immunohistochemistry, the inter-rater and intermethods agreements in H. pylori identification about Hematoxylin-Eosin Saffron (HES), Giemsa, and immunohistochemistry stains and the histopathologic features associated with low amounts of H. pylori.

Results

First, the rate of H. pylori-positive gastric biopsies significantly diminished after the implementation of upfront immunohistochemistry (from 21.15% to 12.56%, P<.0001), suggesting potential overdiagnosis of H. pylori infection before the use of immunohistochemistry. Secondly, immunohistochemistry was the most reproducible and performing stain (kappa values >0.80), but HES and Giemsa stains also presented good-to-very good agreements. Finally, less than 1% of gastric biopsies with inconspicuous H. pylori infection showed no mucosal injury pointing out that any HES-detected mucosal injury could help to preselect the gastric biopsies requiring ancillary stains for the detection of H. pylori.

Conclusions

Albeit being considered as a gold standard in the detection of H. pylori, the interest of using immunohistochemistry as an upfront stain on gastric biopsies is still debated. In our opinion, its use in second line in case of ambiguous HE/HES-Giemsa result is more appropriate. Further effort is needed to optimize the inexpensive but feasible HE/HES-based detection of H. pylori.

http://ift.tt/2wOUuoV

Treatment of Eustachian tube dysfunction with balloon dilation: A systematic review

Objective

Balloon dilation is a new entity in the therapeutic approach of Eustachian tube dysfunction. The aim of this systematic review is to evaluate the success of balloon dilation of the tuba auditiva in reducing symptoms in adult patients with Eustachian tube dysfunction.

Data Sources

Embase, PubMed, and Cochrane Library.

Review Methods

The systematic literature search was conducted independently by two authors based on title and abstracts, and resulted in 36 articles. These articles were screened as full text, 15 of them were eligible for critical appraisal. Data were extracted from selected studies and presented in this article. A meta-analysis was conducted for four subgroups. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used as a writing guideline for this systematic review.

Results

All 15 included studies were case series. A total of 1,155 patients were treated with balloon dilation of the tuba auditiva. Outcome parameters were relief of symptoms, otoscopy, Valsalva maneuver or Toynbee test, audiometry, tympanometry, Eustachian tube dysfunction classification, and Eustachian tube score. All articles showed short-term improvement of original symptoms; some showed further improvement over time. Follow-up ranged from just after therapy to 50 months. Relatively mild and self-limiting complications were described in 36 patients.

Conclusion

All current studies suggest that balloon dilation of the Eustachian tube can be a helpful treatment in patients with Eustachian tube dysfunction. However, placebo controlled trials are still warranted. Laryngoscope, 2017

http://ift.tt/2wAdUOT

Rhinology-specific priority setting for quality improvement: a modified Delphi study from the Quality Improvement Committee of the American Rhinologic Society

Background

Improving the quality of healthcare is a complex and resource intensive process. To optimize the allocation of scarce resources, quality improvement (QI) should focus on high-value diseases that will produce the largest improvement in health system performance. Given the breadth and multidisciplinary nature of sinonasal disease management, the purpose of this study was to transparently develop a prioritized list of sinonasal diseases for QI from the perspective of the specialty of rhinology and the American Rhinologic Society (ARS).

Methods

The RAND modified Delphi methodology was used to rank the priority of nine sinonasal disease categories from 1 (lowest priority) to 9 (highest priority). Two rounds of ranking along with a teleconference meeting was performed by a panel of 9 experts from the ARS Quality Improvement Committee.

Results

The final QI-prioritized list of sinonasal diseases are as follows: chronic rhinosinusitis (CRS) (mean score = 8.9), recurrent acute rhinosinusitis (RARS) (mean score = 7.9), sinonasal neoplasms (mean score = 7.0), anatomic nasal obstruction (mean score = 5.9), refractory epistaxis (mean score = 5.2), complicated acute rhinosinusitis (mean score = 5.2), chronic nonallergic rhinitis (mean score = 4.4), orbital disease (mean score = 4.3), uncomplicated acute rhinosinusitis (mean score = 4.1), and allergy/allergic rhinitis (mean score = 3.7).

