Hypertension and cataract surgery under loco-regional anaesthesia: not to be ignored?

The presence of sight-impairing opacification, cataract, is an age-related condition. Modern phacoemulsification procedures allow cataract removal safely and efficiently under loco-regional anaesthesia.¹ Increasing numbers of patients with comorbid conditions, including dementia, diabetes mellitus, cardiovascular disease on concurrent antithrombotics and hypertension, present for cataract surgery. The British Journal of Anaesthesia has recently addressed anaesthesia-related issues for ophthalmic surgery in patients with dementia,² diabetes mellitus³ and anticoagulation.⁴ This editorial addresses issues related specifically to hypertension. Hypertension impacts 1 billion adults across the globe affecting up to 80% of patients in the general population aged 60 yr and older.⁵⁶ Like the sensation of a fishbone stuck in the throat, the impact of hypertension on perioperative outcome after cataract surgery should not be ignored without meticulous interrogation.

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Peripheral i.v. analysis (PIVA) of venous waveforms for volume assessment in patients undergoing haemodialysis

Abstract

Background

The assessment of intravascular volume status remains a challenge for clinicians. Peripheral i.v. analysis (PIVA) is a method for analysing the peripheral venous waveform that has been used to monitor volume status. We present a proof-of-concept study for evaluating the efficacy of PIVA in detecting changes in fluid volume.

Methods

We enrolled 37 hospitalized patients undergoing haemodialysis (HD) as a controlled model for intravascular volume loss. Respiratory rate (F₀) and pulse rate (F₁) frequencies were measured. PIVA signal was obtained by fast Fourier analysis of the venous waveform followed by weighing the magnitude of the amplitude of the pulse rate frequency. PIVA was compared with peripheral venous pressure and standard monitoring of vital signs.

Results

Regression analysis showed a linear correlation between volume loss and change in the PIVA signal (R²=0.77). Receiver operator curves demonstrated that the PIVA signal showed an area under the curve of 0.89 for detection of 20 ml kg⁻¹ change in volume. There was no correlation between volume loss and peripheral venous pressure, blood pressure or pulse rate. PIVA-derived pulse rate and respiratory rate were consistent with similar numbers derived from the bio-impedance and electrical signals from the electrocardiogram.

Conclusions

PIVA is a minimally invasive, novel modality for detecting changes in fluid volume status, respiratory rate and pulse rate in spontaneously breathing patients with peripheral i.v. cannulas.

http://ift.tt/2yc6LZk

Lost in translation? Comparing the effectiveness of electronic-based and paper-based cognitive aids

It is now established that the use of cognitive aids, such as checklists and algorithms leads to improved technical¹ and team performance² during anaesthetic emergencies. The unpredictable nature of emergencies means that it is difficult to examine these outside of a simulation setting. Consequently, it is challenging to prove these observed behaviours translate to improved patient outcomes, although many anecdotal reports exist.³⁴ Research is now focused on the nature of these cognitive aids and how they can be integrated into the clinical setting, working with, rather than against the instincts of experienced practitioners.⁵

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SmartPilot ® view-guided anaesthesia improves postoperative outcomes in hip fracture surgery: a randomized blinded controlled study

Abstract

Background

Both under-dosage and over-dosage of general anaesthetics can harm frail patients. We hypothesised that computer-assisted anaesthesia using pharmacokinetic/pharmacodynamic models guided by SmartPilot^® View (SPV) software could optimise depth of anaesthesia and improve outcomes in patients undergoing hip fracture surgery.

Methods

This prospective, randomized, single-centre, blinded trial included patients undergoing hip fracture surgery under general anaesthesia. In the intervention group, anaesthesia was guided using SPV with predefined targets. In the control group, anaesthesia was delivered by usual practice using the same agents (propofol, sufentanil and desflurane). The primary endpoint was the time spent in the "appropriate anaesthesia zone" defined as bispectral index (BIS) (blinded to the anaesthetist during surgery) of 45–60 and systolic arterial pressure of 80–140 mm Hg. Postoperative complications were recorded for one month in a blinded manner.

Results

Of 100 subjects randomised, 97 were analysed (n=47 in SPV and 50 in control group). Anaesthetic drug consumption was reduced in the SPV group (for propofol and desflurane). Intraoperative duration of low BIS (<45) was similar, but cumulative time of low systolic arterial pressure (<80 mm Hg) was significantly shorter in the SPV group (median (Q1-Q3); 3 (0–40) vs 5 (0–116) min, P=0.013). SPV subjects experienced fewer moderate or major postoperative complications at 30-days (8 (17)% vs 18 (36)%, P=0.035) and shorter length of hospitalisation (8 (2–20) vs 8 (2–60) days, P=0.017).

Conclusions

SmartPilot^® View-guided anaesthesia reduces intraoperative hypotension duration, occurrence of postoperative complications and length of stay in hip fracture surgery patients.

Clinical trial registration.

NCT 02556658.

http://ift.tt/2x1kP2w

Does variable training lead to variable care?

Entrants to anaesthesia training programs in the developed world are broadly comparable in terms of readiness for specialist training as a result of global standards established by the World Federation for Medical Education. While the context of national health systems has undeniable significance, the competencies required to provide anaesthesia for patients undergoing surgery should also be broadly comparable. In this issue of the British Journal of Anaesthesia, Jonker and colleagues¹ report wide variability in anaesthesia training programmes across the European Union (EU), and variable certification processes. Could this potentially result in variable quality in patient care? Jonker and colleagues propose that variability of training and certification limits the easy movement of anaesthetists around the EU. National health systems around the world remain dependent on a mobile workforce, often trained in other jurisdictions. Determining if a foreign graduate is competent is a key concern for employers.

http://ift.tt/2yc6tlc

Point-of-care paediatric gastric sonography: can antral cut-off values be used to diagnose an empty stomach?

Abstract

Background

Gastric sonography is emerging as a valuable clinical point-of-care tool to assess aspiration risk. A recent study proposed that a single cut-off cross-sectional area (CSA) in the supine position could diagnose an empty stomach in the parturient. This study establishes the sensitivity and specificity of a single CSA cut-off measurement in both supine and right lateral decubitus (RLD) positions in the diagnosis of an empty antrum in paediatric patients.

Methods

Following induction of anaesthesia, antral sonography was performed in supine and RLD positions in 100 fasted paediatric patients prior to upper endoscopic evaluation. Following upper endoscopy, any residual stomach content was suctioned under direct visualization and antral sonography was immediately performed. Antral CSA values were compared using Wilcoxon signed rank test. Receiver operator characteristic (ROC) curves were plotted to estimate the discriminating power of antral sonography position in the diagnosis of an empty antrum.

Results

Significant differences were found between pre-suctioned and post-suctioned CSA values in the RLD position. The cut-off CSAs of the empty antrum in the supine and RLD positions were 2.19 cm² (sensitivity 75%, specificity 36%) and 3.07 cm² (sensitivity 76%, specificity 67%), respectively.

Conclusions

The RLD position produces the most sensitive and specific CSA cut-off value where an antral CSA of ≤ 3.07 cm² in the RLD position presents with acceptable performance in the ability to discriminate an empty antrum in paediatric patients over 1 yr of age. As age increases, the sensitivity and specificity of this test increases in the RLD position.

http://ift.tt/2ybJ6Ie

Use of a hand-held digital cognitive aid in simulated crises: the MAX randomized controlled trial

Abstract

Background

Cognitive aids improve the technical performance of individuals and teams dealing with high-stakes crises. Hand-held electronic cognitive aids have rarely been investigated. A randomized controlled trial was conducted to investigate the effects of a smartphone application, named MAX (for Medical Assistance eXpert), on the technical and non-technical performance of anaesthesia residents dealing with simulated crises.

Methods

This single-centre randomized, controlled, unblinded trial was conducted in the simulation centre at Lyon, France. Participants were anaesthesia residents with >1 yr of clinical experience. Each participant had to deal with two different simulated crises with and without the help of a digital cognitive aid. The primary outcome was technical performance, evaluated as adherence to guidelines. Two independent observers remotely assessed performance on video recordings.

