Seeking to close the loopholes in transplant tourism and organ trafficking.

No abstract available

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Sequential and urgent coronary artery bypass surgery followed by kidney transplantation in a highly sensitized patient with unstable angina.

No abstract available

http://ift.tt/2hi9buj

Early effects of renal replacement therapy on cardiovascular comorbidity in children with end-stage kidney disease: findings from the 4C-T Study.

Background: The early impact of renal transplantation on subclinical cardiovascular measures in pediatric patients has not been widely investigated. This analysis is performed for pediatric patients participating in the prospective 4C study and focuses on the early effects of RRT modality on cardiovascular comorbidity in patients receiving a preemptive transplant or started on dialysis. Methods: We compared measures indicating subclinical cardiovascular organ damage (aortal pulse wave velocity, carotid intima media thickness, left ventricular mass index) and evaluated cardiovascular risk factors in 166 pediatric patients before and 6 to 18 months after start of RRT (n=76 transplantation, n=90 dialysis). Results: RRT modality had a significant impact on the change in arterial structure and function: compared to dialysis treatment, transplantation was independently associated with decreases in pulse wave velocity ([latin sharp s]=-0.67; p

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Table of contents

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Masthead

http://ift.tt/2xQ0gLj

Granuloma annulare can occur on a scar, mimicking sarcoidosis

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Oral administration of milk-derived phospholipids inhibits penetration of cutaneous nerve fibres into epidermis in a mouse model of acute dry skin

Summary

The density of intraepidermal nerve fibres has been shown to be higher in itchy dry skin than in healthy skin, suggesting that epidermal hyperinnervation is at least partly involved in peripheral itch sensitization. We investigated whether oral administration of milk-derived phospholipids (MPLs) would inhibit epidermal hyperinnervation in a mouse model of dry skin. We found that the number of intraepidermal nerve fibres was significantly lower in the MPL group than in the control group. Expression of nerve growth factor (NGF) levels in the epidermis was significantly decreased by oral administration of MPLs, whereas expression of semaphorin (Sema)3A, a nerve repulsion factor, was increased in the MPL group. These results suggest that dietary MPLs attenuate the penetration of nerve fibres into the epidermis by reducing epidermal NGF levels and increasing Sema3A level. Thus, dietary MPLs may have beneficial effects in the prevention and/or alleviation of dry skin-induced itch by reducing intraepidermal nerve fibre density.

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Plantar keratoderma climatericum: Successful improvement with a topical estriol cream

Summary

Keratoderma climatericum affects menopausal women, and the diagnosis relies on typical clinical findings and exclusion of other potential causes of acquired keratoderma. Although its pathophysiology is still unknown, there has been speculation about its relation to hormonal dysregulation (possibly a local estrogen deficiency) since the 1930s. A female patient with long-lasting keratoderma climatericum was initially prescribed a topical 50% urea ointment and clobetasol propionate 0.05% ointment, with just a slight improvement after 2 months of daily use. The patient was started on topical estriol 0.125 mg/g vaginal cream applied on the plantar surface after her daily shower and application of the same topical 50% urea ointment and clobetasol propionate 0.05% ointment on alternate nights. There was a marked improvement under this regimen with total and fast control of the pruritus. At 6-month follow-up the patient retained total symptomatic control and was just applying the estriol cream and the 50% urea containing ointment. We report a case of a difficult to treat plantar keratoderma that markedly improved after adding a daily topical application of a vaginal cream containing estriol 0.125 mg/g. Trials that determine the efficacy and safety of topical estrogens for keratoderma climatericum are warranted.

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The influence of immune status, age, and sex on Majocchi granuloma: a review of 52 cases from a tertiary level hospital and published Korean cases in literature

Abstract

Background

Majocchi granuloma (MG) is a rare dermal and subcutaneous granulomatous inflammation caused by dermatophytes. The detailed characteristics of MG are not fully elucidated. This study investigated the influence of systemic immune status, age, and sex on the clinical, demographic, mycological, and therapeutic characteristics of MG in Korea.

Methods

We analyzed cases of histopathologically diagnosed MG at our tertiary referral center from January 2001 to December 2016. We also analyzed all Korean MG cases published in Korean and English literature to date. The different features based on immune status, age, and sex were compared. P < 0.05 were considered statistically significant.

Results

We enrolled 52 patients, 33 (63.5%) were male and 19 (36.5%) were female. The mean age was 45.4 ± 23.1 years. Immunosuppression was reported in 13 cases (26.5%). Statistical analysis showed that the immune status affects the anatomical location and clinical manifestation. Age has an influence on involved sites and identified fungal species. The frequent fungal pathogens were different based on sex.

Conclusion

The results of our study revealed that distinctive features of MG exist based on immune status, age, and sex.

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Pediatric vasculitis: a single center experience

Abstract

Background

Existing studies of children with vasculitis are limited. The aim of this study was to assess the epidemiology, clinical manifestations, laboratory findings, course, and outcome of Greek children presenting with vasculitic rash.

Methods

The relevant data included in the study were collected retrospectively using a standardized form from children who were admitted into our department between 2003 and 2013, with the provisional diagnosis of vasculitis of the skin.

Results

The study sample consisted of 95 children (58 boys, 37 girls) with a mean age of 5.9 years. In total, 76 out of 95 (80%) of the children were diagnosed with Henoch-Schönlein purpura, 10/95 (10.5%) with hypersensitivity vasculitis, 6/95 (6.3%) with urticarial vasculitis, and 3/95 (3.1%) with acute hemorrhagic edema of infancy. The mean age of the children was 5.7 years for Henoch-Schönlein purpura, 9 years for hypersensitivity vasculitis, 5.1 years for urticarial vasculitis, and 0.5 years for acute hemorrhagic edema of infancy.

Conclusions

(i) The most common vasculitis presenting with skin rash in children is Henoch-Schönlein purpura; (ii) hypersensitivity vasculitis occurs in older children more often when compared to other types of vasculitis; (iii) urticarial vasculitis lesions may be a sign of severe underlying disease; therefore a thorough examination of these patients is warranted; (iv) Despite relapses, the overall prognosis of patients with pediatric skin vasculitides is good, with the exception of those with the urticarial vasculitis type.

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Beyond classic dermoscopic patterns of dermatofibromas: a prospective research study

The usual stereotypical dermoscopic pattern associated with dermatofibromas is a pigment network and central white patch. However, this pattern may be difficult to diagnose in some variant cases. We aimed to d...

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Detection of Malignancy Among Suspicious Thyroid Nodules

Thyroid , Vol. 0, No. 0.


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A targeted next-generation sequencing panel reveals novel mutations in Japanese patients with primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) is a rare genetic disorder caused by functional impairment of cilia throughout the body. The early diagnosis of PCD is important for the prevention of long-term sequelae; however, this is often challenging because of the phenotypic heterogeneity of PCD and difficulty in genetic analysis. The majority of PCD patients in Japan are not diagnosed properly. To diagnose PCD more accurately, we developed a targeted next-generation sequencing (NGS) panel.

http://ift.tt/2wvooTj

An unusual case of temporal bone encephalomeningocele occurring together with normal pressure hydrocephalus

Temporal bone encephalomeningoceles are uncommon clinical entities that can be challenging to diagnose and treat. Common presenting complaints include symptoms of aural fullness, hearing loss, clear otorrhea and meningitis. Common etiologies are chronic middle ear disease and trauma. A significant proportion of cases are spontaneous, which occurs in relation to benign intracranial hypertension. Normal pressure hydrocephalus associated with temporal bone encepahomeningoceles has not been previously described.

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Cost-effectiveness assessment in outpatient sinonasal surgery

Publication date: Available online 18 September 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): G. Mortuaire, D. Theis, R. Fackeure, D. Chevalier, I. Gengler
AimsTo assess the cost-effectiveness of outpatient sinonasal surgery in terms of clinical efficacy and control of expenses.MethodsA retrospective study was conducted from January 2014 to January 2016. Patients scheduled for outpatient sinonasal surgery were systematically included. Clinical data were extracted from surgical and anesthesiology computer files. The cost accounting methods applied in our institution were used to evaluate logistic and technical costs. The standardized hospital fees rating system based on hospital stay and severity in diagnosis-related groups (Groupes homogènes de séjours: GHS) was used to estimate institutional revenue.ResultsOver 2years, 927 outpatient surgical procedures were performed. The crossover rate to conventional hospital admission was 2.9%. In a day-1 telephone interview, 85% of patients were very satisfied with the procedure. All outpatient cases showed significantly lower costs than estimated for conventional management with overnight admission, while hospital revenue did not differ between the two.ConclusionThis study confirmed the efficacy of outpatient surgery in this indication. Lower costs could allow savings for the health system by readjusting the rating for the procedure. More precise assessment of cost-effectiveness will require more fine-grained studies based on micro costing at hospital level and assessment of impact on conventional surgical activity and post-discharge community care.



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Cervical-transoral robotic oropharyngectomy and thin anterolateral thigh free flap

Publication date: Available online 18 September 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): P. Gorphe, S. Temam, F. Kolb, Q. Qassemyar
The transoral robotic oropharyngectomy surgical technique was initially described for resection of small stage T1 or T2 lesions and the surgical defect is usually allowed to heal by secondary intention. We propose a refined surgical approach adapted to more complex situations such as salvage surgery and surgery in an irradiated field, based on previous experience in open approaches for oropharyngeal cancer. Via a combined cervical-transoral approach, we perform en bloc resection of the parapharyngeal space combined with transoral robotic lateral oropharyngectomy. Reconstruction of the surgical defect is performed with a thin anterolateral thigh free flap.



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… And Then There Was Charlottesville …

Violence and Gender Sep 2017, Vol. 4, No. 3: 67-68.


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An Exploration of the Risk, Protective, and Mobilization Factors Related to Violent Extremism in College Populations

Violence and Gender Sep 2017, Vol. 4, No. 3: 81-101.