Conclusion

The three most important disease categories for QI from the perspective of the specialty of rhinology were CRS, RARS, and sinonasal neoplasms. Future studies need to define and validate quality metrics for each of these important disease categories in order to facilitate appropriate measurement and improvement initiatives.

http://ift.tt/2uMC5rk

Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis

Background

Endoscopic posterior nasal nerve (PNN) resection has been described as an efficacious surgical treatment of allergic and nonallergic rhinitis, but the requirement for surgery under general anesthesia has limited its acceptance. We report the first series of patients treated for chronic rhinitis using a novel device designed for office-based cryosurgical ablation of the PNN.

Methods

Twenty-seven patients with chronic rhinorrhea and/or nasal congestion for >3 months were recruited (allergic or nonallergic rhinitis), with minimum rhinorrhea and/or congestion subscores of 2 as part of the Total Nasal Symptom Score [TNSS]). Under local anesthesia, the cryotherapy device was applied endoscopically to the posterior middle meatus and was used to freeze the PNN region bilaterally. Patients were followed up after 7, 30, 90, 180, and 365 days to assess TNSS.

Results

The procedure was successfully completed in 100% of patients, with no complications; 74% reported no or mild discomfort by the first postprocedure day. TNSS was reduced significantly at 30 days (mean ± standard deviation: 6.2 ± 0.5 at baseline, 2.6 ± 0.3 at 30 days, n = 27, p < 0.001), with continued reduction at 90 (2.7 ± 0.4, n = 24, p < 0.001), 180 (2.3 ± 0.5, n = 21, p < 0.001), and 365 days (1.9 ± 0.3, n = 15, p < 0.001). Both rhinorrhea and congestion subscores decreased significantly at 30, 90, 180, and 365 days compared to baseline (p < 0.001). Allergic and nonallergic subcohorts both appeared to benefit from treatment.

Conclusion

Office-based cryotherapy of the PNN region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days.

http://ift.tt/2uv8nf0

Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safety Initiatives.

Related Articles

Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safety Initiatives.

JAMA Otolaryngol Head Neck Surg. 2017 Aug 10;:

Authors: Morrison RJ, Bowe SN, Brenner MJ

PMID: 28796866 [PubMed - as supplied by publisher]

http://ift.tt/2uw3azz

The Economic Impact of Adult Hearing Loss: A Systematic Review.

Related Articles

The Economic Impact of Adult Hearing Loss: A Systematic Review.

JAMA Otolaryngol Head Neck Surg. 2017 Aug 10;:

Authors: Huddle MG, Goman AM, Kernizan FC, Foley DM, Price C, Frick KD, Lin FR

Abstract
Importance: Hearing impairment (HI) is highly prevalent in older adults and has been associated with adverse health outcomes. However, the overall economic impact of HI is not well described.
Objective: The goal of this review was to summarize available data on all relevant costs associated with HI among adults.
Evidence Review: A literature search of PubMed, Embase, the Cochrane Library, CINAHL, and Scopus was conducted in August 2015. For this systematic review, data extraction and quality assessment were performed by 2 independent reviewers. Eligibility criteria for included studies were presence of quantitative estimation of economic impact or loss of productivity of patients with HI, full-text English-language access, and publication in an academic, peer-reviewed journal or government report prior to August 2015. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A meta-analysis was not performed owing to the studies' heterogeneity in outcomes measures, methodology, and study country.
Findings: The initial literature search yielded 4595 total references. After 2043 duplicates were removed, 2552 publications underwent title and abstract review, yielding 59 articles for full-text review. After full-text review, 25 articles were included. Of the included articles, 8 incorporated measures of disability; 5 included direct estimates of medical expenditures; 8 included other cost estimates; and 7 were related to noise-induced or work-related HI. Estimates of the economic cost of lost productivity varied widely, from $1.8 to $194 billion in the United States. Excess medical costs resulting from HI ranged from $3.3 to $12.8 billion in the United States.
Conclusions and Relevance: Hearing loss is associated with billions of dollars of excess costs in the United States, but significant variance is seen between studies. A rigorous, comprehensive estimate of the economic impact of hearing loss is needed to help guide policy decisions around the management of hearing loss in adults.