Results

Fifty-two residents were included between July 2015 and February 2016. Six participants were excluded for technical issues; 46 participants were confronted with a total of 92 high-fidelity simulation scenarios (46 with MAX and 46 without). Mean (sd) age was 27 (1.8) yr and clinical experience 3.2 (1.0) yr. Inter-rater agreement was 0.89 (95% confidence interval 0.85–0.92). Mean technical scores were higher when residents used MAX [82 (11.9) vs 59 (10.8)%; P<0.001].

Conclusion

The use of a hand-held cognitive aid was associated with better technical performance of residents dealing with simulated crises. These findings could help digital cognitive aids to find their way into daily medical practice and improve the quality of health care when dealing with high-stakes crises.

Clinical trial registration

NCT02678819.

http://ift.tt/2x1huRc

Volumes of the spinal canal and caudal space in children zero to three years of age assessed by magnetic resonance imaging: implications for volume dosage of caudal blockade

Abstract

Background

The primary aim of this study was to objectively assess the different spinal and caudal volumes that are of interest for caudal block volume dosing.

Methods

Three directly assessed (volume of spinal canal/caudal space, volume of the dural sac and volume of spinal cord) and two derived volumes (volume of the epidural space and cerebrospinal fluid volume) were determined from magnetic resonance images (MRI) in 20 children (zero - three yr of age). The assessed volumes were correlated to age, height and weight. Furthermore, the volumes of the epidural space from caudal canal to three different clinically relevant target levels (L 1, Th 10 and Th 6) and the epidural volume of each individual spinal segment at the caudal, lumbar and thoracic levels were calculated.

Results

All volumes correlated in a linear manner to length and weight (R² 0.614 – 0.867) whereas a curvilinear correlation was associated with best curve fit for age (R² 0.696 – 0.883). The median volumes of the epidural space from caudal canal to L 1, Th 10 and Th 6 were 1.30 ml kg⁻¹ (95%CI 1.08-1.51), 1.57 ml kg⁻¹ (95%CI 1.29-1.81) and 1.78 ml kg⁻¹ (95%CI 1.52-2.08), respectively. The median volumes of the epidural space per vertebral segment were Thoracic: 0.60 ml (95%CI 0.38-0.75); Lumbar: 1.18 ml (95%CI 0.94-1.43) and Caudal: 0.85 ml (95%CI 0.56-1.18).

Conclusions

The spinal volumes of interest show a linear correlation to height and weight whereas a curvilinear correlation was found for age. The volume of the epidural space per segment was found to be significantly higher at the lumbar level compared with the caudal and thoracic levels.

http://ift.tt/2yc69D0

Heterogeneity of studies in anesthesiology systematic reviews: a meta-epidemiological review and proposal for evidence mapping

Abstract

Heterogeneity among the primary studies included in a systematic review (SR) is one of the most challenging considerations for systematic reviewers. Current practices in anaesthesiology SRs have not been evaluated, but traditional methods may not provide sufficient information to evaluate the true nature of these differences. We address these issues by examining the practices for evaluating heterogeneity in anesthesiology reviews. Also, we propose a mapping method for presenting heterogeneous aspects of the primary studies in SRs.We evaluated heterogeneity practices reported in SRs published in highly ranked anesthesiology journals and Cochrane reviews. Elements extracted from the SRs included heterogeneity tests, models used, analyses conducted, plots used, and I² values. Additionally, we selected a SR to develop an evidence map in order to display clinical heterogeneity.Our statistical analysis showed 150/207 SRs reporting a test for statistical heterogeneity. Plots were used in 138 reviews to display heterogeneity. Subgroup analyses were the most commonly reported analysis (54%). Meta-regression and sensitivity analyses were used sparingly (25%; 23% respectively). A random effects model was most commonly reported (33%). Heterogeneity statistics across meta-analyses suggested that, in our sample, the majority (55%) did not present sufficient heterogeneity to be of great concern. Cochrane reviews (n=58) were also analysed. Plots were used in 88% of Cochrane reviews. Subgroup analysis was used in 59% Cochrane reviews, while sensitivity analysis was used in 62%.Many reviews did not provide sufficient detail regarding heterogeneity. We are calling for improvement to reporting practices.

http://ift.tt/2x15HCd

Low-dose buprenorphine infusion to prevent postoperative hyperalgesia in patients undergoing major lung surgery and remifentanil infusion: a double-blind, randomized, active-controlled trial

Abstract

Background

. Postoperative secondary hyperalgesia arises from central sensitization due to pain pathways facilitation and/or acute opioid exposure. The latter is also known as opioid-induced hyperalgesia (OIH). Remifentanil, a potent μ-opioid agonist, reportedly induces postoperative hyperalgesia and increases postoperative pain scores and opioid consumption. The pathophysiology underlying secondary hyperalgesia involves N-methyl-D-aspartate (NMDA)-mediated pain pathways. In this study, we investigated whether perioperatively infusing low-dose buprenorphine, an opioid with anti-NMDA activity, in patients receiving remifentanil infusion prevents postoperative secondary hyperalgesia.

Methods

. Sixty-four patients, undergoing remifentanil infusion during general anaesthesia and major lung surgery, were randomly assigned to receive either buprenorphine i.v. infusion (25 μg h⁻¹ for 24 h) or morphine (equianalgesic dose) perioperatively. The presence and extent of punctuate hyperalgesia were assessed one day postoperatively. Secondary outcome variables included postoperative pain scores, opioid consumption and postoperative neuropathic pain assessed one and three months postoperatively.

Results

. A distinct area of hyperalgesia or allodynia around the surgical incision was found in more patients in the control group than in the treated group. Mean time from extubation to first morphine rescue dose was twice as long in the buprenorphine-treated group than in the morphine-treated group: 18 vs 9 min (P=0.002). At 30 min postoperatively, patients receiving morphine had a higher hazard ratio for the first analgesic rescue dose than those treated with buprenorphine (P=0.009). At three months, no differences between groups were noted.

Conclusions

. Low-dose buprenorphine infusion prevents the development of secondary hyperalgesia around the surgical incision but shows no long-term efficacy at three months follow-up.

http://ift.tt/2wnb8Md

Review: Brown’s Atlas of Regional Anesthesia . E Farag and L Mounir-Soliman (editors) & Brown’s Regional Anesthesia Review . E Farag and L Mounir-Soliman (editors)

Review: Brown's Atlas of Regional Anesthesia.FaragE and Mounir-SolimanL (editors), 5^th edn, 2017. Published by Elsevier. Pp. 376. Price $199.99. ISBN-13: 978-0323354905.

http://ift.tt/2k7MEoR

Is the bougie redundant in direct laryngoscopic grade 3 intubations?

A 51-year-old woman presented for major elective colorectal surgery with predicted difficult intubation (Mallampati score 3, small mouth opening) and a video laryngoscope was prepared as a 'plan B'. After induction, the patient's lungs were easily ventilated with a bag valve mask. Direct laryngoscopy was performed that demonstrated a grade 3 view. An experienced operator intubated successfully using a bougie, which was carefully advanced in one attempt blindly behind the epiglottis into the trachea.