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Cirugía virtual para pacientes con obstrucción nasal: empleo de un software basado en dinámica de fluidos (MeComLand®, Digbody® & Noseland®) para documentar parámetros objetivos de flujo y optimizar resultados quirúrgicos

Publication date: Available online 18 September 2017
Source:Acta Otorrinolaringológica Española
Author(s): Manuel A. Burgos, Maria Agustina Sevilla García, Enrique Sanmiguel Rojas, Carlos Del Pino, Carlos Fernández Velez, Francisco Piqueras, Francisco Esteban Ortega
IntroducciónLa dinámica de fluidos computacional (CFD) es una herramienta matemática que permite analizar el flujo aéreo. Presentamos un software innovador basado en CFD para mejorar los resultados de la cirugía nasal.MétodosMediante colaboración de ingenieros especialistas en mecánica de fluidos y otorrinolaringólogos se ha desarrollado un software de fácil uso denominado MeComLand^®, que utilizando los cortes de tomografía computarizada de un paciente permite obtener gran cantidad de información como flujo, presiones, temperatura, velocidad o fricción sobre la pared de las fosas nasales. El programa DigBody^® permite modificar en 3D la anatomía del modelo y realizar cirugías virtuales para simular resultados antes de la cirugía real. Por último, NoseLand^® permite viajar virtualmente por el interior de la fosa nasal, mostrando todo tipo de magnitudes termo-fluido mecánicas.ObjetivoPresentar un programa innovador para mejorar los resultados de la cirugía nasal. Emplear este software sobre cortes tomográficos de un paciente con desviación septal para planificar distintas opciones quirúrgicas (septoplastia, turbinectomía, spreader-grafts, colgajo en J y combinaciones) a fin de conseguir la mejor alternativa con la menor morbilidad.ResultadosLa combinación de todos los procedimientos considerados no produce los mejores resultados en cuanto a flujo nasal. Estos se consiguen asociando septoplastia y turbinectomía. La turbinectomía aislada obtuvo resultados muy similares a la septoplastia.ConclusionesLa técnica computacional CFD proporciona una información complementaria valiosa en el diagnóstico del paciente con obstrucción nasal y sobre los resultados de distintas alternativas quirúrgicas respecto al flujo nasal, contribuyendo a un mejor manejo del enfermo. El software MeComLand^® con sus respectivos módulos DigBody^® y NoseLand^® suponen una alternativa barata y no invasiva al estudio funcional del paciente con obstrucción nasal.IntroductionComputational fluid dynamics (CFD) is a mathematical tool to analyse airflow. We present a novel CFD software package to improve results following nasal surgery for obstruction.MethodsA group of engineers in collaboration with otolaryngologists have developed a very intuitive CFD software package called MeComLand®, which uses the patient's cross-sectional (tomographic) images, thus showing in detail results originated by CFD such as airflow distributions, velocity profiles, pressure, or wall shear stress. NOSELAND® helps medical evaluation with dynamic reports by using a 3D endoscopic view. Using this CFD-based software a patient underwent virtual surgery (septoplasty, turbinoplasty, spreader grafts, lateral crural J-flap and combinations) to choose the best improvement in nasal flow.ObjectiveTo present a novel software package to improve nasal surgery results. To apply the software on CT slices from a patient affected by septal deviation. To evaluate several surgical procedures (septoplasty, turbinectomy, spreader-grafts, J-flap and combination among them) to find the best alternative with less morbidity.ResultsThe combination of all the procedures does not provide the best nasal flow improvement. Septoplasty plus turbinoplasty obtained the best results. Turbinoplasty alone rendered almost similar results to septoplasty in our simulation.ConclusionsCFD provides useful complementary information to cover diagnosis, prognosis, and follow-up of nasal pathologies based on quantitative magnitudes linked to fluid flow. MeComLand®, DigBody® and NoseLand® represent a non-invasive, low-cost alternative for the functional study of patients with nasal obstruction.



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Predictive Biomarkers for Asthma Therapy

Abstract

Purpose of Review

Asthma is a heterogeneous disease characterized by multiple phenotypes. Treatment of patients with severe disease can be challenging. Predictive biomarkers are measurable characteristics that reflect the underlying pathophysiology of asthma and can identify patients that are likely to respond to a given therapy. This review discusses current knowledge regarding predictive biomarkers in asthma.

Recent Findings

Recent trials evaluating biologic therapies targeting IgE, IL-5, IL-13, and IL-4 have utilized predictive biomarkers to identify patients who might benefit from treatment. Other work has suggested that using composite biomarkers may offer enhanced predictive capabilities in tailoring asthma therapy.

Summary

Multiple biomarkers including sputum eosinophil count, blood eosinophil count, fractional concentration of nitric oxide in exhaled breath (FeNO), and serum periostin have been used to identify which patients will respond to targeted asthma medications. Further work is needed to integrate predictive biomarkers into clinical practice.

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Skin-Directed Tactics Optimal for Early Cutaneous Lymphoma

The many first-line treatments for this rare malignancy are being assessed in the Prospective Cutaneous Lymphoma International Prognostic Index (PROCLIPI) trial.
Medscape Medical News

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Paradigm shift in head and neck oncology patient management

Abstract

Objective

This article describes a paradigm shift in what is considered to be good care for patients living with and after (head and neck) cancer. HNO patients often experience severe and difficult physical and psychosocial problems due to the nature and location of the disease. Many disciplines are involved in their treatment, so their voice is only one amongst many others in the decision making process. For this patient group it seems complicated to put the concept of Shared Decision Making into practice. As a step in this direction, patient reported outcomes which ask patients to select the disconcerting issues and symptoms can be used as a basis for referral, supportive care and treatment decision making. We need to provide more tailored and personalized information that is specific to individual circumstances, preferences and concerns and focuses more on the impact of treatment and access to help and support. Follow up of these patients should be concentrated on both medical and emotional aspects.

Practice implications

A shift in the way caregivers provide their information contributes to a more profound involvement of patients in treatment decisions.

http://ift.tt/2xkE76x

Chronic high-protein diet induces oxidative stress and alters the salivary gland function in rats

Publication date: December 2017
Source:Archives of Oral Biology, Volume 84
Author(s): Urszula Kołodziej, Mateusz Maciejczyk, Wiesława Niklińska, Danuta Waszkiel, Małgorzata Żendzian-Piotrowska, Piotr Żukowski, Anna Zalewska
ObjectiveChronic high protein intake leads to an increase in reactive oxygen species (ROS) generation. However, there is no data on the impact of high-protein diet on the antioxidant barrier, oxidative stress and secretory function in the salivary glands of healthy individuals.Design16 male Wistar rats were randomly divided into 2 groups (n=8): normal protein (C) and high-protein diet (HP) for 8 weeks. Salivary antioxidants: peroxidase (Px), catalase (CAT), superoxide dismutase 1 (SOD 1), uric acid (UA), total antioxidant status (TAS), total oxidant status (TOS) and the oxidative stress index (OSI), as well as protein carbonyls (PC), 4-hydroxynonenal protein adduct (4-HNE protein adduct), 8-isoprostanes (8-isoP), 8-hydroxy-2′-deoxyguanosine (8-OHdG) and protein content were determined in the salivary glands and plasma. Salivary unstimulated and stimulated flow rates were examined.ResultsParotid Px, TAS, UA, TOS, OSI, PC were significantly higher, the total protein content was statistically lower in the HP group as compared to the control. Submandibular UA, TOS, OSI, 8-isoP, 4-HNE-protein adduct, 8-OHdG were statistically elevated, SOD 1 and Px were significantly lower in the HP group as compared to the control rats. The unstimulated salivary flow rate was significantly depressed in the HP group as compared to the controls.ConclusionsHigher antioxidant capacity in the parotid glands of HP rats vs. control rats seems to be a response to a higher ROS formation. In the submandibular glands severe oxidative modification of almost all cellular components was observed. Administration of HP resulted in the weakening of the salivary gland function.



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Evaluation of tooth root surface area using a three-dimensional scanning technique and cone beam computed tomographic reconstruction in vitro

Publication date: December 2017
Source:Archives of Oral Biology, Volume 84
Author(s): Tong Wang, Xibo Pei, Feng Luo, Lingling Jia, Han Qin, Xinting Cheng, Yiyuan Xue, Jian Wang, Qianbing Wan
ObjectiveTo study the feasibility of measuring root surface area (RSA) by 3D scanning technique and cone beam computed tomography (CBCT) reconstruction in vitro.DesignTwenty extracted teeth (10 single-rooted teeth and 10 multi-rooted teeth) were collected in this study. The RSA of the extracted teeth was measured by the membrane technique, 3D scanning technique, and CBCT reconstruction. A standard part was also designed to check the accuracy of each method. All statistical analyses were performed using the SPSS software.ResultsAccording to the results of one-way ANOVA, there was no significant difference among the values of RSA measured by the three techniques (p>0.05). The results of Wilcoxon matched-pairs signed-rank test further demonstrated that there was no significant difference among the values of RSA in both single- and multi-rooted teeth measured by the three techniques (p>0.05).ConclusionsThe membrane technique, the 3D scanning technique, and CBCT reconstruction are novel reliable techniques for measuring the RSA in both single- and multi-rooted teeth, which will provide wide clinical applications in the future.



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Influence of age on the electromyographic fatigue threshold of the masseter and temporal muscles of healthy individuals

Publication date: December 2017
Source:Archives of Oral Biology, Volume 84
Author(s): Lígia Franco Oliveira, Marcelo Palinkas, Paulo Batista de Vasconcelos, Isabela Hallak Regalo, Flávia Argentato Cecilio, Erica Franco Oliveira, Marisa Semprini, Selma Siéssere, Simone Cecilio Hallak Regalo




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Effect of Postoperative Family Nutrition Mode on Weight/BMI of Patients With Esophageal Cancer

Condition:   Esophageal Cancer
Interventions:   Dietary Supplement: Oral nutrition supplement;   Dietary Supplement: Tube feeding nutrition supplement
Sponsors:   Beijing Cancer Hospital;   Sun Yat-sen University;   Zhejiang Cancer Hospital;   Shanghai Chest Hospital;   China-Japan Friendship Hospital;   Fudan University;   Shandong Provincial Hospital;   Hebei Medical University Fourth Hospital;   Anyang Tumor Hospital;   The First Affiliated Hospital of Anhui Medical University;   First Affiliated Hospital Bengbu Medical College;   Tongji Hospital;   Shanxi Province Cancer Hospital;   The Third Affiliated Hospital of Harbin Medical University;   Liaoning Tumor Hospital & Institute;   Wuhan General Hospital of Guangzhou Military Command;   Second Xiangya Hospital of Central South University;   First Hospital of Jilin University;   Chinese PLA General Hospital;   Hunan Provincial People's Hospital;   Fujian Cancer Hospital;   Qilu Hospital of Shandong University;   Union hospital of Fujian Medical University;   Daping Hospital and the Research Institute of Surgery of the Third Military Medical University
Not yet recruiting - verified September 2017

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PET/MRI to Enhance Precision Guidance in Head and Neck Radiation Treatment Planning

Condition:   Head and Neck Neoplasms
Intervention:   Device: PET/MRI
Sponsors:   University of Wisconsin, Madison;   National Cancer Institute (NCI)
Not yet recruiting - verified September 2017

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An Investigational Immuno-therapy Study to Assess the Safety, Tolerability and Effectiveness of Anti-LAG-3 With and Without Anti-PD-1 in the Treatment of Solid Tumors

Condition:   Neoplasms by Site
Interventions:   Biological: Relatlimab;   Biological: BMS-936558
Sponsor:   Bristol-Myers Squibb
Recruiting - verified September 2017