PMID: 28796850 [PubMed - as supplied by publisher]

http://ift.tt/2uMxHbD

Neutrophil Extracellular Traps and Fibrin in Otitis Media: Analysis of Human and Chinchilla Temporal Bones.

Related Articles

Neutrophil Extracellular Traps and Fibrin in Otitis Media: Analysis of Human and Chinchilla Temporal Bones.

JAMA Otolaryngol Head Neck Surg. 2017 Aug 10;:

Authors: Schachern PA, Kwon G, Briles DE, Ferrieri P, Juhn S, Cureoglu S, Paparella MM, Tsuprun V

Abstract
Background: Bacterial resistance in acute otitis can result in bacterial persistence and biofilm formation, triggering chronic and recurrent infections.
Objective: To investigate the middle ear inflammatory response to bacterial infection in human and chinchilla temporal bones.
Design, Setting, and Participants: Six chinchillas underwent intrabullar inoculations with 0.5 mL of 106 colony-forming units (CFUs) of Streptococcus pneumoniae, serotype 2. Two days later, we counted bacteria in middle ear effusions postmortem. One ear from each chinchilla was processed in paraffin and sectioned at 5 µm. The opposite ear was embedded in epoxy resin, sectioned at a thickness of 1 µm, and stained with toluidine blue. In addition, we examined human temporal bones from 2 deceased donors with clinical histories of otitis media (1 with acute onset otitis media, 1 with recurrent infection). Temporal bones had been previously removed at autopsy, processed, embedded in celloidin, and cut at a thickness of 20 µm. Sections of temporal bones from both chinchillas and humans were stained with hematoxylin-eosin and immunolabeled with antifibrin and antihistone H4 antibodies.
Main Outcome Measures: Histopatological and imminohistochemical changes owing to otitis media.
Results: Bacterial counts in chinchilla middle ear effusions 2 days after inoculation were approximately 2 logs above initial inoculum counts. Both human and chinchilla middle ear effusions contained bacteria embedded in a fibrous matrix. Some fibers in the matrix showed positive staining with antifibrin antibody, others with antihistone H4 antibody.
Conclusions and Relevance: In acute and recurrent otitis media, fibrin and neutrophil extracellular traps (NETs) are part of the host inflammatory response to bacterial infection. In the early stages of otitis media the host defense system uses fibrin to entrap bacteria, and NETs function to eliminate bacteria. In chronic otitis media, fibrin and NETs appear to persist.

PMID: 28796849 [PubMed - as supplied by publisher]

http://ift.tt/2uMAy4y

In This Issue

http://ift.tt/2vLgKmo

Cover

http://ift.tt/2vsTas7

Subscriptions

http://ift.tt/2vKGKhY

Table of Contents

http://ift.tt/2vsWFyU

Neuro-immune interactions in allergic diseases: novel targets for therapeutics

Abstract

Recent studies have highlighted an emerging role for neuro-immune interactions in mediating allergic diseases. Allergies are caused by an overactive immune response to a foreign antigen. The peripheral sensory and autonomic nervous system densely innervates mucosal barrier tissues including the skin, respiratory tract and gastrointestinal (GI) tract that are exposed to allergens. It is increasingly clear that neurons actively communicate with and regulate the function of mast cells, dendritic cells, eosinophils, T_h2 cells and type 2 innate lymphoid cells in allergic inflammation. Several mechanisms of cross-talk between the two systems have been uncovered, with potential anatomical specificity. Immune cells release inflammatory mediators including histamine, cytokines or neurotrophins that directly activate sensory neurons to mediate itch in the skin, cough/sneezing and bronchoconstriction in the respiratory tract and motility in the GI tract. Upon activation, these peripheral neurons release neurotransmitters and neuropeptides that directly act on immune cells to modulate their function. Somatosensory and visceral afferent neurons release neuropeptides including calcitonin gene-related peptide, substance P and vasoactive intestinal peptide, which can act on type 2 immune cells to drive allergic inflammation. Autonomic neurons release neurotransmitters including acetylcholine and noradrenaline that signal to both innate and adaptive immune cells. Neuro-immune signaling may play a central role in the physiopathology of allergic diseases including atopic dermatitis, asthma and food allergies. Therefore, getting a better understanding of these cellular and molecular neuro-immune interactions could lead to novel therapeutic approaches to treat allergic diseases.