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In the October BJA …

This issue of the BJA contains a special section on pain medicine that includes articles on acute and chronic pain in the context of anaesthesia. The main section of the Journal includes a number of articles relevant to perioperative outcomes in sepsis and septic shock, and in cardiac, abdominal, and lung resection surgery. There are also articles on the impact of non-depolarising neuromuscular blocking agents, beta-blockers, and statins on perioperative outcomes. The Neurosciences and Neuroanaesthesia section features three articles and three editorials related to anaesthetic effects on neuronal network connectivity as it relates to unconsciousness. And the Quality and Patient Safety section features an article with an editorial on the impact of anaesthetist gender on communication in simulated crisis situations.

http://ift.tt/2k7XHhF

The paradox in the current use of videolaryngoscopes in the UK

Editor—The recent national survey by Cook and Kelly¹ is the first to provide a comprehensive overview of the current usage and practices of videolaryngoscopes (VLs) in UK clinical practice. We feel we can add to this area and would like to present some of the results of a regional survey on VLs that we conducted to gain an understanding of current practices and decision-making in the use of VLs in general airway management in the operating theatre (OT). The survey was conducted electronically via SurveyMonkey (San Mateo, CA, USA) and was distributed to 10 departments of anaesthesia in the London Deanery (London, UK) in December 2016. There were 171 responses collected between December 2016 and January 2017 with a response rate of about 51%, including 44% consultants, 21% specialty Registrar (StR) yr 7–yr 5, 14% StR yr 4–yr 3, and 7% core trainees. Selected findings from the survey were as follows:

• When asked whether VLs should be first line management strategy for anticipated difficult intubation (where bag mask ventilation was not predicted difficult), when given the choice between a VL and a Macintosh laryngoscope short/long blade +/–bougie, 51% of those surveyed preferred to use a VL.
• When asked whether VLs should be used routinely for intubation in all patients, regardless of predicted difficulty of intubation, 14% of respondents thought that VLs should be used routinely.
• When asked how many uses it approximately required to gain subjective competence in the use of any VL, 68% of respondents felt it required over 10 uses, 32% felt it required over 20 uses and 13% felt it required over 30 uses.
• When asked whether anaesthetists should begin their core training with VLs alongside the Macintosh laryngoscope as first line for all intubations, 10% of respondents were of the opinion that this should be the case.

http://ift.tt/2wo9pGB

Diastolic dysfunction and sepsis: the devil is in the detail

Diastolic dysfunction is the consequence of impaired left ventricular relaxation, decreased recoil and decreased ventricular compliance.¹ Before the era of tissue Doppler imaging (TDI), pulmonary vein Doppler imaging in conjunction with transmitral Doppler, was a major tool in identifying diastolic dysfunction, also in septic shock patients.² Pulmonary vein Doppler assessment with a systolic (S) < diastolic (D) flow velocity supports the finding of elevated left ventricular filling pressures in a euvolaemic patient.

http://ift.tt/2wmGbI7

Preadmission statin use improves the outcome of less severe sepsis patients - a population-based propensity score matched cohort study

Abstract

Background

Randomized controlled trials on the post-admission use of statins in sepsis patients have not shown a survival benefit. Whether preadmission use of statins would confer any beneficial effects in sepsis patients has not been well studied.

Methods

We conducted a population-based cohort study on a national health insurance claims database between 1999 and 2011. Sepsis patients were identified by ICD-9 codes compatible with the third International consensus definitions for sepsis. Use of statin was defined as the cumulative use of any statin for more than 30 days before the indexed sepsis admission. We determined the association between statin use and sepsis outcome by multivariate-adjusted Cox proportional hazard models and propensity score matched analysis. To minimize baseline imbalance between statin users and non-statin users, we matched/adjusted for social economic status, comorbidities, proxies for healthy lifestyle, health care facility utilization, and use of medications.

Results

We identified 52 737 sepsis patients, of which 3599 received statin treatment. Statins use was associated with a reduced 30-day mortality after multivariable adjustment (HR 0.86, 95% CI, 0.78–0.94) and propensity score matching (HR, 0.88; 95% CI, 0.78–0.99). On subgroup analysis, the beneficial effects of statins were not significant in patients receiving ventilator support or requiring ICU admission.

Conclusions

In this national cohort study, preadmission statin therapy before sepsis development was associated with a 12% reduction in mortality when compared with patients who never received a statin. There were no consistent beneficial effects of statins in all patient subgroups.

http://ift.tt/2k8k3zN

Readmission after surgery: are neuromuscular blocking drugs a cause?

Neuromuscular blocking drugs (NMBDs) play an integral role in balanced anaesthesia. They improve intubating conditions, reduce iatrogenic damage to the upper airway and decrease postoperative hoarseness.¹ They also improve surgical operating conditions.² But use of NMBDs always carries the risk of residual neuromuscular block postoperatively. About 30% of all patients who receive NMBDs intraoperatively show signs of residual neuromuscular block when arriving in the post-anaesthesia care unit.^3–5 It has been suggested that residual neuromuscular block can cause postoperative pulmonary complications.^6–8

http://ift.tt/2wnldJi

Tissue Doppler assessment of diastolic function and relationship with mortality in critically ill septic patients: a systematic review and meta-analysis

Abstract

Background

Myocardial dysfunction may contribute to circulatory failure in sepsis. There is growing evidence of an association between left ventricular diastolic dysfunction (LVDD) and mortality in septic patients. Utilizing echocardiography, we know that tissue Doppler imaging (TDI) variables e′ and E/e′ are reliable predictors of LVDD and are useful measurements to estimate left ventricular (LV) filling pressures.

Methods

We conducted a systematic review and meta-analysis to investigate the association of e′ and E/e′ with mortality of patients with severe sepsis or septic shock. In the primary analysis, we included studies providing transthoracic TDI data for e′ and E/e′ and their association with mortality. Subgroup analyses were conducted according to myocardial regional focus of TDI assessment (septal, lateral or averaged). Three secondary analyses were performed: one included data from a transoesophageal study, another excluded studies reporting data at a very early (<6 h) or late (>48 h) stage following diagnosis, and the third pooled data only from studies excluding patients with heart valve disease.

Results

The primary analysis included 16 studies with 1507 patients with severe sepsis and/or septic shock. A significant association was found between mortality and both lower e′ [standard mean difference (SMD) 0.33; 95% confidence interval (CI): 0.05, 0.62; P=0.02] and higher E/e′ (SMD –0.33; 95% CI: –0.57, –0.10; P=0.006). In the subgroup analyses, only the lateral TDI values showed significant association with mortality (lower e′ SMD 0.45; 95% CI: 0.11, 0.78; P=0.009; higher E/e′ SMD –0.49; 95% CI: –0.76, –0.22; P=0.0003). The findings of the primary analysis were confirmed by all secondary analyses.

Conclusions

There is a strong association between both lower e′ and higher E/e′ and mortality in septic patients.

http://ift.tt/2k84b06

Age and inflammation after cardiac surgery

The cardiac surgical population is aging and these patients have increased expectations with respect to quantity and quality of postoperative survival. Some of the physiological changes related to aging that impact surgical outcomes are better understood than others, and recently we are also beginning to gain a better understanding of the impact of aging on immunity and the immune response to surgery.¹²

http://ift.tt/2wnQ5JO

An algorithm for suboptimally placed supraglottic airway devices: the choice of videolaryngoscope

Editor—We agree with Zundert and colleagues¹ that anaesthetists sometimes accept lower standards for supraglottic airway device (SAD) placement than for tracheal tube placement. They advocate the use of videolaryngoscopy to correct a suboptimal SAD position using an algorithm, however they do not make any specific recommendation about which type of videolaryngoscope to use. A variety of classifications of videolaryngoscopes exist,^2–5 and some classes (for example, channelled videolaryngoscopes) might prove to be very difficult to use in this situation; some may even cause trauma in the reduced space available when an SAD is present. Zundert and colleagues ⁶ have previously referenced the C-MAC videolaryngoscope (Karl Storz, Tuttlingen, Germany) in this situation, but presumably other Macintosh-type bladed scopes would be acceptable. We would be keen to learn whether they have experience of other videolaryngoscopes, and we also wondered whether they had considered the place of the optical stylet.

http://ift.tt/2k846cO

Hierarchy in disruption of large-scale networks across altered arousal states

Understanding how anaesthetics act within neural circuits to induce altered arousal states that range from sedation to general anaesthesia is an important question in neuroscience. Studies in laboratory animals demonstrate that anaesthetics including propofol, ether derivatives, and dexmedetomidine induce activity patterns in brainstem arousal nuclei that are similar to natural sleep.^1–3 However, anaesthetic drug action in brainstem arousal nuclei may provide only a partial answer to explain the behavioural and neurophysiological distinctions between anaesthesia-induced states and sleep, because anaesthetics also significantly modulate neuronal activity in other brain regions such as the thalamus and cortex.⁴⁵ Insights into how anaesthetics disrupt networks that sustain consciousness have been constrained by the practical and ethical challenges involved in noninvasively studying human brain activity. Guldenmund and colleagues⁶ used human neuroimaging to study large-scale network disruptions that are associated with dexmedetomidine and propofol sedation, two anaesthetic drugs with different receptor level targets.