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Trois cas de scombroïdose

Publication date: Available online 18 September 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): Y. Harmelin, T. Hubiche, M. Pharaon, P. Del Giudice
IntroductionLa scombroïdose est une intoxication alimentaire méconnue due à la présence d'histamine dans la chair de poissons de la famille des scombridés, lorsqu'ils ont été conservés dans de mauvaises conditions. Nous rapportons trois cas de scombroïdose vus à l'hôpital de Fréjus–Saint-Raphaël, Var.ObservationsTrois patientes ont présenté, environ trente minutes après avoir ingéré un repas contenant du thon, des symptômes variés : sensation de malaise, éruption cutanée prurigineuse, céphalées et pour deux d'entre elles des nausées. Le diagnostic de scombroïdose a été posé devant les circonstances d'apparition et les signes cliniques. Les patientes ont été traitées par antihistaminiques et une injection de corticothérapie intra-veineuse, avec régression des symptômes en quelques heures.DiscussionLes symptômes de la scombroïdose apparaissent dans les quelques minutes qui suivent la consommation de poissons de la famille des scombridés ou d'espèces apparentées, dont la chair contient de l'histamine. Les premiers symptômes comprennent souvent une symptomatologie cutanée avec flush, prurit et érythème du visage et du tronc d'aspect plutôt urticariforme, associés à une sensation de malaise. Les symptômes digestifs comprennent nausées, vomissements, crampes abdominales et parfois diarrhées. La durée des symptômes est de quelques heures. La présence d'histamine dans la chair des poissons est due à la décarboxylation de l'histidine par l'action de bactéries Gram négatif dont le développement a été favorisé par la chaleur et le soleil. La scombroïdose est une des causes les plus fréquentes d'intoxication par l'ingestion de poisson mais reste mal connue, notamment des dermatologues. Le diagnostic de certitude se fait par la mesure du taux d'histamine dans le poisson ou dans le plasma du patient.IntroductionScombroid poisoning is a poorly known type of food poisoning due to the presence of histamine in spoiled fish of the Scombridae family. We report 3 cases of scombroid poisoning seen at the Fréjus–Saint-Raphaël hospital in the Var region.ObservationsWithin around thirty minutes of eating a meal containing tuna, three patients presented varied symptoms: malaise, itchy rash, headache, and for two of them, nausea. The diagnosis of scombroid poisoning was based on the circumstances in which the clinical signs appeared and on the signs themselves. The patients were given antihistamines and one injection of intravenous corticosteroids, and symptoms regressed rapidly within a few hours.DiscussionThe symptoms of scombroid poisoning appear within a few minutes after eating fish of the Scombridae family and related species. The first symptoms are cutaneous, with flush, pruritus, and erythema of the face and trunk having an urticarial appearance, together with faintness. Gastrointestinal symptoms include nausea, vomiting, abdominal cramps and occasionally diarrhea. Symptoms subside within a few hours. Histamine is present in the flesh of these fish due to decarboxylation of histidine through the action of Gram-negative bacteria whose development is enhanced by heat and sun. Scombroid poisoning is one of the most common types of poisoning caused by eating fish but it is underdiagnosed by dermatologists. The diagnosis is made by measuring histamine levels in the incriminated fish or in the patient's plasma.



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Redefining Approaches to Asthma: Bridging the Gap Between Heparin and Its Anti-inflammatory Activities

Abstract

Heparin is widely used as an anticoagulant. Currently, this macromolecule is at the forefront in the field of glycobiology because of the recognition of its therapeutic potential in a wide range of medical conditions including inflammation. Heparin is composed of anticoagulant and non-anticoagulant molecules. A large body of evidence suggests that the anti-inflammatory activities of heparin are attributed to its non-anticoagulant molecules and are therefore independent to its anticoagulant effect. However, the potential therapeutic use of heparin in inflammatory conditions is hindered by the presence of anticoagulant molecules causing the risk of bleeding. Therefore, there is an emerging interest in identifying non-anticoagulant molecules of heparin responsible for the anti-inflammatory effects of the parent molecule. The present editorial commentary focuses on the non-anticoagulant applications of heparin for the management of asthma. The commentary concisely describes the plausible mechanisms of action of heparin involved in the therapy of asthma. It also discusses various approaches that are utilised for the development of novel non-anticoagulant analogues of heparin that possess the potent anti-asthmatic activity of the parent molecule but are devoid of anticoagulant effect. We also briefly outline potential future approaches for the use of this molecule as an effective anti-inflammatory agent.

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Autosomal recessive epidermolysis bullosa simplex: report of three cases from India

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Issue Information

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Announcement

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Olfactory reference syndrome (ORS) successfully treated with a selective serotonin reuptake inhibitor

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Spiral Fracture in Young Infant Causing a Diagnostic Dilemma: Nutritional Rickets versus Child Abuse

Fractures are uncommon in young, nonambulatory infants. The differential diagnosis includes nonaccidental injury (NAI) and metabolic bone disease, including rickets. While rickets typically present after six months of age, multiple cases have been reported in younger infants. We report a case of an 11-week-old male infant who presented with a spiral fracture of the humerus and no radiologic evidence of rickets. A detailed psychosocial assessment failed to reveal any risk factors for NAI. The patient had elevated alkaline phosphatase and PTH with low 25 hydroxyvitamin D and 1,25 dihydroxyvitamin D levels. Additionally, the mother was noncompliant with prenatal vitamins, exclusively breastfeeding without vitamin D supplementation, and had markedly low vitamin D levels 15 weeks postpartum. The biochemical data and history were consistent with rickets. Given the diagnostic dilemma, the working diagnosis was rickets and the patient was started on ergocalciferol with subsequent normalization of his laboratory values and healing of the fracture. These findings are consistent with nutritional rickets largely due to maternal-fetal hypovitaminosis D. This case highlights that in young infants rickets should be considered even in the absence of positive radiologic findings. Additionally, it illustrates the importance of maintaining adequate vitamin D supplementation during pregnancy and early infancy.

http://ift.tt/2fxcQUU

Is there an increased risk of cervical neoplasia in atopic dermatitis patients treated with oral immunosuppressive drugs?

Abstract

Background

Oral immunosuppressive drugs are frequently prescribed in young women with atopic dermatitis (AD). Immunocompromised patients may have a higher risk of developing high risk HPV infections, CIN and cervical carcinoma. Most literature on patients using oral immunosuppressive drugs is available in organ transplant patients. Literature on the risk of developing cervical carcinoma in AD patients treated with oral immunosuppressive drugs is lacking. At this moment there is no clear guideline/consensus on this topic, but in daily practice, questions arise concerning whether this risk is increased and whether more intensive screening in women using immunosuppressive drugs should take place.

Objective

To investigate the occurrence of cervical carcinoma in women with AD treated with oral immunosuppressive drugs.

Methods

In this retrospective cohort study in two university medical centers in the Netherlands, all female adult AD patients receiving oral immunosuppressive drugs (cyclosporine A, azathioprine, methotrexate, mycophenolate mofetil, enter-coated mycophenolic acid and extended release tacrolimus) for more than 2 months between 1989 and January 1^st 2014 were included. Patient files in the national histopathology register were screened for PAP3a, CIN I, CIN II, CIN III and cervical carcinoma.

Results

A total of 257 female AD patients with one or more treatment episodes from 1989 until January 1^st 2014 were identified and included in this study. In 189 patients (73.5%) results of cervical examination were reported in the national histopathology database. Median total duration of treatment in these 189 women was 407.0 days (IQR 243.0-940.0). No cervical carcinoma during or following immunosuppressive therapy was found in our patient group.

Conclusions

No intensified screenings program for cervical neoplasia seems necessary for women with AD using oral immunosuppressive drugs.

This article is protected by copyright. All rights reserved.

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Interstitial lung disease in the connective tissue diseases; a paradigm shift in diagnosis and treatment

Publication date: Available online 17 September 2017
Source:Clinical Immunology
Author(s): Paul F. Dellaripa
Interstitial lung disease (ILD) in the connective tissue diseases (CTD) is amongst the most challenging aspect of care of patients with rheumatic diseases and is the source of significant morbidity and mortality. While there has been progress in our understanding of the natural history of these complications, we still suffer from a limited reservoir of data to confidently determine which patients are at highest risk for disease and those who are at highest risk for disease progression. Treatment options until recently have been limited to anti-inflammatory therapies but with the emerging availability of anti-fibrotic therapies, a shift in strategy is emerging to target therapies based on the specific radiographic, histopathologic features and biomarker profiles that are unique to patients with rheumatic diseases and ILD.



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Peripheral blood monocytes reveal an activated phenotype in pediatric uveitis

Publication date: Available online 17 September 2017
Source:Clinical Immunology
Author(s): Karoline Walscheid, Lisa Neekamp, Arnd Heiligenhaus, Toni Weinhage, Dirk Holzinger, Carsten Heinz, Maren Kasper, Dirk Foell
ObjectiveTo characterize peripheral blood monocytes in uveitis associated with juvenile idiopathic arthritis (JIAU).MethodsPeripheral blood monocytes from children with JIA (either with (n=18) or without uveitis (n=11)), idiopathic anterior uveitis (IAU; n=12) and healthy controls (n=11) were analyzed by flow cytometry.ResultsPercentage of CD14+CD86+ monocytes and CD86 expression on single cell level were significantly higher in all patient groups than in controls, whereas no major differences existed between patient groups. Frequency of CD39+ (p<0.05 all groups) and CD73+ monocytes (p=0.03 JIAU vs controls) was elevated in patients. Disease activity did not influence monocyte phenotypes, but in methotrexate-treated patients numbers of CCR2+ monocytes were reduced and numbers of CD86+ and CD39+ cells increased.ConclusionMonocytes from children with JIAU display a distinct phenotype when compared to cells from healthy children. Phenotypic changes seem to be neither arthritis- nor uveitis-dependent, but may be modified by treatment.



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What have we learned from BeSt?

Publication date: Available online 18 September 2017
Source:Clinical Immunology
Author(s): Cornelia F. Allaart, Iris M. Markusse, Willem F. Lems
BackgroundHow have the long term outcomes of RA improved in the last decade?MethodsPatients with DMARD naïve RA were randomized to 4 treatment strategies: 1. sequential DMARD monotherapy, 2. step-up combination therapy, 3. initial combination therapy including prednisone or 4. including infliximab. Treatment-to-target was aimed at DAS≤2.4 (three-monthly calculations). Functional ability (HAQ), radiologic damage progression (Sharp/vanderHeijde Score) and overall survival were reported.ResultsPatients in arms 3 and 4 showed earlier clinical improvement. Up to 50% achieved DAS-remission (<1.6), up to 29% achieved drug free remission. Damage progression was well suppressed (median after 10years in completers 2 SHS points), functional ability approached normality (mean HAQ 0.6). There was no increased mortality (Standardized Mortality Ratio 1.16, 95% CI 0.92–1.46).ConclusionsEarly treatment determines early clinical improvement, treatment-to-target determines long term outcomes. Prevention of relevant radiologic damage progression and disability, drug free remission and normalized survival are realistic goals.