http://ift.tt/2vLknsy

Mice expressing human ERAP1 variants associated with ankylosing spondylitis have altered T-cell repertoires and NK cell functions, as well as increased in utero and perinatal mortality

Abstract

Specific variants of endoplasmic reticulum-associated aminopeptidase 1 (ERAP1) identified by genome-wide association study modify the risk for developing ankylosing spondylitis. We previously confirmed that disease-associated ERAP1 variants have altered enzymatic abilities that can impact upon the production of pro-inflammatory cytokines from cells expressing the same ERAP1 variants. To determine if these ERAP1 variants also impacted immune responses in vivo, we generated two strains of transgenic mice expressing human ERAP1 genes containing non-synonymous single-nucleotide polymorphisms associated with an increased (ERAP1-High) or decreased (ERAP1-Low) risk for developing autoimmune disease. After vaccination with foreign antigens, ERAP1-High mice generated unique populations of antigen-specific T-cell clones. The expression of ERAP1-High also reduced MHC-I expression on the surface of multiple cell types, demonstrating a global impact on the MHC-I peptidome. ERAP1 variants also affected the innate immune system, because NK cells from murine ERAP1 (mERAP1) knockout mice and ERAP1-High/mERAP1^−/− mice had decreased surface expression of the activating receptor NKG2D on their NK and T cells, and NK cells derived from mERAP1^−/− mice or ERAP1-Low mice demonstrated more active NK cell killing than NK cells derived from wild-type or ERAP1-High mice. Finally, these studies were conducted in female mice, as all male ERAP1-High mice died in utero or shortly after birth, making ERAP1-High one of the only dominant lethal autosomal genes known in mammals. Together, these results present the first direct evidence that human disease-associated ERAP1 variants can greatly alter survival, as well as antigen presentation, T-cell repertoire and NK cell responses in vivo.

http://ift.tt/2vsKuSH

Commercial rodent diets differentially regulate autoimmune glomerulonephritis, epigenetics and microbiota in MRL/lpr mice

Abstract

The course and severity of lupus in spontaneous murine lupus models varies among laboratories, which may be due to variations in diet, housing and/or local environmental conditions. In this study, we investigated the influence of common rodent diets while keeping other factors constant. Female lupus-prone MRL/lpr (MRL/MpJ-Fas^lpr/J) mice were subjected to the same housing conditions and given one of the three diets: Teklad 7013 containing isoflavone-rich soy and alfalfa, Harlan 2018 isoflavone-rich soy-based diet or Research Diets Inc. D11112226 (RD) purified-ingredients diet containing casein and no phytoestrogens. While the total caloric intake was similar among all three treatment groups, mice fed on the 2018 diet developed higher levels of proteinuria and mice fed on either 7013 or 2018 developed higher levels of glomerular immune complex deposition. Remarkably, mice fed the RD diet had markedly decreased proteinuria with diminished C3, total IgG, IgG1 and IgG3 immune complex deposition, along with reduced CD11b⁺ cellular infiltration into the glomeruli. The type of diet intake also influenced cytokine production, fecal microbiota (increased Lachnospiraceae in mice fed on 2018), altered microRNAs (miRNAs; higher levels of lupus-associated miR-148a and miR-183 in mice fed on 7013 and/or 2018) and altered DNA methylation. This is the first study to comprehensively compare the cellular, molecular and epigenetic effects of these commercial diets in murine lupus.

http://ift.tt/2vLbm2I

Identification of biomarker sets for predicting the efficacy of sublingual immunotherapy against pollen-induced allergic rhinitis