http://ift.tt/2k7Mxtr

Humour therapy intervention to reduce stress and anxiety in paediatric anaesthetic induction, a pilot study

Editor—Hospitalization is a particularly negative experience for the paediatric population. Infants experiencing surgery can develop problematic behaviour, such as preoperative anxiety (50–75%)¹ and postoperative negative behavioural changes (75%), sleep and eating disorders, cognitive alterations, enuresis and disobedience. These complications can persist for several months after the surgical procedure.² In addition, it is well known that stress slows the healing process, decreases inflammatory responses, and likewise increases fear and anxiety. From a pathophysiological point of view, the increase in levels of circulating cortisol, secondary to an increase in the production of corticotropin releasing hormone and the action of the autonomic nervous system, can create harmful effects in different organs and tissues.³ Salivary cortisol has been used in several studies to measure levels of stress in children, as an index of the amount in blood, but which is a noninvasive procedure ideal for use in the paediatric population.

http://ift.tt/2wmG7In

Fading whispers down the lane: signal propagation in anaesthetized cortical networks

An active area of enquiry in the neuroscientific investigation of general anaesthesia is the question of whether anaesthetic-induced unconsciousness is mediated by bottom-up or top-down mechanisms in the brain. Candidates for the bottom-up approach include suppression of arousal centres in the brainstem and diencephalon,¹² activation of sleep-promoting neurones or nuclei in similar locations,¹³ blockade of sensory information en route from the thalamus to the cortex,⁴ and a disabled thalamic conductor for the neuronal orchestra of the cortex.⁵ Candidates for the top-down approach include direct effects on long-latency activity in cortical networks,⁶ with a consequent disruption of higher-order information synthesis that occurs beyond the level of the primary sensory cortex.^7–9 This bottom-up vs top-down distinction is almost surely artificial given the integrated circuits required for the normal function of neural systems and the widespread effects of general anaesthetics on the brain. We recently proposed that anaesthetics alter the level of consciousness (e.g. awake vs somnolent) through bottom-up mechanisms while degrading the contents of consciousness (e.g. the particular qualities of experience) through top-down mechanisms.¹⁰ Developing a clearer understanding of these processes is important because it can inform (i) the neurobiology of consciousness, a fundamental question in science, and (ii) our approach to brain monitoring, a fundamental and unmet challenge in clinical anaesthesia. However, it is difficult to address this question by investigating individual brain areas or molecular targets in the laboratory and also difficult to distinguish cortical and subcortical mechanisms through human neuroimaging and neurophysiology. In this issue of the British Journal of Anaesthesia, Hentschke and colleagues¹¹ examine an intermediate level of neuroanatomy and neurophysiology in a cortical slice model, finding more profound effects of isoflurane on signal propagation through the cortex than to the cortex.

http://ift.tt/2wo3G3I

Disruption of cortical network activity by the general anaesthetic isoflurane

Abstract

Background

Actions of general anaesthetics on activity in the cortico-thalamic network likely contribute to loss of consciousness and disconnection from the environment. Previously, we showed that the general anaesthetic isoflurane preferentially suppresses cortically evoked synaptic responses compared with thalamically evoked synaptic responses, but how this differential sensitivity translates into changes in network activity is unclear.

Methods

We investigated isoflurane disruption of spontaneous and stimulus-induced cortical network activity using multichannel recordings in murine auditory thalamo-cortical brain slices.

Results

Under control conditions, afferent stimulation elicited short latency, presumably monosynaptically driven, spiking responses, as well as long latency network bursts that propagated horizontally through the cortex. Isoflurane (0.05–0.6 mM) suppressed spiking activity overall, but had a far greater effect on network bursts than on early spiking responses. At isoflurane concentrations >0.3 mM, network bursts were almost entirely blocked, even with increased stimulation intensity and in response to paired (thalamo-cortical + cortical layer 1) stimulation, while early spiking responses were <50% blocked. Isoflurane increased the threshold for eliciting bursts, decreased their propagation speed and prevented layer 1 afferents from facilitating burst induction by thalamo-cortical afferents.

Conclusions

Disruption of horizontal activity spread and of layer 1 facilitation of thalamo-cortical responses likely contribute to the mechanism by which suppression of cortical feedback connections disrupts sensory awareness under anaesthesia.

http://ift.tt/2wmIsmJ

Speaking up: does anaesthetist gender influence teamwork and collaboration?

Speaking up can be defined as explicitly communicating observations or concerns, requesting clarification or explanation, or explicitly challenging a colleague's decision or action.¹ Speaking up provides an opportunity to intervene before patient harm occurs, or to mitigate actual harm, and is a key element in effective teamwork and collaboration.² The importance of speaking up is most evident in its absence, where colleagues remain silent or make ineffectual attempts at speaking up, and erroneous actions proceed to cause patient harm. There are many prominent examples where failing to speak up in an effective manner has contributed to accidents and catastrophes in aviation,³ space exploration⁴ and in healthcare.⁵

http://ift.tt/2k83VhE

Prediction of persistent post-surgery pain by preoperative cold pain sensitivity: biomarker development with machine-learning-derived analysis

Abstract

Background

To prevent persistent post-surgery pain, early identification of patients at high risk is a clinical need. Supervised machine-learning techniques were used to test how accurately the patients' performance in a preoperatively performed tonic cold pain test could predict persistent post-surgery pain.

Methods

We analysed 763 patients from a cohort of 900 women who were treated for breast cancer, of whom 61 patients had developed signs of persistent pain during three yr of follow-up. Preoperatively, all patients underwent a cold pain test (immersion of the hand into a water bath at 2–4 °C). The patients rated the pain intensity using a numerical ratings scale (NRS) from 0 to 10. Supervised machine-learning techniques were used to construct a classifier that could predict patients at risk of persistent pain.

Results

Whether or not a patient rated the pain intensity at NRS=10 within less than 45 s during the cold water immersion test provided a negative predictive value of 94.4% to assign a patient to the "persistent pain" group. If NRS=10 was never reached during the cold test, the predictive value for not developing persistent pain was almost 97%. However, a low negative predictive value of 10% implied a high false positive rate.

Conclusions

Results provide a robust exclusion of persistent pain in women with an accuracy of 94.4%. Moreover, results provide further support for the hypothesis that the endogenous pain inhibitory system may play an important role in the process of pain becoming persistent.

http://ift.tt/2k7Mi1v

Special section on pain: progress in pain assessment and management

This issue of the British Journal of Anaesthesia has a special section on pain, featuring a number of editorials, reviews and original articles across a range of areas in pain medicine. The last BJA special issue on pain medicine was in July 2013, entitled "Managing pain: recent advances and new challenges", as summarized in the lead editorial of that issue.¹ A similar title could be used for this month's special section. Pain medicine continues to evolve, with advances in acute, chronic and cancer pain understanding and management. However, the challenges remain, and arguably, increase, as our population ages: Pain is one of the biggest causes of disability globally, with musculoskeletal pain being the leading cause of disability in most countries in 2015.²³ Managing pain successfully - acute, chronic or cancer - is an area where there is potential major clinical benefit both at an individual and societal level.

http://ift.tt/2wo78LK

Response to: Emergency front-of-neck access: scalpel or cannula—and the parable of Buridan’s ass

Editor—I was interested to read the editorial by Greenland and colleagues¹ that contributes further to the debate that has raged for some time over whether a cannot intubate, cannot oxygenate (CICO) situation should be managed with a fine needle or scalpel cricothyroidotomy approach.

http://ift.tt/2wnZot7

Guidelines for perioperative pain management: need for re-evaluation

Optimal perioperative pain management facilitates postoperative ambulation and rehabilitation, and is considered a prerequisite to enhancing recovery after surgery.¹² Despite well-documented benefits, postoperative pain continues to be inadequately treated.^3–5 Although the reasons for the lack of appropriate pain management are not precisely known, conflicting and confusing evidence as well as lack of clear guidance could be contributing factors.