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CAR T cell immunotherapy in hematology and beyond

Publication date: Available online 17 September 2017
Source:Clinical Immunology
Author(s): Claudia Rossig
Chimeric T cell receptors (CARs) combine extracellular antigen recognition domains and T cell activation components in single molecules. CAR gene transfer thereby allows to generate T cells with engineered specificities. The translational development of CAR-based T cell therapies is most advanced in B cell cancers where CAR-engineered T cells against the B lineage antigen CD19 have generated impressive results in early clinical trials. CARs are now also explored as tools to eliminate autoreactive B cell clones and to engineer T cells with immunosuppressive function for preventing pathological auto- or alloresponses. With ongoing intensive preclinical investigation and the advent of simplified manufacturing techniques, CAR T cells are expected to enter clinical investigation in a broader variety of hematological and solid cancers and in autoimmune diseases in the near future.



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Tonsillectomy in adults: Analysis of indications and complications

Publication date: Available online 18 September 2017
Source:Auris Nasus Larynx
Author(s): Blanca Pilar Galindo Torres, Félix De Miguel García, Jaime Whyte Orozco
ObjectiveTonsillectomy is one of the surgical techniques most practiced by otolaryngologists, and despite being a relatively simple technique; it presents a considerable percentage of complications, such as postoperative bleeding. The aim of this study is to describe the surgical indications and most frequent complications, analyze whether surgical suture of the tonsillar pillars has an influence on bleeding, and study the data of hospital stay and its importance for the control of complications.MethodsA retrospective study of 326 patients who underwent a tonsillectomy in our Department of Otolaryngology from 2006 to 2014 was conducted. The obtained data were statistically analyzed using the Excel and SPSS 21.0 programs.ResultsThe most frequent indication was recurrent tonsillitis, with a 74.85% (244) occurrence, and the most recurrent complication was bleeding, in 5.21% (17) of the tonsillectomies, requiring surgical revision 13 of the 17 patients. No statistically significant differences in the risk of bleeding were observed in patients in whom tonsil pillars were sutured comparing to those that were not. No statistically significant differences were detected associating surgical indication and oropharyngeal post-tonsillectomy hemorrhage. All operated patients were admitted, with a postoperative average hospital stay of 2.17 days, gaining a quick and effective control of the immediate complications.ConclusionBleeding is the most common and important complication. No statistically significant association between bleeding and tonsil pillar suture or surgical indication was found. Tonsillectomy was not set as outpatient surgery at the time.



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A novel IKAROS haploinsufficiency kindred with unexpectedly late and variable B cell maturation defects

Publication date: Available online 18 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Delfien J. Bogaert, Hye Sun Kuehn, Carolien Bonroy, Katherine R. Calvo, Joke Dehoorne, Arnaud V. Vanlander, Marieke De Bruyne, Urszula Cytlak, Venetia Bigley, Frans De Baets, Elfride De Baere, Sergio D. Rosenzweig, Filomeen Haerynck, Melissa Dullaers

Teaser

We report on the first truncating IKZF1 mutation associated with IKAROS haploinsufficiency and illustrate an unexpectedly late and variable block in central and peripheral B cell development in two patients and their asymptomatic mother.


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Effect of endotoxin and alum adjuvant vaccine on peanut allergy

Publication date: Available online 18 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Brandi T. Johnson-Weaver, Susan McRitchie, Kelly A. Mercier, Wimal Pathmasiri, Susan J. Sumner, Cliburn Chan, Dori Germolec, Michael Kulis, A. Wesley Burks, Herman F. Staats

Teaser

Environmental endotoxin and alum-adjuvanted vaccines did not influence peanut-allergy development in mice. Exposure to alum and CpG-adjuvanted vaccines indirectly reduced allergic disease severity. Fecal metabolites differentiated mice based on disease severity.


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CD4-T cell-restricted IL-2 signaling defect in a patient with a novel IFNGR1-deficiency

Publication date: Available online 18 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Aaruni Khanolkar, Dawn A. Kirschmann, Edward A. Caparelli, Jeffrey D. Wilks, Jillian M. Cerullo, Jenna R.E. Bergerson, Lawrence J. Jennings, Ramsay L. Fuleihan

Teaser

In depth analysis of immune function in a patient with a defined defect in IFNγR1 expression additionally identified an IL-2 associated signaling deficiency that was restricted primarily to the circulating CD4 T cell subset.


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Specific Allergy & Asthma Prevention Coming to an Age: A Milestone in Children

Publication date: Available online 18 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Claus Bachert, Cezmi Akdis




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A novel role for cilia function in atopy: ADGRV1 and DNAH5 interactions

Publication date: Available online 18 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Pierre-Emmanuel Sugier, Myriam Brossard, Chloé Sarnowski, Amaury Vaysse, Andréanne Morin, Lucile Pain, Patricia Margaritte-Jeannin, Marie-Hélène Dizier, William O.C.M. Cookson, Mark Lathrop, Miriam F. Moffatt, Catherine Laprise, Florence Demenais, Emmanuelle Bouzigon
BackgroundAtopy, an endotype underlying allergic diseases, has a substantial genetic component.ObjectiveOur goal was to identify novel genes associated with atopy in asthma-ascertained families.MethodsWe implemented a three-step analysis strategy in three datasets: The Epidemiological study on the Genetics and Environment of Asthma (EGEA) dataset: 1,660 subjects; The Saguenay-Lac-Saint-Jean (SLSJ) dataset: 1,138 subjects; and The Medical Research Council (MRC) dataset: 446 subjects). This strategy included a single-SNP genome-wide association study (GWAS), the selection of related gene pairs based on statistical filtering of GWAS results and text-mining filtering using GRAIL and SNP-SNP interaction analysis of selected gene pairs.ResultsWe identified the 5q14 locus, harboring the adhesion G protein-coupled receptor V1 (ADGRV1) gene, that showed genome-wide significant association with atopy (rs4916831; Pmeta=6.8x10^-9). Statistical filtering of GWAS results followed by text-mining filtering revealed relationships between ADGRV1 and three genes showing suggestive association with atopy (P≤10^-4). SNP-SNP interaction analysis between ADGRV1 and these three genes showed significant interaction between ADGRV1 rs17554723 and two correlated SNPs (rs2134256 and rs1354187) within dynein axonemal heavy chain 5 (DNAH5) gene (Pmeta-int=3.6x10^-5 and 6.1x10^-5, that met the multiple-testing corrected threshold of 7.3x10^-5). Further conditional analysis indicated that rs2134256 alone accounted for the interaction signal with rs17554723.ConclusionAs both DNAH5 and ADGRV1 contribute to function of cilia, this study suggests that cilia dysfunction may represent a novel mechanism underlying atopy. Combining GWAS and epistasis analysis driven by statistical and knowledge-based evidence represents a promising approach for identifying new genes involved in complex traits.

Teaser

This study in three family-based studies identified association between ADGRV1 and atopy and interaction between ADGRV1 and DNAH5, two genes that contribute to ciliary functions.


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GJB2 mutations: Genotypic and phenotypic correlation in a cohort of 690 hearing-impaired patients, toward a new mutation?

Publication date: November 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 102
Author(s): Jean-Christophe Leclère, Marie-Suzanne Le Gac, Cedric Le Maréchal, Claude Ferec, Rémi Marianowski
ObjectivesTo analyze the clinical features of hearing impairment and to search for correlations with the genotype in patients with GJB2 mutations.DesignCase series.SettingCollaborative study in referral centers, institutional practice.PatientsA total of 690 hearing-impaired patients were genotypically and phenotypically described. The mutations of GJB2 and GJB6 were studied. Heterozygous patients were searched for another mutation by microsatellite approach.Main outcome measuresPrevalence of GJB2 mutations, microsatellite approach, hearing-impairment.ResultsIn 498 patients (72,17% of the cohort), no mutation was found. Homozygotous patients were 59 (8,55%), with 51 for c.35delG, 6 for p.M34T and 2 for GJB6. Compound heterozygous were 64 (9,28%) with 56 c.35delG-others mutations.Genotypes with biallelic non sense mutations had a high risk of severe to profound hearing impairment. It was frequently milder in compound heterozygotes than in c.35delG homozygotes.Heterozygous patients were 69 (10%) with 21 c.35delG, 20 p.M34T and 28 others mutations. We selected patients with a complete historical medical file (clinical and audiometric data). Then, we performed a microsatellite approach (multiplex PCR of short DNA fragments) to localize a new pathologic allele. Seventeen heterozygous patients were studied. Six patients (35%) showed the same haplotype. They were compound heterozygous bearing a new pathologic allele.ConclusionGenotype may affect deafness severity, but environmental and other genetic factors may also modulate the severity and evolution of GJB2-GJB6 deafness. A new haplotype for GJB2 is described but the exact mutation remains unknown.



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An animal model of deep brain stimulation for treating tinnitus: A proof of concept study

Objective

This proof-of-concept study aimed to demonstrate therapeutic effects of deep brain stimulation (DBS) on noise-induced tinnitus.

Study Design

Experimental animal study.

Methods

After Institutional Animal Care and Use Committee approval, nine adult rats were implanted in the caudate nucleus with custom-made electrode array. The rats were exposed to noise to induce tinnitus. Auditory brainstem response was performed to evaluate hearing threshold changes. Noise-induced tinnitus and its suppression by DBS were evaluated using the gap-detection acoustic startle reflex behavioral paradigm and electrophysiological evaluation of modulatory effects on neural correlates of tinnitus. Various stimulation parameters were used to determine the most effective ones in affecting behavioral changes, along with corresponding neural activity in the caudate nucleus. The correlation between the caudate nucleus and auditory cortex also was determined. Analysis of variance with Bonferroni correction was performed to examine DBS-induced effects on behavioral evidence of tinnitus.

Results

Bursting activity, a neural marker of tinnitus, was noted to decrease compared to baseline in tinnitus (+) animals. After stimulation, spontaneous and bursting activity increased in the tinnitus (+) animals but decreased in the tinnitus (−) animals. Behavioral data suggested suppression of tinnitus after DBS. These effects lasted up to 5 days. To our knowledge, this is the first development of an animal model to test deep brain stimulation of the caudate region for the treatment of tinnitus.

Conclusions

Deep brain stimulation of the caudate nucleus can modulate tinnitus in a rat model of tinnitus.