Abstract

Sublingual immunotherapy (SLIT) is effective against allergic rhinitis, although a substantial proportion of individuals is refractory. Herein, we describe a predictive modality to reliably identify SLIT non-responders (NRs). We conducted a 2-year clinical study in 193 adult patients with Japanese cedar pollinosis, with biweekly administration of 2000 Japanese allergy units of cedar pollen extract as the maintenance dose. After identifying high-responder (HR) patients with improved severity scores and NR patients with unchanged or exacerbated symptoms, differences in 33 HR and 34 NR patients were evaluated in terms of peripheral blood cellular profiles by flow cytometry and serum factors by ELISA and cytokine bead array, both pre- and post-SLIT. Improved clinical responses were seen in 72% of the treated patients. Pre-therapy IL-12p70 and post-therapy IgG1 serum levels were significantly different between HR and NR patients, although these parameters alone failed to distinguish NR from HR patients. However, the analysis of serum parameters in the pre-therapy samples with the Adaptive Boosting (AdaBoost) algorithm distinguished NR patients with high probability within the training data set. Cluster analysis revealed a positive correlation between serum T_h1/T_h2 cytokines and other cytokines/chemokines in HR patients after SLIT. Thus, processing of pre-therapy serum parameters with AdaBoost and cluster analysis can be reliably used to develop a prediction method for HR/NR patients.

http://ift.tt/2vszJ2B

Beyond Ultrasound Guidance for Regional Anesthesiology.

Despite its popularity, ultrasound (US)-guided regional anesthesiology is associated with significant limitations. The latter can be attributed to either the US machine (ie, decreased ability to insonate deep neural structures, as well as the thoracic spine) or the operator. Shortcomings associated with the operator can be explained by errors in perception (ie, ambiguous criteria for needle/catheter tip-to-nerve proximity and subparaneural local anesthetic injection) or interpretation. Perhaps the greatest confusion afflicting US-guided regional anesthesiology originates from an intellectual misconception pertaining to its application. Increasingly, authors are using US to identify interfascial planes where local anesthetic can be injected thereby "discovering" new truncal blocks. Often these novel blocks suffer from a lack of proper randomized, comparative validation. Fortunately, solutions have been proposed to remedy many shortcomings associated with US guidance. The inability of US to reliably insonate deep neural structures can be circumvented with adjunctive neurostimulation. Fluoroscopy and waveform analysis have been proven to increase the success rate of thoracic epidural blocks. For continuous nerve blocks, combined US-neurostimulation may provide an objective end point (ie, an evoked motor response) for neural proximity and subparaneural positioning of the catheter tip. Finally, the solution to the plethora of nonvalidated US-guided blocks is both elegant and simple. New nerve blocks should answer a specific clinical need, and their first descriptions should take the form of an adequately powered, observer-blinded, randomized comparison against the established standard of care or, at the very least, a large case series (eg, a Brief Technical Report). Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

http://ift.tt/2uvOmAZ

Optimal Point of Insertion and Needle Angle in Neuraxial Blockade Using a Midline Approach: A Study in Computed Tomography Scans of Adult Patients.

Background and Objectives: Neuraxial blockade using a midline approach can be challenging. Part of this challenge lies in finding the optimal approach of the needle to its target. The present study aimed at finding (1) the optimal point of insertion of the needle between the tips of 2 adjacent spinous processes and (2) the optimal angle relative to the skin at which the needle should approach the epidural or subarachnoid space. Methods: A computer algorithm systematically analyzed computed tomography scans of vertebral columns of a cohort of 52 patients. On midsagittal sections, the possible points of insertion of a virtual needle and the corresponding angles through which the epidural or subarachnoid space can be reached were calculated. Results: The point chosen to introduce the needle between 2 adjacent spinous processes determines the range of angles through which the epidural or subarachnoid space can be reached. At the thoracic interspaces 1-2 through 3-4, thoracic interspaces 5-6 through 9-10, and at the lumbar vertebral interspaces 2-3 through 4-5, the optimal point of insertion is slightly inferior to the point halfway between the tips of the spinous processes. For thoracic interspace 4-5, the optimal point of insertion is slightly superior to the point halfway between the tips of the spinous processes. For the other interspaces, the optimal point of insertion is approximately halfway between the tips of the spinous processes. The optimal angle to direct the needle varies from 9 degrees at the thoracolumbar junction and at the lumbar interspaces 3-4 and 4-5, to 53 degrees at the thoracic interspace 7-8. Conclusions: Our study has resulted in practical suggestions-based on accurate, reproducible measurements in patients-as to where to insert the needle and how to angulate the needle when performing neuraxial anesthesia using a midline approach. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

http://ift.tt/2vVt9E5

Ocular surface lubricants.