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Top Reviewers 2016

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Longitudinal Comparison of Auditory Steady-State Evoked Potentials in Pretermand Term Infants: The Maturation Process

Abstract Introduction Preterm neonates are at risk of changes in their auditory system development, which explains the need for auditory monitoring of this population. The Auditory Steady-State Response (ASSR) is an objective method that allows obtaining the electrophysiological thresholds with greater applicability in neonatal and pediatric population. Objective The purpose of this study is to compare the ASSR thresholds in preterm and term infants evaluated during two stages. Method The study included 63 normal hearing neonates: 33 preterm and 30 term. They underwent assessment of ASSR in both ears simultaneously through insert phones in the frequencies of 500 to 4000Hz with the amplitude modulated from 77 to 103Hz. We presented the intensity at a decreasing level to detect the minimum level of responses. At 18 months, 26 of 33 preterm infants returned for the new assessment for ASSR and were compared with 30 full-term infants. We compared between groups according to gestational age. Results Electrophysiological thresholds were higher in preterm than in full-term neonates (p < 0.05) at the first testing. There were no significant differences between ears and gender. At 18 months, there was no difference between groups (p > 0.05) in all the variables described. Conclusion In the first evaluation preterm had higher thresholds in ASSR. There was no difference at 18 months of age, showing the auditory maturation of preterm infants throughout their development.

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Auditory Speech Perception Development in Relation to Patient’s Age with Cochlear Implant

Abstract Introduction A cochlear implant in adolescent patients with pre-lingual deafness is still a debatable issue. Objective The objective of this study is to analyze and compare the development of auditory speech perception in children with pre-lingual auditory impairment submitted to cochlear implant, in different age groups in the first year after implantation. Method This is a retrospective study, documentary research, in which we analyzed 78 reports of children with severe bilateral sensorineural hearing loss, unilateral cochlear implant users of both sexes. They were divided into three groups: G1, 22 infants aged less than 42 months; G2, 28 infants aged between 43 to 83 months; and G3, 28 older than 84 months.We collectedmedical record data to characterize the patients, auditory thresholds with cochlear implants, assessment of speech perception, and auditory skills. Results There was no statistical difference in the association of the results among groups G1, G2, and G3 with sex, caregiver education level, city of residence, and speech perception level. There was a moderate correlation between age and hearing aid use time, age and cochlear implants use time. There was a strong correlation between age and the age cochlear implants was performed, hearing aid use time and age CI was performed. Conclusion There was no statistical difference in the speech perception in relation to the patient's age when cochlear implant was performed. There were statistically significant differences for the variables of auditory deprivation time between G3 - G1 and G2 - G1 and hearing aid use time between G3 - G2 and G3 - G1.

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Sudden Sensorioneural Hearing Loss and Autoimmune Systemic Diseases

Abstract Introduction Several authors have demonstrated the relationship between sudden sensorineural hearing loss (SNHL) and systemic autoimmune diseases (SAD). Immunemediated SNHL can rarely present as unilateral sudden SNHL and manifests itself in the contralateral ear only after years. It presents clinical relevance for being one of the few SNHL that may be reversible given that early and appropriate treatment is applied. Objective The objective of this study is to describe the clinical presentations and audiological findings from patients with idiopathic sudden SNHL and SAD associated with a probable diagnosis of immune-mediated SNHL. Furthermore, we strive to estimate the prevalence of SAD in patients with sudden SNHL. Methods This is an observational retrospective cohort. We have selected and studied patients with SAD. Revision of available literature on scientific repositories. Results We evaluated 339 patients with sudden SNHL. Among them, 13 (3.83%) patients suffered from SAD. Three patients had bilateral involvement, a total of 16 ears. We evaluate and describe various clinical, epidemiological, and audiological aspects of this sample. Conclusion In our sample of patients with sudden SNHL, the prevalence of SAD was found relevant. The majority had tinnitus and dizziness concomitant hearing loss, unilateral involvement and had experienced profound hearing loss at the time of the installation. In spite of instituted treatment, most cases showed no improvement in audiometric thresholds. Apparently, patients with sudden SNHL and SAD have a more severe initial impairment, higher percentage of bilateral, lower response to treatment, and worse prognosis than patients with sudden SNHL of unknown etiology.

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A Comparative Study on Hearing Aid Benefits of Digital Hearing Aid Use (BTE) from Six Months to Two Years

Abstract Introduction For many reasons, it is important for audiologists and consumers to document improvement and benefit fromamplification device at various stages of uses of amplification device. Professional are also interested to see the impact of amplification device on the consumer's auditory performance at different stages i.e. immediately after fitting and over several months of use. Objective The objective of the study was to measure the hearing aid benefit following 6 months - 1-year usage, 1 year - 1.5 yeaŕs usage, and 1.5 yeaŕs - 2 years' usage. Methods A total of 45 subjects participated in the study and were divided equally in three groups: hearing aid users from 6 months to 1 year, 1 year to 1.5 year, and 1.5 year to two years. All subjects responded to the Hearing Aid Benefit Questionnaire (63 questions), which assesses six domains of listening skills. Result Results showed the mean scores obtained were higher for all domains in the aided condition, as compared with unaided condition for all groups. Results also showed a significant improvement in the overall score between first-time users with hearing aid experience of six months to one year and hearing aid users using hearing aids for a period between 1.5 and 2 years. Conclusion It is possible to conclude that measuring the hearing aid benefit with the self-assessment questionnaires will assist the clinicians in making judgments about the areas in which a patient is experiencing more difficulty in everyday listening environment and in revising the possible technologies.

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Auditory Evoked Potential Mismatch Negativity in Normal-Hearing Adults

Abstract Introduction Mismatch Negativity (MMN) corresponds to a response of the central auditory nervous system. Objective The objective of this study is to analyze MMN latencies and amplitudes in normal-hearing adults and compare the results between ears, gender and hand dominance. Methods This is a cross-sectional study. Forty subjects participated, 20 women and 20 men, aged 18 to 29 years and having normal auditory thresholds. A frequency of 1000Hz (standard stimuli) and 2000Hz (deviant stimuli) was used to evoked the MMN. Results Mean latencies in the right ear were 169.4ms and 175.3ms in the left ear, with mean amplitudes of 4.6μV in the right ear and 4.2μV in the left ear. There was no statistically significant difference between ears. The comparison of latencies between genders showed a statistically significant difference for the right ear, being higher in the men than in women. There was no significant statistical difference between ears for both right-handed and left-handed group. However, the results indicated that the latency of the right ear was significantly higher for the left handers than the right handers. We also found a significant result for the latency of the left ear, which was higher for the right handers. Conclusion It was possible to obtain references of values for the MMN. There are no differences in the MMN latencies and amplitudes between the ears. Regarding gender, the male group presented higher latencies in relation to the female group in the right ear. Some results indicate that there is a significant statistical difference of the MMN between right- and left-handed individuals.

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Relation between Ossicular Erosion and Destruction of Facial and Lateral Semicircular Canals in Chronic Otitis Media

Abstract Introduction Chronic otitis media can cause multiple middle ear pathogeneses. The surgeon should be aware of relation between ossicular chain erosion and other destructions because of the possibility of complications. Objective This study aimed to investigate the rates of ossicular erosion in cases of patients with and without facial nerve canal destruction, who had undergone mastoidectomy due to chronic otitis media with or without cholesteatoma. Methods We retrospectively analyzed three hundred twenty-seven patients who had undergone tympanomastoidectomy between April 2008 and February 2014. We documented the types of mastoidectomy (canal wall up, canal wall down, and radical mastoidectomy), erosion of themalleus, incus and stapes, and the destruction of facial and lateral semi-circular canal. Results Out of the 327 patients, 147 were women (44.95%) and 180 were men (55.04%) with a mean age 50.8 ± 13 years (range 8-72 years). 245 of the 327 patients (75.22%) had been operated with the diagnosis of chronic otitis media with cholesteatoma. FNCD was present in 62 of the 327 patients (18.96%) and 49 of these 62 (79.03%) patients had chronic otitis media with cholesteatoma. The correlation between the presence of FNCD with LSCC destruction and stapes erosion in chronic otitis media with cholesteatoma is statistically significant (p < 0.05). Conclusion Although incus is the most common of destructed ossicles in chronic otitis media, facial canal destruction is more closely related to stapes erosion.