Level of Evidence

NA. Laryngoscope, 2017

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Segmental lichen aureus: a prodromal stage of localized morphoea

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Hairless lesion on the scalp

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Lichen scrofulosorum: a clinical marker for sexually transmitted tuberculosis

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Necrotizing fasciitis of the lower leg caused by Escherichia coli, and an association with pyogenic spondylitis

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Clinical comparison of actinic changes preceding squamous cell carcinoma vs. intraepidermal carcinoma in renal transplant recipients

Summary

Intraepidermal carcinoma (IEC) is a type of in situ squamous cell carcinoma (SCC), although progression of IEC is rare. We sought to investigate differences between the actinic skin changes preceding the development of both SCC and IEC. Photographs of 63 skin sites at which either SCC or IEC subsequently developed in 37 renal transplant recipients (RTRs) were examined for features of actinic change. We found that areas of skin with an actinic keratosis (AK) > 1 cm² in size were four times more likely to develop SCC as opposed to IEC (OR = 4.42; 95% CI 1.25–15.60). Skin sites with ≥ 25% of the area affected by AK were again four times more likely to develop SCC than IEC. These results highlight the scale of visible actinic damage required for development of SCC compared with IEC, emphasizing the importance of treating areas of skin with marked visible actinic change to reduce SCC risk in RTRs.

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Apremilast in psoriasis - a prospective real-world study

Abstract

Background

Apremilast is a novel oral phosphodiesterase-4 inhibitor approved for psoriasis treatment. Randomized trials have documented its efficacy and safety, but data on real-world patients are scarce.

Objectives

We aim to characterize psoriasis patients treated with apremilast in a real-world setting and calculate drug survival as an important measure of efficacy and compliance.

Methods

All psoriasis patients that received apremilast between April 1^st 2015 and January 19^th 2017 were evaluated every 4 weeks and we documented: age, weight, height, smoking status, family history of psoriasis, joint involvement, previous treatments, psoriasis area severity index (PASI) scores, and the onset and duration of adverse events (AE). Efficacy was analyzed by PASI50, PASI75, and PASI90, reflecting the improvement of skin lesions compared to the PASI-baseline. Kaplan-Meier statistics were used for drug survival estimates.

Results

Forty-eight patients were included. The median apremilast drug survival was 12.5 weeks (range 1-87). Three patients (6.3%) reached PASI90, nine (18.8%) PAIS75 and eight patients (16.7%) PASI50. Patient weight inversely correlated with a PASI50 response (p<0.05, n=37), and none of the obese patients (BMI>30.0, n=6) reached PASI75, compared to 32% of the non-obese patients (BMI<30.0, n=31). Thirty-one patients (64.6%) reported at least one AE, most frequently diarrhea (n=21, 43.8%), headache (n=7, 14.6%) and joint pain (n=5, 10.4%).

Conclusions

Despite differences between real-world and trial patients, apremilast is safe and effective for the treatment of skin psoriasis in the daily practice. Up to 40% of patients will reach PASI50 or higher, but only few patients will reach PASI90. Body-weight might affect drug efficacy.

This article is protected by copyright. All rights reserved.

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Alopecia areata complicated with Good's syndrome

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Melanoma, eruptive naevi and natalizumab: Causal relation or coincidence?

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Hyperlipidaemia presenting as palmoplantar pain

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Psoriasis aggravation due to capecitabine: A case study and review of the literature

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Filarial pleural effusion without peripheral blood or pleural fluid eosinophilia

Lymphatic filariasis is a tropical parasitic disease and is endemic in India. It is present in various forms but its manifestation as pleural effusion is rare. Here, we describe a case of 58-year-old male who presented with complaint of left side chest pain and breathlessness. He was investigated and diagnosed as a case of left side pleural effusion due to filariasis, with peripheral blood lymphocytosis but without peripheral blood or pleural fluid eosinophilia. Our case foregrounds that filariasis can present with peripheral blood lymphocytosis and without peripheral blood or pleural fluid eosinophilia.

http://ift.tt/2hbNPlT

Coexistent duplication of urethra and a refluxing ectopic ureter presenting as recurrent epididymo-orchitis in a child

Congenital anomalies of the kidney and urinary tract (CAKUTs) occur in 3–6 per 1000 live births, accounting for most cases of paediatric end-stage kidney disease.¹ However, the molecular basis of CAKUT and anomalies of the external genitalia is poorly understood. We, herein, describe a case with left recurrent epididymo-orchitis with a coexistent urethral duplication and an ectopic ureter with an ipsilateral non-functioning kidney, which is, to the best of our knowledge, the first reported case of its kind. This case may bring about a paradigm shift in our comprehension of the development of the two entities. Understanding the pathogenesis may help develop preventive and renal preservation strategies. The Sonic hedgehog gene and bone morphogenetic protein 4 play crucial roles in preventing anomalies of the ureters and the external genitalia. In this article, we look at possible molecular pathways that could explain the synchronicity of this rare entity.

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Acute carpal tunnel syndrome caused by thrombosed persistent median artery associated with bifurcated median nerve in a pregnant woman

Carpal tunnel syndrome (CTS) is a common form of peripheral nerve entrapment, which is observed due to compression of the median nerve at the level of the carpal tunnel in the wrist. Bifid median nerve and persistent median artery association are rare, and they may be independent risk factors for CTS. These rare entities are usually asymptomatic, but in cases of acute thrombosis or dilatation of the persistent median artery, acute findings can be seen. We report a case of acute CTS due to thrombosis of a persistent median artery and associated bifurcated median nerve during pregnancy.

http://ift.tt/2hdES7W

Whipples endocarditis presenting as ulnar artery aneurysm; if you dont look, you wont find

A 54-year-old female patient presented to her local district general hospital with a painful, swollen left arm. Imaging revealed an ulnar artery aneurysm. The aetiology was embolic, with an echocardiogram revealing vegetations on the aortic valve. The patient was treated empirically for 6 weeks with amoxicillin and gentamicin for endocarditis. Eight months later, she had an elective aortic valve replacement for symptomatic aortic regurgitation. The valve was culture negative but analysis by 16S rDNA PCR was positive for Tropheryma whipplei. In retrospect, the ulnar artery aneurysm and a history of arthralgia were attributed to an underlying diagnosis of Whipple's endocarditis. She continues on antibiotic treatment with resolution of her arthralgia and no clinical signs of infection. Once thought to be rare entity, molecular assays have revolutionised the diagnosis of Whipple's endocarditis, but this case highlights the difficulties and pitfalls in diagnosis.

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Two types of varicella zoster in one patient

Description

A 79-year-old patient, with a background of chronic lymphocytic leukaemia, presents with herpes zoster (HZ) affecting the left C2/3 dermatome (figure 1). Three days after initial development, a secondary diffuse vesicular papuloblistering rash developed on the trunk, resembling varicella zoster virus (VZV) infection (figure 2).

Figure 1

Vesicular plaque located to C2/3 dermatome.

Figure 2

Disseminated vesiculopapular lesions.

Vesicular fluid from both rashes was positive for VZV on Fast Track Diagnostic multiplex real-time PCR assay, which has a specificity of 100% and sensitivity of 100% to 10³ copies/mL dilution. Other methods of detection include directly with viral isolation and culture, detection of antigen in cell specimens, visualisation via light microscopy with Tzanck smears or electron microscopy or indirectly with western blotting or IgG detection.1 Further samples were sent for bacterial and fungal microscopy,...

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Melioidosis mimicking tubercular cold abscess

Burkholderia pseudomallei is a Gram-negative bacillus found in soil. The infection is thought to occur by inoculation or inhalation. It usually affects people with predisposing factors like diabetes mellitus and chronic alcoholism. A 36-year-old man, on the treatment of diabetes in the past 4 years, on oral hypoglycaemic drugs, presented to us with pain and insidious onset of swelling over left loin like a lumbar cold abscess. He underwent incision and drainage of the abscess. As per the culture report, we used ceftazidime for 2 weeks, followed by cotrimoxazole for 6 months. Surgical drainage of large abscesses is indicated. A dedicated team of microbiologist and physicians is required to identify and treat the disease. Orthopaedic manifestations are uncommon.

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Sarcomatoid urothelial carcinoma with disseminated metastases: an aggressive and rare cancer

Description

A 48-year-old woman with medical history of chronic obstructive pulmonary disease (COPD), hypertension and chronic tobacco abuse. She presented to the emergency department with new-onset supraventricular tachycardia. She denied any urological symptoms. Physical examination revealed a cachectic woman but otherwise unremarkable. Her laboratory investigations showed hypercalcaemia at 1.58 (Ref: 1.1 to 1.3mmol/L) with low 25-Hydroxy low vitamin D 25-Hydroxy at 5.6 at 5.6 (Ref: 30 to 100 ng/mL), low parathyroid hormone level <6.3 (Ref: 14 to 72 pg/mL) and elevated Parathyroid-related protein 83 (Ref: 14 to 27 pg/mL).

She had a chest, abdomen and pelvis CT scan to rule out any underlining malignancy. The results revealed significant enhancement and nodular urinary bladder wall with intraluminal hyperdensities. In addition, there were innumerable small cavitating lung nodules scattered throughout the lung fields, hypodense lesion involving the right hepatic lobe, splenic nodule, disseminated lymphadenopathy, osseous diseases involving L4, L2, T8 and compression deformity with superior endplate...

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Sudden death and acute myocarditis: a unique forensic case of double origin of coronary arteries

Description

The doubling of the right coronary artery is a rare congenital coronary anomaly. Generally, this malformation is asymptomatic and therefore benign. But, in some cases, it constitutes a real silent killer. The aim of this study is to show how the double right coronary artery can cause fatal events without clinical signs of its presence. We reported the association between this anomaly and the acute necrotising myocarditis. In the forensic literature, cases of sudden death associated with the double coronary origin are not described.1 2

We reported the case of a sudden death in a 14-year-old girl. At autopsy, the heart showed greyish areas and the histopathological surveys demonstrated the doubling of the right coronary artery (figures 1–4). The left ventricular myocardium showed a phlegmonous exudative inflammation, large necrotic areas and interstitial leucocyte infiltration, which...

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Implantable cardiac defibrillator infections: the emerging importance of Mycobacterium fortuitum

Infection is a clinically relevant complication associated with intracardiac devices. Atypical mycobacteria, particularly Mycobacterium fortuitum, have been increasingly implicated in cardiovascular implantable electronic device (CIED) infections. We present a case of M. fortuitum CIED infection in a patient with ischaemic cardiomyopathy occurring approximately 3 weeks after insertion. The recognition and adequate treatment, including device removal, tissue sampling and the determination of antimicrobial sensitivities, are essential in the proper management of these patients.

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Upper eyelid ectropion repair

Description

A 75-year-old man presented with a constant, not repositioned left upper eyelid ectropion (figure 1). The patient had suffered several episodes of infectious keratitis due to eyeball exposure. The lower eyelid presented also an ectropion due to hyperlaxity. Severely injected and hypertrophied superior tarsal conjunctiva was observed. The cornea was tarnished with loss of brightness due to poor lubrication by exposition (figure 1). The patient had no history of previous surgery, traumatic event, obstructive sleep apnoea (OSA) syndrome or multiple endocrine neoplasia. He underwent an upper lid lateral full thickness semilunar wedge resection of 15 mm and levator muscle aponeurosis reattachment through the eyelid crease (figures 2 and 3). A lateral tarsal sling was performed in lower eyelid. Epithelial hyperplasia with parakeratosis was informed in the histological study (figure 4). Cosmetic and functional results were rapidly obtained. No...