Purpose of review: The purpose of this article is to provide an overview of the ocular lubricants currently available, consider the components of the various formulations and highlight the status of preservative use in the treatment of anterior ocular surface diseases. Recent findings: The primary components of ocular surface lubrication have been, in the past, based on various cellulose formulations that increase hydration. Advances in lubrication have come from areas of the human body requiring lubrication such as the skeletal joints as well as examining the use of natural components of the tear fluid. These have resulted in novel modifications of existing tear components, for example, thiolated carboxymethyl hyaluronic acid which creates crosslinking to mechanically increase retention time for ocular surface hydration. Other proteoglycans such as lubricin, having one of the lowest coefficients of friction in nature, to a lipopolysaccharide derivative of tamarind seed, may provide a unique delivery system for lubricants and medications. Summary: The present state of ocular surface lubrication is slowly advancing from the routine use of cellulose-based solutions and gels to more advanced replacement with natural tear components. The advances that are occurring on other lubricating surfaces of the musculoskeletal system are also providing some insights into potential use on the ocular surface. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2votYEL

Hymenoptera-induced anaphylaxis: is it a mast cell driven hematological disorder?.

Purpose of review: Hymenoptera-induced allergy (HVA) is a common cause of anaphylaxis and may be fatal. It is associated with systemic mastocytosis in about 7% of adult patients. Systemic mastocytosis is a proliferative disorder of hematopoietic mast cell progenitors. There is recent data on the association between systemic mastocytosis and HVA. Recent findings: Hymenoptera venoms are the most common immunoglobulin E-mediated elicitors of anaphylaxis in patients with mastocytosis. Some patients with systemic mastocytosis do not have cutaneous involvement and have only been identified because of HVA. These patients do have distinct demographic, clinical, and laboratory features as compared with patients with mastocytosis with skin lesions. They show a male predominance, more severe (cardiovascular) as compared to skin symptoms, lower baseline serum tryptase, less bone marrow mast cell aggregates, and KIT mutations restricted to mast cell lineage. Summary: Although hymenoptera-induced anaphylaxis is not primarily a mast cell-driven hematological disorder, the latter is present in a significant proportion of patients and has to be excluded by basal serum tryptase determination, skin inspection as well as exclusion of systemic mastocytosis by D816V mutation analysis in peripheral blood and/or bone marrow examination in selected patients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2wzSiSD

Climate changes and Hymenoptera venom allergy: are there some connections?.

Purpose of review: This review aims to update the world status of the main allergenic stinging Hymenoptera. Recent findings: In this review, we consider the problems that social Hymenoptera (bees, wasps and ants) could represent in the nearest future for human health in different parts of the world. Summary: Distribution and consistency of allergenic species including venomous insects are interested by accelerated dynamics caused by climate changes and globalization. Owing to the expansion of ranges of native species and colonization of invasive ones, even in the uncertainty of present available models, new challenges presented by stinging Hymenoptera should be expected in the future. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2vnIvAy

Neuromuscular Monitoring in the Perioperative Period.

Neuromuscular monitoring devices were introduced into clinical practice in the 1970s. Qualitative neuromuscular monitors, or peripheral nerve stimulators, provide an electrical stimulus to a motor nerve and the response of corresponding muscle subjectively evaluated. A standard peripheral nerve stimulator provides several patterns of nerve stimulation, including train-of-four (TOF), double-burst, tetanic, and post-tetanic count. Qualitative (and quantitative) monitors are needed to determine onset of neuromuscular blockade, maintain the required depth of muscle relaxation during the surgical procedure, and assess an appropriate dose of reversal agent. However, absence of fade measured with a peripheral nerve stimulator does not exclude residual neuromuscular block; TOF ratios as low as 0.4-0.6 may be present when fade is no longer observed. In addition, the risk of incomplete neuromuscular recovery may be influenced by monitoring site. The adductor pollicis is more sensitive to the effects of neuromuscular blocking agents (compared to the muscles surrounding the eye), and monitoring at this site may more accurately reflect recovery of pharyngeal muscles (the last muscles to recover from the effects of neuromuscular blocking agents, in which dysfunction may persist even at a TOF ratio of 1.0). Quantitative monitors are devices that measure and quantify the degree of muscle weakness and display the results numerically. Several different technologies have been developed, including mechanomyography, electromyography, acceleromyography, kineograph, and phonomyography. Lower doses of anticholinesterases may be used to effectively reverse neuromuscular blockade at TOF ratios of 0.4-0.6; quantitative monitoring is required to determine that this level of neuromuscular recovery has occurred. As clinical tests of muscle strength, peripheral nerve stimulators are unable to determine whether full recovery of neuromuscular function is present at the end of the surgical procedure. The use of quantitative monitors is essential in excluding clinically important muscle weakness (TOF ratios