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Effectiveness of Low Cut Modified Amplification using Receiver in the Canal Hearing Aid in Individuals with Auditory Neuropathy Spectrum Disorder

Abstract Introduction The studies on hearing aid benefit in individuals with auditory neuropathy spectrum disorder (ANSD) shows limited benefit. Low cut modified amplification is found to be effective in few individuals with ANSD. With advancement in technology, receiver in the canal (RIC) hearing aids have proven to be more effective than traditional behind the ear (BTE) hearing aids. Objective Thus, the present study attempts to determine the effectiveness of low cut modified amplification using RIC and BTE. Method Twenty participants with ANSD were fitted with BTE and RIC using traditional and low cut modified amplification. We divided them into good and poor performers based on unaided speech identification scores (SIS). We then compared aided SIS and aided benefit across conditions in good and poor performers with ANSD across both conditions using BTE and RIC. Results The results of the study showed that the aided performance improved with low cut modified amplification in both BTE and RIC hearing aids. The improvement noticed with low-cut modified fitting with RIC was significant in more than BTE, especially in good performers with ANSD. Conclusion The improved clarity and naturalness of sound with RIC may have led to better aided scores and better acceptance of the hearing aid. Thus, low-cut modified amplification, preferably with RIC, needs to be attempted in fitting individuals with ANSD, especially in those with good unaided SIS in quiet.

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Study of Various Prognostic Factors Affecting Successful Myringoplasty in a Tertiary Care Centre

Abstract Introduction Myringoplasty is a commonly performed otologic surgery. Objectives The objective of this study is to evaluate the effect of prognostic factors like - size, site of perforation, status of operating ear, approach, status of contralateral ear, experience of surgeon, primary or revision myringoplasty, and smoking in graft uptake, as well as to evaluate the hearing results after myringoplasty. Methods This is a prospective study. We included in our sample patients aged over 13 years with a Tubotympanic Chronic Otitis Media diagnosis. The patients underwent preoperative evaluation and Pure Tone Audiogram within one week prior to surgery.We performed myringoplasty using temporalis fascia graft with conventional underlay technique. We evaluated postoperative graft uptake and various factors related to the study and did a Pure Tone Audiogram at one year after surgery. Results The graft uptake rate after myringoplasty was 83.1% at one year in 219 patients. Graft uptake with normal opposite ear was 88.2%, and with Tubotympanic Chronic Otitis Media was 75% (statistically significant). We found no statistically significant difference in graft uptake results with other factors. We calculated hearing results of 132 patients with normal ossicular status who underwent myringoplasty. The average Air Conduction Threshold improvement was 11.44dB (p < 0.001) and the average Air-Bone Gap closure was 8.89dB, highly statistically significant (p < 0.001). Conclusion Diseased contralateral ear was a statistically significant poor prognostic factor for graft uptake after myringoplasty. Other factors studied were not statistically significant determining factor for graft uptake. Hearing improves significantly after myringoplasty if the ossicles are normal.

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The Accuracy of Digital Radiography for Diagnosis of Fishbone Foreign Bodies in the Throat

Abstract Introduction Some patients with a fishbone as a foreign body of difficult diagnosis may require further investigations. Generally, radiography is used as the first choice for finding the fishbone. Objective The objective of this study is to determine the accuracy of digital radiography for diagnosis of fishbone foreign body in the throat Methods This descriptive experimental study design has three phases. In the first phase, we assessed subject contrast and visibility of fishbone on a homogeneous background; as for the second phase, we evaluated the embedded fishbone in the fresh cadaver's throat. In the last phase, we studied the accuracy of radiography in diagnosing the fishbone foreign body at any site of the cadaver's throat. Results The subject contrast of 15 fishbones ranged from 0.94 to 0.99. All types of fishbone were obvious in the first phase, whereas, in the second phase, visibility of fishbone was varied. The subject contrast and diameter of fishbone did not show statistically significant correlation with visibility (p = 0.09 and p = 0.24, respectively). In the third phase, embedded fishbone in the base of tongue was detected with the highest accuracy (sensitivity of 1.00 (95%CI: 0.44-1.00) and specificity of 0.92 (95%CI: 0.65-0.99)); whereas, the tonsil was of difficult interpretation with poorest diagnostic value (sensitivity of 0.00 (95%CI: 0.00-0.56) and specificity of 1.00 (95%CI: 0.76-1.00)). Conclusion The digital radiography provides the highest accuracy and benefit to the diagnosis of a fishbone foreign body at the base of the tongue; whereas, the tonsil was of difficult interpretation.

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The Temporalis Muscle Flap for Palate Reconstruction: Case Series and Review of the Literature

Abstract Introduction The temporalis myofascial (TM) is an important reconstructive flap in palate reconstruction. Past studies have shown the temporalismyofascial flap to be safe as well as effective. Free flap reconstruction of palate defects is also a popular method used by contemporary surgeons. We aim to reaffirm the temporalis myofascial flap as a viable alternative to free flaps for palate reconstruction. Objective We report our results using the temporalis flap for palate reconstruction in one of the largest case series reported. Our literature review is the first to describe complication rates of palate reconstruction using the TM flap. Methods Retrospective chart review and review of the literature. Results Fifteen patients underwent palate reconstruction with the TMflap. There were no cases of facial nerve injury. Five (33%) of these patients underwent secondary cranioplasty to address temporal hollowing after the TM flap. Three out of fifteen (20%) had flap related complications. Fourteen (93%) of the palate defects were successfully reconstructed, with the remaining case pending a secondary procedure to close the defect. Ultimately, all of the flaps (100%) survived. Conclusion The TM flap is a viable method of palate defect closure with a high defect closure rate and flap survival rate. TM flaps are versatile in repairing palate defects of all sizes, in all regions of the palate. Cosmetic deformity created from TM flap harvest may be addressed using cranioplasty implant placement, either primarily or during a second stage procedure.

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Relationship of Tumor Thickness with Neck Node Metastasis in Buccal Squamous Cell Carcinoma: An Experience at a Tertiary Care Hospital

Abstract Introduction Squamous cell carcinoma is the most common malignancy of the head and neck, with the buccal mucosa being the most common site involved. Early locoregional metastasis is a hallmark of this disease, and early stage tumors may harbor metastatic nodes that are occult. Certain parameters can help identify high-risk patients for whom the pattern of occult nodal metastasis can be predicted. Tumor thickness is one such objective parameter. Objective To determine the relationship of tumor thickness with neck node metastasis in squamous cell carcinoma of the buccal mucosa. Methods A retrospective chart review of 102 patients with biopsy-proven squamous cell carcinoma of the buccal mucosa with N0 Necks was performed. All patients underwent tumor resection with neck dissection, and the tumor thickness was measured. Univariate and multivariate analyses were performed. Results A total of 102 patients, of which 73.53% were males and 26.47% were females. Themean age of the patients was 49.3 ± 11.1 years. It was found that the risk of neck node metastasis in buccal squamous cell carcinoma increases 35.5 times for a tumor thickness ≥ 2 mm, and the risk of neck nodemetastasis in buccal squamous cell carcinoma decreases by 0.58 times for each centimeter decrease in tumor size, while the rate of occult neck lymph node metastasis was found to be 37%. Conclusion We conclude that tumor thickness is significantly related with neck nodal metastasis in buccal squamous cell carcinoma, considering the age of the patient and the size of the tumor.

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Late-term Effects of Surgery on Nasal Functions in Patients who Underwent Total Laryngectomy Surgery

Abstract Introduction There is a common opinion that losing airway functions in total laryngectomy patients cause changes in nasal physiological rates. Studies conducted to review the subject present gaps, especially in terms of objective measurements. Objective We evaluated late-term effects of surgery on nasal functions in patients who underwent total laryngectomy surgery more than two years ago. Methods We included in the study 22 patients who had undergone total laryngectomy, as well as 24 healthy subjects with similar demographic characteristics as the control group. We performed acoustic rhinometry for intranasal volume and cross-sectional area measurements, saccharin test formeasurement of nasalmucociliary clearance, and smell identification test for evaluation of olfactory function in the patient and control groups. We compared and statistically analyzed the data obtained from the groups. Results In our study, although late-term (>2 years) measurements were not statistically significant, we detected more nasal passage patency in the patient group than in the control group. In smell identification test, lower scores were obtained in the patient group. The difference between measurements in both groups was statistically significant. Conclusion We believe that since the upper respiratory tract is disabled due to tracheostomy in patients with total laryngectomy, atrophy occurs in the late term and, consequently, nasal mucociliary clearance is impaired. We also see diminished olfactory function in total laryngectomy patients.