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Refractory coeliac disease: or is it?

A previously healthy 33-year-old man presented with a 3-month history of nausea, anorexia and weight loss. Coeliac disease was diagnosed at another hospital with positive serology and D2 biopsies and he was started on a gluten-free diet. The details of these tests were not available to us. Despite good adherence to a gluten-free diet, he continued to lose weight and became anaemic. A repeat gastroscopy showed D2 ulcers. Helicobacter pylori infection was excluded, coeliac serology remained negative but D2 biopsies showed partial duodenal villous flattening with intraepithelial lymphocytosis. Type 1 refractory coeliac disease was diagnosed. Prednisolone and azathioprine were commenced but the vomiting and weight loss progressed. A subsequent gastroscopy and CT scan revealed a D3 stricture and duodenal dilatation, respectively, in keeping with superior mesenteric artery syndrome. An infracolic duodenojejunostomy was performed and immunosuppression stopped. Subsequently, all his symptoms resolved and he remains well on a gluten-free diet.

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Anisocoria secondary to inadvertent contact with scopolamine patch

A unilaterally fixed mydriasis, also known as a 'blown pupil,' is considered an ominous sign concerning for intracranial pathology. Causes of anisocoria can range from benign to immediately life-threatening. When a patient presents with anisocoria, the concern for a fatal diagnosis leads the clinician to obtain numerous tests, many of which may be unnecessary. The authors present a case of a healthy woman in her 30s who presented with an acute unilateral mydriasis likely secondary to inadvertent contact with a scopolamine patch. On examination, she had no other neurological deficits. Further investigation did not reveal any abnormality. In the event of a patient with an isolated mydriasis in an otherwise healthy and conversant patient with no other neurological deficits, it is essential to rule out other causes before pursuing aggressive and unnecessary testing and treatment.

http://ift.tt/2w598YT

Erosive pustular dermatosis of the scalp after aplasia cutis congenita in a 9-year-old patient: A 5-year follow-up

Abstract

Erosive pustular dermatosis of the scalp (EPDS) is a rare inflammatory skin disease that occurs mainly in elderly adults with a history of trauma to the scalp, but a few cases of EPDS in children have been reported. We report a rare case of EPDS after aplasia cutis congenita in a child.

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Grandmaternal smoking increases asthma risk in grandchildren: a nationwide Swedish cohort

Abstract

Background

There is growing interest in exposures prior to conception as possible risk factors for offspring asthma. Although partially supported by evidence from limited human studies, current evidence is inconsistent, and based on recall of exposure status.

Objective

We aimed to investigate grandmaternal smoking during pregnancy and the risk of asthma in grandchildren using prospectively collected population-based data.

Methods

Information on grandmaternal and maternal smoking during pregnancy and grandchild use of asthma medications was collected from national Swedish registries. Associations between grandmaternal smoking during pregnancy (10-12 weeks), and asthma medication use in grandchildren were investigated using generalized estimating equations. Ages at which asthma medications were prescribed classified childhood asthma into never, early transient (0-3years), late onset (3-6 years) and early persistent (0-3 and 3-6 years) phenotypes.

Results

From 1982 to 1986, 44,583 grandmothers gave birth to 46,197 mothers, who gave birth to 66,271 grandchildren (born 1996-2010). Children aged 1-6 years had an increased asthma risk if their grandmothers had smoked during pregnancy, with a higher risk for more exposure (10+ cigs/day; adjusted OR 1·23; 1·17, 1·30). Maternal smoking did not modify this relationship.

Conclusions & clinical Relevance

Children had an increased risk of asthma in the first six years of life if their grandmothers smoked during early pregnancy, independent of maternal smoking. Importantly this exhibited a dose-response relationship and was associated with a persistent childhood asthma phenotype. These findings support possible epigenetic transmission of risk from environmental exposures in previous generations.

This article is protected by copyright. All rights reserved.

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Determinants of low risk of asthma exacerbation during pregnancy

Abstract

Background

Assessment of asthma control every 4-6 weeks during pregnancy is recommended to reduce risk of exacerbation, and by that improve outcome.

Objective

To identify determinants of pregnancies with low risk of asthma exacerbation.

Methods

All pregnant women enrolled into the Management of Asthma during Pregnancy (MAP) program at Hvidovre Hospital since 2007. Assessment of asthma control, adjustment of treatment, spirometry and measurement of exhaled nitric oxide (F_ENO) were performed, and baseline characteristics and exacerbation history was collected at enrolment. Determinants of low-exacerbation risk pregnancies were identified by logistic regression analysis (stepwise backward elimination).

Results

In 1,283 pregnancies, 107 exacerbations were observed. Multiple regression analysis revealed that no history of pre-pregnancy exacerbations (p<0.001), no prescribed controller medication (p<0.001), and clinically stable asthma at enrolment (p=0.002)were significantly associated with low risk of exacerbation during pregnancy, with these combined characteristics only two out of 385 pregnancies were complicated by an exacerbation (OR 0.04, 95% CI 0.01-0.18, p<0.001).

Conclusion and clinical relevance

Clinically stable asthma at enrolment, together with no history of previous exacerbations and no prescribed controller medication, are determinants of low risk of an asthma exacerbation during pregnancy, which may guide clinicians in individualising surveillance of asthma during pregnancy.

This article is protected by copyright. All rights reserved.

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A Home for Surgical Pain Management: The Perioperative Pain Service

No abstract available

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Red Blood Cell Transfusion and Surgical Site Infection After Colon Resection Surgery: A Cohort Study

BACKGROUND: Surgical site infections (SSIs) after colon surgery remain a critical safety issue. Patients with an SSI have an increased risk of death, prolonged hospitalization, and increased costs of care. Red blood cell (RBC) transfusion is given during the perioperative period to increase blood oxygen delivery, but it is associated with complications, including infection. We hypothesized that RBC transfusion would be associated with increased SSI risk in patients undergoing colon resection surgery. METHODS: A retrospective cohort study was performed using the 2014 National Surgical Quality Improvement Program participant use file. Patients who had colon resection surgery were identified using current procedural terminology codes. The association between perioperative RBC transfusion and superficial and deep incisional SSIs, organ space SSIs, and postoperative septic shock was modeled using logistic regression with propensity score analysis. RESULTS: Of 23,388 patients who had colon resection surgery, 1845 (7.9%) received perioperative RBC transfusion. After controlling for confounders with propensity score analysis and inverse probability of treatment weighting, RBC transfusion had no apparent association with superficial incisional SSI (odds ratio [OR], 1.18; 99% confidence interval [CI], 0.48–2.88) or deep incisional SSI (OR, 1.47; 99% CI, 0.23–9.43). However, RBC transfusion appeared to be associated with increased risk of organ space SSI (OR, 2.93; 99% CI, 1.43–6.01) and septic shock (OR, 9.23; 99% CI, 3.53–24.09). CONCLUSIONS: RBC transfusion has no apparent association with increased risk for incisional SSIs, but may be associated with increased risk for organ space SSI and septic shock after colon resection surgery.

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Does the [beta]-receptor antagonist esmolol have analgesic effects? A randomised placebo-controlled cross-over study on healthy volunteers undergoing the cold pressor test.

BACKGROUND: Esmolol may attenuate the sympathetic response to pain and reduce postoperative opioid consumption. It is not clear whether esmolol has an analgesic effect per se. OBJECTIVES: The aim of this study was to evaluate the analgesic effect of esmolol in the absence of anaesthetics and opioids. We tested the hypothesis that esmolol would reduce the maximum pain intensity perceived during the cold pressor test (CPT) by 2 points on a 0 to 10 numeric pain rating scale (NRS) compared to placebo. DESIGN: Randomised, placebo-controlled cross-over study. SETTING: Postoperative recovery area, Orebro University Hospital. Study period, November 2013 to February 2014. PARTICIPANTS: Fourteen healthy volunteers. Exclusion criteria included ongoing medication, pregnancy and breastfeeding and participation in other medical trials. INTERVENTIONS: At separate study sessions, participants received interventions: esmolol (0.7 mg kg-1 bolus over 1 min followed by infusion at 10 [mu]g kg-1 min-1); 0.9% normal saline bolus then remifentanil infusion at 0.2 [mu]g kg-1 min-1 and 0.9% normal saline bolus and infusion according to a random sequence. All infusions were administered over 30 min. MAIN OUTCOME MEASURES: Perceived maximum pain intensity score, pain tolerance and haemodynamic changes during CPT, and occurrence of side-effects to interventions compared to placebo, respectively. RESULTS: Esmolol did not reduce perceived pain intensity or pain tolerance during the CPT. The NRS-max score was similar for esmolol, 8.5 (+/-1.4) and placebo, 8.4 (+/-1.3). The mean difference was 0.1 [95% confidence interval (-1.2 to 1.4)], P value equal to 0.83. Remifentanil significantly reduced NRS-max scores, 5.4 (+/-2.1) compared to placebo, [mean difference -3.1 (95% confidence interval (-4.4 to -1.8)), P

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Incidence and risk factors of anaesthesia-related perioperative cardiac arrest: A 6-year observational study from a tertiary care university hospital.

BACKGROUND: In recent decades, the incidences of anaesthesia-related perioperative mortality and adverse outcomes have decreased drastically. However, to date, data on perioperative cardiac arrest and risk factors of perioperative cardiac arrest from European countries are scarce. OBJECTIVES: To determine the incidences of perioperative cardiac arrest and rates of anaesthesia-related and anaesthesia-contributory cardiac arrest. Identification of pre-existing risk factors leading to perioperative cardiac arrest. DESIGN: Retrospective cohort study. SETTING: Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany. INTERVENTIONS: Perioperative critical incident reports between 2007 and 2012 were screened, and reports on cardiac arrest within 24 h postoperatively were identified. Cardiac arrests were classified as 'anaesthesia-related', 'anaesthesia-contributory' or 'anaesthesia-unrelated' by two reviewers independently. Univariate and multi-variate logistic regression analysis was used to identify risk factors associated with perioperative cardiac arrest. RESULTS: Analysis of 318 critical incidents from 169 500 anaesthetics revealed 99 perioperative cardiac arrests. This is an overall incidence of perioperative cardiac arrest of 5.8/10 000 anaesthetics [95% confidence interval (CI), 4.7 to 7.0]. The rate of anaesthesia-related cardiac arrest was 0.7/10 000 (95% CI, 0.3 to 1.1), and the rate of anaesthesia-contributory cardiac arrest was 1.7/10 000 (95% CI, 1.1 to 2.3). Most cardiac arrests related to anaesthesia were due to respiratory events. From the multi-variate analysis, American Society of Anesthesiologists physical status grade at least 3 [P = 0.007, odds ratio (OR) 2.59 (95% CI, 1.29 to 5.19)], emergency surgery [P

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The impact of continuous non-invasive arterial blood pressure monitoring on blood pressure stability during general anaesthesia in orthopaedic patients: A randomised trial.