http://ift.tt/2uvIPKL

Prolongation of Apnea Time in Obese Patients-Concerns With Rate of Rise of CO2.

No abstract available

http://ift.tt/2vVu5IN

The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management.

The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease. (C) 2017 International Anesthesia Research Society

http://ift.tt/2uwiBrJ

The Perioperative Surgical Home: A New Role for the Acute Pain Service.

No abstract available

http://ift.tt/2vVdYLm

Differential Roles of the Right and Left Toe Perfusion Index in Predicting the Incidence of Postspinal Hypotension During Cesarean Delivery.

BACKGROUND: Aortocaval compression by the gravid uterus, low baseline vasomotor tone, and spinal anesthesia-related sympathetic blockade contribute to spinal anesthesia-induced hypotension during cesarean delivery. The finger perfusion index (PI) can predict spinal hypotension by reflecting baseline vasomotor tone, but cannot directly reflect aortocaval compression by the gravid uterus. This study aimed to examine whether baseline toe PIs predict the incidence of maternal hypotension and reflect aortocaval compression by the gravid uterus during cesarean delivery under spinal anesthesia. METHODS: One hundred parturients undergoing elective cesarean delivery were enrolled. The relationship between baseline toe PI and the incidence of hypotension following induction of spinal anesthesia was quantified using area under the receiver operator curves, and results compared for the right and left toe PIs. RESULTS: The area under the receiver operator curves for left and right toe baseline PIs were 0.81 (95% confidence interval, 0.71-0.88) and 0.76 (95% confidence interval, 0.66-0.84), respectively. Following induction of spinal anesthesia, the toe PIs did not change in parturients with hypotension, but increased significantly among those who did not develop hypotension. CONCLUSIONS: Our study demonstrated that baseline toe PIs were inversely associated with the incidence of postspinal hypotension during cesarean delivery. Continuous monitoring of toe PIs during induction of spinal anesthesia might help to predict the development of postspinal hypotension and reflect the aortocaval compression by the gravid uterus. (C) 2017 International Anesthesia Research Society

http://ift.tt/2uw1hTy

Reducing Mortality in the Perioperative Period: 2nd ed.

No abstract available

http://ift.tt/2vVfxsK

Future prospect of faecal microbiota transplantation as a potential therapy in asthma

Publication date: Available online 10 August 2017
Source:Allergologia et Immunopathologia
Author(s): Y. Kang, Y. Cai
There is convincing evidence from both human and animal studies suggesting that the gut microbiota plays an important role in regulating immune responses associated with the development of asthma. Certain intestinal microbial strains have been demonstrated to suppress or impair immune responsiveness in asthma experimental models, suggesting that specific species among gut commensal microbiota may play either a morbific or phylactic role in the progression of asthma. Evidence to date suggests that the intestinal microbiota represent fertile targets for prevention or management of asthma. The faecal microbiota transplantation (FMT) is a rather straightforward therapy that manipulates the human gastrointestinal (GI) microbiota, by which a healthy donor microbiota is transferred into an existing but disturbed microbial ecosystem. The FMT may therefore represent a therapeutic approach for asthma treatment in the foreseeable future. At present, FMT therapy for asthma is very limited and should be actively studied. Considerable efforts are needed to increase our knowledge in the field of FMT therapy for asthma. In this review, we aimed to provide several insights into the development of FMT therapy for asthma.



http://ift.tt/2uMlQKV