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Impact of Successful Choanal Atresia Repair on the Nasal Mucosa: A Preliminary Study

Abstract Introduction Themain histological features of the nasalmucosa in choanal atresia are distorted cilia, marked increase of mucous submucosal glands associated with marked reduction of goblet cell density, and lymphocytic cellular infiltration. Objective To study the nasal mucosal changes in cases of choanal atresia after successful repair compared with pre-repair mucosal histological features. Methods Tissue samples were taken from the inferior turbinate of 3 patients (1 bilateral and 2 unilateral) who were successfully operated. Then, the biopsies were subjected to histopathological, histochemical and immunohistochemical studies. After that, the results were compared with pre-repair findings in the choanal atresia side and in the normal side. Results Four biopsies (4 repaired choanal atresia sides) of the mucosa of the inferior turbinate revealed that 1 patient (who had a bilateral choanal atresia repaired), after achieving a patent choana for 8 months, had not completely recovered a normal nasal mucosa. The other 2 patients, after 18 and 23 months of achieving a patent choana, showed normal nasal cavities. Conclusion The main histological features of the nasal mucosa in choanal atresia could be reversed by surgery, making the patients regain their choanal patency, with their mucosae changing back to normal gradually with time.

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A Comparative Study between Universal Eclectic Septoplasty Technique and Cottle

Abstract Introduction Since the last century surgical correction of nasal septum deviation has been improved. The Universal Eclectic Technique was recently reported and there are still few studies dedicated to address this surgical approach. Objective The objective of this study is to compare the results of septal deviation correction achieved using the Universal Eclectic Technique (UET) with those obtained through Cottle's Technique. Methods This is a prospective study with two consecutive case series totaling 90 patients (40 women and 50 men), aged between 18 and 55 years. We divided patients into two groups according to the surgical approach. Fifty-three patients underwent septoplasty through Universal Eclectic Technique (UET) and thirty-seven patients were submitted to classical Cottle's septoplasty technique. All patients have answered the Nasal Obstruction Symptom Evaluation Scale (NOSE) questionnaire to assess pre and postoperative nasal obstruction. Results Statistical analysis showed a significantly shorter operating time for the UET group. Nasal edema assessment performed seven days after the surgery showed a prevalence of mild edema in UET group and moderate edema in Cottle's technique group. In regard to complication rates, UET presented a single case of septal hematoma while in Cottle's technique group we observed: 02 cases of severe edemas, 01 case of incapacitating headache, and 01 complaint of nasal pain. Conclusion The Universal Eclectic Technique (UET) has proven to be a safe and effective surgical technique with faster symptomatic improvement, low complication rates, and reduced surgical time when compared with classical Cottle's technique.

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Treatment Challenges of Group A Beta-hemolytic Streptococcal Pharyngo-Tonsillitis

Abstract Introduction Despite its in vitro efficacy, penicillin often fails to eradicate Group A β-hemolytic streptococci (GABHS) from patients with acute and relapsing pharyngotonsillitis (PT). Objective This review of the literature details the causes of penicillin failure to eradicate GABHS PT and the therapeutic modalities to reduce and overcome antimicrobial failure. Data Synthesis The causes of penicillin failure in eradicating GABHS PT include the presence of β lactamase producing bacteria (BLPB) that "protect" GABHS from any penicillin; the absence of bacteria that interfere with the growth of GABHS; coaggregation between GABHS and Moraxella catarrhalis; and the poor penetration of penicillin into the tonsillar tissues and the tonsillo-pharyngeal cells, which allows intracellular GABHS and Staphylococcus aureus to survive. The inadequate intracellular penetration of penicillin can allow intracellular GABHS and S. aureus to persist. In the treatment of acute tonsillitis, the use of cephalosporin can overcome these interactions by eradicating aerobic BLPB (including M. catarrhalis), while preserving the potentially interfering organisms and eliminating GABHS. Conclusion In treatment of recurrent and chronic PT, the administration of clindamycin, or amoxicillin-clavulanic acid, can eradicate both aerobic and anaerobic BLPB, as well as GABHS. The superior intracellular penetration of cephalosporin and clindamycin also enhances their efficacy against intracellular GABHS and S. aureus.

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Methods of Hearing Preservation during Cochlear Implantation

Abstract Introduction Recent advances in surgical techniques and electrode design have made residual hearing preservation during cochlear implantation (CI) possible, achievable, and desirable. Objectives The objective of this study was to review the literature regarding methods used for hearing preservation during CI surgery. Data Synthesis We performed a search in the LILACS, MEDLINE, SciELO, PubMed databases, and Cochrane Library, using the keywords CI, hearing preservation, CI electrode design, and CI soft surgery. We fully read about 15 studies that met the criteria described in "study selection". The studies showed that several factors could contribute to possible cochlear damage during or after CI surgery and must be kept in mind; mechanical damage during electrode insertion, shock waves in the perilymph fluid due to implantation, acoustic trauma due to drilling, loss of perilymph and disruption of inner ear fluid homeostasis, potential bacterial infection, and secondary intracochlear fibrous tissue formation. The desire to preserve residual hearing has led to the development of the soft-surgery protocols with its various components; avoiding entry of blood into the cochlea and the use of hyaluronate seem to be reasonably supported, whereas the use of topical steroids is questionable. The site of entry into the cochlea, electrode design, and the depth of insertion are also important contributing factors. Conclusion Hearing preservation would be useful for CI patients to benefit from the residual low frequency, as well as for the children who could be candidate for future regenerative hair cell therapy.

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Pathophysiology and Diagnosis of Vertebrobasilar Insufficiency: A Review of the Literature

Abstract Introduction Vertebrobasilar insufficiency is defined as transitory ischemia of the vertebrobasilar circulation. Dizziness, vertigo, headaches, vomit, diplopia, blindness, ataxia, imbalance, and weakness in both sides of the body are the most common symptoms. Objective To review the literature regarding the three available diagnostic testing in patients with dizziness complaints secondary to vertebrobasilar insufficiency (VBI): magnetic resonance angiography; transcranial Doppler ultrasound; and vertebrobasilar deprivation testing. Data Synthesis We selected 28 studies that complied with our selection criteria for appraisal. The most frequent cause of the hemodynamic changes leading to VBI is atherosclerosis. The main clinical symptoms are dizziness, vertigo, headaches, vomit, diplopia, blindness, ataxia, imbalance, and weakness in both sides of the body. Even though arteriography is considered the most important exam to diagnose the disease, the inherent risks of this exam should be taken into consideration. The magnetic resonance angiography has been widely studied and is a good method to identify and localize any occlusions and stenosis in both neck and intracranial great vessels. Conclusion Each patient with a suspected diagnosis of VBI should be individually evaluated and treated, taking in consideration the pros and cons of each diagnostic testing and treatment option.

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Adenomatous Tumors of the Middle Ear: A Literature Review

Abstract Introduction Neuroendocrine adenomas of the middle ear (NAME) are uncommon causes of middle ear masses. Mostly limited to case reports and small series, the literature is poor in providing an overall assessment of these tumors. Objective To review the current literature about all aspects of the disease, including its etiology, clinical manifestations, diagnosis, and treatment. Data Synthesis The pathogenesis of adenomatous tumors of the middle ear is not clear yet. One potential explanation is that an undifferentiated pluripotent endodermal stem cell may still be present in the middle ear mucosal surface, and may be the origin of the tumors. It typically appears as a nonspecific retrotympanic mass. The average age of onset for the disease is the fifth decade, and the most common clinical symptom is conductive hearing loss. Malign behavior is rare. There are numerous differential diagnoses of NAME. The final diagnosis depends on microscopic findings. The preoperative evaluation should include the use of computed tomography and magnetic resonance imaging. The adjunctive therapy of middle ear adenomatous tumors with radiotherapy, chemotherapy or somatostatin analogs is generally not recommended. Conclusion There is still much debate on pathogenesis and classification of NAME. Saliba's classification is currently the most complete and preferable one. Aggressive surgical procedure with ossicular chain excision is the gold standard treatment. Followup with physical and radiological exams is mandatory, particularly if the first procedure was conservative, without the removal of the encased ossicles.