BACKGROUND: In patients undergoing general anaesthesia, intraoperative hypotension occurs frequently and is associated with adverse outcomes such as postoperative acute kidney failure, myocardial infarction or stroke. A history of chronic hypertension renders patients more susceptible to a decrease in blood pressure (BP) after induction of general anaesthesia. As a patient's BP is generally monitored intermittently via an upper arm cuff, there may be a delay in the detection of hypotension by the anaesthetist. OBJECTIVE: The current study investigates whether the presence of continuous BP monitoring leads to improved BP stability. DESIGN: Randomised, controlled and single-centre study. PATIENTS: A total of 160 orthopaedic patients undergoing general anaesthesia with a history of chronic hypertension. INTERVENTION: The patients were randomised to either a study group (n = 77) that received continuous non-invasive BP monitoring in addition to oscillometric intermittent monitoring, or a control group (n = 83) whose BP was monitored intermittently only. The interval for oscillometric measurements in both groups was set to 3 min. After induction of general anaesthesia, oscillometric BP values of the two groups were compared for the first hour of the procedure. Anaesthetists were blinded to the purpose of the study. MAIN OUTCOME MEASURE: BP stability and hypotensive events. RESULTS: There was no difference in baseline BP between the groups. After adjustment for multiple testing, mean arterial BP in the study group was significantly higher than in the control group at 12 and 15 min. Mean +/- SD for study and control group, respectively were: 12 min, 102 +/- 24 vs. 90 +/- 26 mmHg (P = 0.039) and 15 min, 102 +/- 21 vs. 90 +/- 23 mmHg (P = 0.023). Hypotensive readings below a mean pressure of 55 mmHg occurred more often in the control group (25 vs. 7, P = 0.047). CONCLUSION: Continuous monitoring contributes to BP stability in the studied population. TRIAL REGISTRATION: NCT02519101. (C) 2017 European Society of Anaesthesiology

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Role of the internet as an information resource before anaesthesia consultation: A French prospective multicentre survey.

BACKGROUND: Use of the internet as an information search tool has increased dramatically. Our study assessed preoperative use of the internet by patients to search for information regarding anaesthesia, surgery, pain or outcomes. OBJECTIVE(S): The aim of this study was to test whether patients used the internet prior to surgery and what kinds of information they looked for (anaesthetic technique, pain, adverse events, outcomes and surgery). Correlation between patient age and information sought about surgery from the internet was also explored. DESIGN: A prospective multicentre observational study. SETTING: In total, 14 French private and public institutions from May 2015 to January 2016. PATIENTS: In total, 3161 adult patients scheduled for elective surgery under regional or general anaesthesia. INTERVENTION(S): An anonymous questionnaire was presented to adult patients scheduled for elective surgery under regional or general anaesthesia for completion before the first meeting with the anaesthesiologist. The investigator at each centre completed specific items that the patient could not complete. MAIN OUTCOME MEASURES: We defined the primary endpoint as the number of patients who searched for information about their anaesthesia or surgery on the internet by the time of the their preanaesthetic consultation. RESULTS: Of the 3234 questionnaires distributed, responses were received from 3161 patients. Within this respondent sample, 1304 (45%) were professionally active and 1664 (59%) used the internet at least once per day. Among 3098 (98%) patients who answered the question concerning the primary endpoint, 1506 (48%) had searched the internet for information about their health. In total, 784 (25%) used the internet to find information about their surgery and 113 (3.5%) looked for specific information about anaesthesia. Of the 3161, 52% reported difficulty searching for appropriate information about anaesthesia on the internet. 'Daily use of the web' [odds ratio (OR) 2.0; (95% CI: 1.65 to 2.55) P

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Trichoscopic spectrum of folliculotropic mycosis fungoides

Abstract

Folliculotropic mycosis fungoides (F-MF) is a variant of mycosis fungoides characterized by preferential infiltration of the follicular epithelium by atypical T lymphocytes, with or without follicular mucinosis or infiltration of the intervening epidermis. It is the most common subtype of mycosis fungoides (MF) in adults, with 4% frequency according to WHO classification. Follicular mucinosis refers to depositions of mucin within the follicular epithelium, which may be idiopathic or associated with different benign or malignant skin diseases, including MF.

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Verrucous Epidermal Nevus - a misleading diagnosis for 28 years

Abstract

Epidermal nevi (EN) are hamartomas of the skin that result from mosaic post-zygotic mutations. There are several variants of EN, the verrucous epidermal nevus (VEN) being the most common. EN can be further subdivided into epidermolytic and nonepidermolytic, important since in contrast with nonepidermolytic EN, epidermolytic EN occurs sporadically (not heritable), and it is not associated with extracutaneous abnormalities.

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Benefit from Reslizumab Treatment in a Patient with Chronic Spontaneous Urticaria and Cold Urticaria

Abstract

Chronic urticaria (CU) is a group of common and debilitating conditions containing both chronic spontaneous urticaria (CSU) and chronic inducible urticarias (CIndU) including cold urticaria (ColdU) [1]. While antihistamines and omalizumab are effective treatments for both CSU and ColdU [2], many patients show insufficient response to either or both of these treatments [3], and additional and better therapies are needed [4].

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Not a simple plantar wart: A case of tungiasis

Abstract

A 62-year-old Caucasian woman complained of a painful nodular lesion on her right heel that restricted her walking. She had noticed the onset of the itching after approximately 3 weeks of travel in Brazil. She was initially treated by her general practitioner with topical salicylic acid, suspecting a plantar wart. After a week of increased itching and unbearable pain, the patient was referred to our dermatological service.

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Acquired A Haemophilia: a case report

Abstract

Acquired haemophilia A (AHA) due to autoantibodies against Factor VIII (FVIII) is a rare disease associated with severe bleeding. Since diffuse cutaneous hematomas and ecchymoses are the main clinical signs of this condition, dermatologists should be aware about this disease. Here, we present a case of AHA in a patient with systemic lupus erythematosus (SLE).

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Incidence and Risk Factors of Coagulation Profile Derangement After Liver Surgery: Implications for the Use of Epidural Analgesia-A Retrospective Cohort Study.

BACKGROUND: Hepatic surgery is a major abdominal surgery. Epidural analgesia may decrease the incidence of postoperative morbidities. Hemostatic disorders frequently occur after hepatic resection. Insertion or withdrawal (whether accidental or not) of an epidural catheter during coagulopathic state may cause an epidural hematoma. The aim of the study is to determine the incidence of coagulopathy after hepatectomy, interfering with epidural catheter removal, and to identify the risk factors related to coagulopathy. METHODS: We performed a retrospective review of a prospective, multicenter, observational database including patients over 18 years old with a history of liver resection. Main collected data were the following: age, preexisting cirrhosis, Child-Pugh class, preoperative and postoperative coagulation profiles, extent of liver resection, blood loss, blood products transfused during surgery. International normalized ratio (INR) >=1.5 and/or platelet count =1.3 (OR = 2.39 [1.10-5.17]; P = .027), preoperative platelet count =1000 mL (OR = 1.85 [1.08-3.18]; P = .025) were associated with postoperative coagulopathy. CONCLUSIONS: Coagulopathy is frequent (53.5% [95% confidence interval, 50.0-57.1]) after liver resection. Epidural analgesia seems safe in patients undergoing minor hepatic resection without preexisting hepatic cirrhosis, showing a normal preoperative INR and platelet count. (C) 2017 International Anesthesia Research Society

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Anesthesia Capacity in Ghana: A Teaching Hospital's Resources, and the National Workforce and Education.

BACKGROUND: Quality anesthetic care is lacking in low- and middle-income countries (LMICs). Global health leaders call for perioperative capacity reports in limited-resource settings to guide improved health care initiatives. We describe a teaching hospital's resources and the national workforce and education in this LMIC capacity report. METHODS: A prospective observational study was conducted at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, during 4 weeks in August 2016. Teaching hospital data were generated from observations of hospital facilities and patient care, review of archival records, and interviews with KATH personnel. National data were obtained from interviews with KATH personnel, correspondence with Ghana's anesthesia society, and review of public records. RESULTS: The practice of anesthesia at KATH incorporated preanesthesia clinics, intraoperative management, and critical care. However, there were not enough physicians to consistently supervise care, especially in postanesthesia care units (PACUs) and the critical care unit (CCU). Clean water and electricity were usually reliable in all 16 operating rooms (ORs) and throughout the hospital. Equipment and drugs were inventoried in detail. While much basic infrastructure, equipment, and medications were present in ORs, patient safety was hindered by hospital-wide oxygen supply failures and shortage of vital signs monitors and working ventilators in PACUs and the CCU. In 2015, there were 10,319 anesthetics administered, with obstetric and gynecologic, general, and orthopedic procedures comprising 62% of surgeries. From 2011 to 2015, all-cause perioperative mortality rate in ORs and PACUs was 0.65% or 1 death per 154 anesthetics, with 99% of deaths occurring in PACUs. Workforce and education data at KATH revealed 10 anesthesia attending physicians, 61 nurse anesthetists (NAs), and 7 anesthesia resident physicians in training. At the national level, 70 anesthesia attending physicians and 565 NAs cared for Ghana's population of 27 million. Providers were heavily concentrated in urban areas, and NAs frequently practiced independently. Two teaching hospitals provided accredited postgraduate training modeled after European curricula to 22 anesthesia resident physicians. DISCUSSION: While important limitations to capacity exist in Ghana, the overall situation is good compared to other LMICs. Many of the challenges encountered resulted from insufficient PACU and CCU provisions and few providers. Inadequate outcomes reporting made analysis and resolution of problem areas difficult. While many shortcomings stemmed from limited funding, strengthening physician commitment to overseeing care, ensuring oxygen supplies are uninterrupted, keeping ventilators in working order, and making vital signs monitors ubiquitously available are feasible ways to increase patient safety with the tools currently in place. (C) 2017 International Anesthesia Research Society

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MicroRNAs as Clinical Biomarkers and Therapeutic Tools in Perioperative Medicine.

Over the past decade, evolutionarily conserved, noncoding small RNAs-so-called microRNAs (miRNAs)-have emerged as important regulators of virtually all cellular processes. miRNAs influence gene expression by binding to the 3'-untranslated region of protein-coding RNA, leading to its degradation and translational repression. In medicine, miRNAs have been revealed as novel, highly promising biomarkers and as attractive tools and targets for novel therapeutic approaches. miRNAs are currently entering the field of perioperative medicine, and they may open up new perspectives in anesthesia, critical care, and pain medicine. In this review, we provide an overview of the biology of miRNAs and their potential role in human disease. We highlight current paradigms of miRNA-mediated effects in perioperative medicine and provide a survey of miRNA biomarkers in the field known so far. Finally, we provide a perspective on miRNA-based therapeutic opportunities and perspectives. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. (C) 2017 International Anesthesia Research Society

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Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis. RESULTS: Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P

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Optimal Dose of Perineural Dexamethasone to Prolong Analgesia After Brachial Plexus Blockade: A Systematic Review and Meta-Analysis.

BACKGROUND: Perineural dexamethasone has gained popularity in regional anesthesia to prolong analgesia duration. However, uncertainty remains regarding the optimal perineural dose. Clarification of this characteristic is of significant importance as the administration of dexamethasone may lead to dose-dependent complications. The objective of this meta-analysis was to define the optimal perineural dexamethasone dose to prolong analgesia after brachial plexus blockade for adult patients undergoing upper limb surgery. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and searched databases including MEDLINE, PubMed, and EMBASE until January 2017, without language restriction. Only trials comparing perineural dexamethasone and local anesthetics with local anesthetics alone for brachial plexus blocks were included in the present meta-analysis. The Cochrane Collaboration's Risk of Bias Tool was used to assess the methodological quality of each trial and meta-analyses were performed following a random effects model. The primary outcome was duration of analgesia for each type of local anesthetic (short-/intermediate-acting and long-acting local anesthetics). A meta-regression followed by a subgroup analysis were performed to assess the impact of different perineural dexamethasone doses on duration of analgesia; for the latter analysis, trials were grouped in low (1-4 mg) and moderate (5-10 mg) dexamethasone doses. Secondary outcomes included the rate of neurologic complication and resting pain scores and morphine consumption within the first 24 hours. RESULTS: Thirty-three controlled trials, including 2138 patients, were identified. The meta-regression revealed a ceiling effect with a perineural dexamethasone dose of 4 mg when combined with short-/intermediate-acting (8 trials; 366 participants) or long-acting local anesthetics (23 trials; 1869 participants). This finding was confirmed by subgroup analyses comparing low and moderate dexamethasone doses. With short-/intermediate-acting local anesthetics, the mean difference (95% confidence interval) of analgesia duration with low and moderate doses was 277 (234-322) minutes and 229 (161-297) minutes, respectively. With long-acting local anesthetics, the mean differences with low and moderate doses were 505 (342-669) minutes and 509 (443-575) minutes. Perineural dexamethasone did not increase the rate of neurologic complications (risk ratio [95% confidence interval], 1.40 [0.54-3.63]). The Grades of Recommendation, Assessment, Development, and Evaluation quality of evidence for the primary and secondary outcomes were very low, due mainly to limitations, inconsistency, indirectness, and publication bias. CONCLUSIONS: There is currently very low quality evidence that 4 mg of perineural dexamethasone represents a ceiling dose that prolongs analgesia duration by a mean period of 6 and 8 hours when combined with short-/intermediate- or long-acting local anesthetics, respectively. Additional data are needed to explore the threshold for this effect, particularly with doses below 4 mg. The risk of neurologic complications is probably not increased (very low evidence). (C) 2017 International Anesthesia Research Society

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Use of Regional Anesthesia for Outpatient Surgery Within the United States: A Prevalence Study Using a Nationwide Database.

BACKGROUND: Regional anesthesia is of benefit for outpatient surgery given its demonstrated improvement in analgesia and decrease in complications, resulting in shorter average recovery room times and lower hospital readmission rates. Unfortunately, there are few epidemiological studies outlining the overall utilization of peripheral nerve blocks (PNBs) in this setting. Therefore, the primary objective of this study was to report the overall utilization of several types of PNBs among all candidate cases in the outpatient setting within the United States. METHODS: We identified all cases from the National Anesthesia Clinical Outcomes Registry that were performed as an outpatient surgery. We reported the frequency of various types of PNBs among all candidate cases, defined as cases that potentially could have received a PNB. Changes in prevalence of PNB utilization from 2010 to 2015 were analyzed by using logistic regression. RESULTS: Of the 12,911,056 outpatient surgeries in the National Anesthesia Clinical Outcomes Registry, 3,297,372 (25.5%) were amenable to a PNB. However, the overall PNB frequency was only 3.3% of the possible cases. The overall utilization for PNB of the brachial plexus, sciatic nerve, and femoral nerve were 6.1%, 1.5%, and 1.9%, respectively. The surgical procedures generating the highest volume of PNBs were shoulder arthroscopies and anterior cruciate ligament reconstruction, in which 41% and 32% received a PNB, respectively. During this time period, there was a significant increase in overall PNB utilization for both single-injection and continuous PNB (P

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The "Ear-Sternal Notch" Line-How Should You Lie?.

No abstract available

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Consensus Statement by the Congenital Cardiac Anesthesia Society: Milestones for the Pediatric Cardiac Anesthesia Fellowship.

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship. (C) 2017 International Anesthesia Research Society

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Perioperative Inflammation and Its Modulation by Anesthetics.

Surgery and other invasive procedures, which are routinely performed during general anesthesia, may induce an inflammatory response in the patient. This inflammatory response is an inherent answer of the body to the intervention and can be both beneficial and potentially harmful. The immune system represents a unique evolutionary achievement equipping higher organisms with an effective defense mechanism against exogenous pathogens. However, not only bacteria might evoke an immune response but also other noninfectious stimuli like the surgical trauma or mechanical ventilation may induce an inflammatory response of varying degree. In these cases, the immune system activation is not always beneficial for the patients and might carry the risk of concomitant, harmful effects on host cells, tissues, or even whole organ systems. Research over the past decades has contributed substantial information in which ways surgical patients may be affected by inflammatory reactions. Modulations of the patient's immune system may be evoked by the use of anesthetic agents, the nature of surgical trauma and the use of any supportive therapy during the perioperative period. The effects on the patient may be manifold, including various proinflammatory effects. This review focuses on the causes and effects of inflammation in the perioperative period. In addition, we also highlight possible approaches by which inflammation in the perioperative may be modulated in the future. (C) 2017 International Anesthesia Research Society

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Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials: An ACTTION Systematic Review.

Objective evaluations comparing different techniques and approaches to pediatric procedural sedation studies have been limited by a lack of consistency among the outcome measures used in assessment. This study reviewed those existing measures, which have undergone psychometric analysis in a pediatric procedural sedation setting, to determine to what extent and in what circumstances their use is justified across the spectrum of procedures, age groups, and techniques. The results of our study suggest that a wide range of measures has been used to assess the efficacy and effectiveness of pediatric procedural sedation. Most lack the evidence of validity and reliability that is necessary to facilitate rigorous clinical trial design, as well as the evaluation of new drugs and devices. A set of core pediatric sedation outcome domains and outcome measures can be developed on the basis of our findings. We believe that consensus among all stakeholders regarding appropriate domains and measures to evaluate pediatric procedural sedation is possible and that widespread implementation of such recommendations should be pursued. (C) 2017 International Anesthesia Research Society

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Minimizing the Harm of Accidental Awareness Under General Anesthesia: New Perspectives From Patients Misdiagnosed as Being in a Vegetative State.

No abstract available

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In Response: Comment on "Assessing the Utility of Fluoroscopy for Thoracic Epidural Catheter Placement: What End Points Are Important?".

No abstract available

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Effect of High Inspiratory Oxygen Fraction on Endothelial Function in Healthy Volunteers: A Randomized Controlled Crossover Pilot Study.

It has been suggested that high inspiratory oxygen concentrations during anesthesia may be associated with higher postoperative mortality due to endothelial dysfunction. A randomized controlled crossover study was conducted with 25 healthy male volunteers. They inhaled an oxygen concentration of 30% and 80%. The endothelial function was assessed using noninvasive digital pulse amplitude tonometry (EndoPAT) supported by endothelial biomarkers. The difference in endothelial function between the 2 treatments was 0.05 (95% confidence interval, -0.36 to 0.27; P = .77). Endothelial biomarkers were unaffected. Inhalation of a high oxygen fraction in healthy volunteers did not result in a significant reduction of endothelial function. (C) 2017 International Anesthesia Research Society

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The Placement of Syringe Labels May Reduce Medication Errors and Cognitive Load

No abstract available

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A Risky Proposition: Blood Transfusion and the Risk of Surgical Site Infections

No abstract available

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

No abstract available

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Opioid-Free Analgesia in the Era of Enhanced Recovery After Surgery and the Surgical Home: Implications for Postoperative Outcomes and Population Health

No abstract available

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Tablet e-Logbooks: Four Thousand Clinical Cases and Complications e-Logged by 14 Nondoctor Anesthesia Providers in Nepal

BACKGROUND: To meet the need for essential surgery across rural Nepal, anesthesia at district level is delivered by nondoctor anesthetists. They require support to maintain confidence and competence, and upgraded professional registration to secure their status. To meet these needs, a distance-blended learning course was pioneered and delivered. A core course requirement was to log all clinical cases; these were logged on a new e-logbook. METHODS: Fourteen nondoctor anesthesia providers working in 12 different districts across Nepal were enrolled in the 1-year course. The course is based on self-completion on a tablet loaded with new learning modules, a resource library, and a case logbook. Continuous educational mentoring was provided by anesthesiologists by phone and email. The logbook included preanesthesia assessment and interventions, American Society of Anesthesiologists (ASA) grading, types of cases and anesthesia given, monitors used, complications, outcomes and free text remarks. Cases were uploaded monthly to a database, and mentors reviewed all logbook entries. RESULTS: The 14 nondoctor anesthesia providers were widely distributed across the country in district, zonal, community, and mission hospitals, and had different levels of clinical experience and caseloads. Logbooks and uploads were regularly completed without difficulty; 1% cases were entered incompletely with no case details provided. A total of 4143 cases were recorded. Annual caseload per nondoctor anesthesia provider ranged from 50 to 788, the majority of which were under spinal anesthesia; 34% of the total cases were cesarean deliveries, of which 99% received spinal anesthesia. Fifty gastrointestinal laparotomies (1% total) were recorded. Ninety-one percent of cases were ASA I, 0.8% ASA III/IV. Pulse oximetry was used in 98% of cases. Complications were recorded in 6% of cases; the most common were circulation problems (69%) including hypotension and occasional bradycardia after spinal anesthesia. Airway complications were usually under ketamine anesthesia requiring basic airway maneuvers; 4 difficult intubations were recorded under general anesthesia. Anesthesia outcomes were good with overall mortality of 0.1% (total 4 cases). Causes of death included severe preeclampsia, sepsis postlaparotomy, and patients with multiorgan failure for minor procedure. CONCLUSIONS: The tablet-based electronic anesthesia logbook was successfully used to record cases, complications, and outcomes across rural Nepal. The nondoctor anesthesia providers had trust and confidence in recording outcomes. It remains to be tested whether an e-logbook would be routinely completed outside of a specific training course. Such a logbook could be incorporated into all continuous professional development programs for rural nondoctor anesthetists.

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