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Ascending upper limb lymphangitis

Description

A 7-year-old boy presented with ascending erythema of his left hand with erythematous extension to his axilla. At presentation, the boy was afebrile, well appearing and complained of itching and swelling of the hand, which started the evening prior. On examination, there were two insect bite marks on the index finger with erythematous, non-tender swelling inclusive of the index, middle fingers and dorsum of the hand with extension via a superficial fine erythematous line from the wrist to the axilla via the cubital fossa figures 1 and 2). A clinical diagnosis of lymphangitis was made. Treatment was commenced with flucloxacillin and immobilisation. Twenty-four hours later, the erythema had faded substantially. Lymphangitis is inflammation of the lymphatic channels that occur as a result of infection at a site distal to the channel and may spread within hours. Group A beta-haemolytic streptococci are the most common causes...

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False acute kidney injury alert due to model car fuel ingestion

We report a case of accidental ingestion of model car fuel (Optifuel) resulting in an apparent elevation of serum creatinine of 274 µmol/L (3.1 mg/dL) as measured by the Jaffe (alkaline picrate) reaction, which resulted in an acute kidney injury (AKI) stage 3 alert being reported. Optifuel contains nitromethane, which has been reported to interfere in the Jaffe reaction causing falsely high creatinine measurements. The laboratory staff were vigilant about this potential interfering substance so repeated the analysis of the creatinine using an enzymatic method that showed a markedly lower result of 47 µmol/L (0.5 mg/dL). This report highlights the ability of nitromethane to potentially mimic AKI and the importance of being aware of the limitations of biochemical tests to avoid misinterpretation of results and instigating inappropriate treatment.

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Typical carcinoid involving the main carina managed with arterial embolisation, endobronchial resection and ablation, ultimately followed by carinal resection

Bronchial carcinoids are uncommon pulmonary tumours, and the gold standard management is surgical resection. Their management is often complicated by their proximal location and propensity to bleed when manipulated. A 22-year-old man was found to have typical carcinoid tumour involving the carina and surgical resection was considered not feasible. We report our experience with a multimodality approach involving arterial embolisation, with subsequent endobronchial resection and ablation. Residual disease was found and managed with definitive carinal resection.

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Possible congenital dilatation of the pancreatic duct

The main pancreatic duct can become dilated in a number of conditions. We describe a patient with gross dilatation of the main pancreatic duct without evidence of causative underlying pathology suggesting congenital dilatation of the pancreatic duct. A 36-year-old man presented with signs of intestinal obstruction and a history of surgery for congenital pyloric stenosis. Incidental findings on CT showed a massively dilated main pancreatic duct. On MRI there was no duct irregularity or solid mural nodule, making a main duct intraductal papillary mucinous neoplasm unlikely. Endoscopic ultrasound findings were in keeping with those on MRI. Fine needle aspiration revealed a non-viscous fluid with a low carcinoembryonic antigen and high amylase concentration, consistent with normal pancreatic fluid levels rather than a mucinous collection. After 1 year, the cyst remains unchanged. This patient will be kept under surveillance with yearly MRI.

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Retroperitoneal teratoma simulating giant adrenal myelolipoma: a diagnostic puzzle

Teratoma is a germ-cell tumour that is common in para-axial regions. Retroperitoneal teratoma is rare and comprise only about 1% of all teratomas. We present a 21-year-old female who presented with a lump in the abdomen. After radiological investigations, she was diagnosed as case of adrenal myelolipoma which on excision turned out histologically to be retroperitoneal teratoma. Our case highlights the limitation of radiological investigations in preoperative diagnosis of teratoma.

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Acromegaly with hypophosphataemia: McCune-Albright syndrome

A 38-year-old man presented with excessive height gain and progressive enlargement of the extremities since childhood. This was compounded by lower limb deformities over the past 5 years. On examination, his height was 196 cm, he had macroglossia, acral enlargement, seborrhoea, hyperhidrosis—suggesting acrogigantism. He had facial asymmetry, wind-swept deformity of lower limbs and a café-au-lait macule over his trunk. Investigations revealed normal-sized pituitary gland with dysplastic cranial bones. Isotope bone scintigraphy was suggestive of polyostotic fibrous dysplasia. A diagnosis of McCune-Albright syndrome was made and trans-sphenoidal hypophysectomy was undertaken. He had persistent hypophosphataemia. Tubular reabsorption of phosphate adjusted for glomerular filtration rate was low and serum FGF-23 level was high. Ga-DOTATATE scintigraphy showed somatostatin-receptor expression in all the dysplastic lesions. FGF-23 produced by the bony lesions could counteract the phosphate-retaining effect of GH excess resulting in hypophosphataemia, which further worsened following hypophysectomy.

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Simultaneous combined complete tear of radial and ulnar collateral ligaments of thumb in an adolescent

Isolated tear of collateral ligaments of thumb are common but combined injuries of both radial and ulnar collateral ligaments are rare. These cases are reported in athletes involved in high-impact sports. Here, we report a case of a 15-year-old boy with pain at base of the thumb and instability following low-impact sporting activity. On subsequent clinicoradiological assessment, simultaneous combined complete tear of both radial and ulnar collateral ligaments of the thumb was noted. Delayed primary repair of both collateral ligaments was done. This case highlights the rarity of this type of injury in an adolescent and also the use of appropriate clinical tests and imaging modalities for early diagnosis of such injuries. Restoration of joint stability as early as possible either by repair or reconstruction of ligaments needs to be considered to prevent secondary osteoarthritis of metacarpophalangeal joint.

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HIV-associated benign lymphoepithelial cysts of the parotid glands confirmed by HIV-1 p24 antigen immunostaining

Approximately 1%–10% of patients with HIV infection have been reported to have salivary gland enlargement. Parotid swelling in patients with HIV is often associated with salivary gland disease, including benign lymphoepithelial cysts (BLECs). The presence of BLEC can serve as an indicator of HIV infection, and the diagnosis of HIV-associated BLEC is usually based on clinical course, HIV confirmatory blood testing, such as western blot or viral detection, and imaging studies, but not on biopsies or immunostaining. To exclude other diseases such as tuberculosis and malignant lymphoma and to further improve the diagnostic accuracy of BLEC, the detection of the HIV-1 p24 antigen by immunohistochemistry is a useful diagnostic method. We report a case of a 65-year-old Japanese man with swelling of the parotid glands and HIV-associated BLEC confirmed via HIV-1 p24 immunohistochemical staining.

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Eficacia de las maniobras de reposicionamiento canalicular en el vértigo posicional paroxístico benigno: revisión de 176 casos tratados en un centro hospitalario de tercer nivel

Publication date: Available online 29 September 2017
Source:Acta Otorrinolaringológica Española
Author(s): Claudio Carnevale, Diego J. Arancibia-Tagle, Elena Rizzo-Riera, Guillermo Til-Perez, Pedro L. Sarría-Echegaray, Julio J. Rama-Lopez, Santiago Quer-Canut, German Fermin-Gamero, Manuel D. Tomas-Barberan
Introducción y objetivosEl vértigo posicional paroxístico benigno es la entidad más frecuente dentro de los vértigos de origen periférico. El objetivo del siguiente trabajo es revisar los resultados obtenidos con las diferentes maniobras de reposicionamiento canalicular específicas para cada tipo de canal semicircular afectado, evaluando posibles factores de riesgo relacionados con un peor pronóstico.MétodosSe han revisado retrospectivamente 176 pacientes diagnosticados de vértigo posicional paroxístico benigno en nuestro centro, de los cuales 150 tenían vértigo del canal semicircular posterior, 20 del horizontal, 3 del superior y 3 multicanal. Se ha usado la maniobra de Epley para el tratamiento del canal posterior y del superior y la maniobra de Lempert para el tratamiento del horizontal. En los casos refractarios se ha realizado siempre un estudio de imagen cerebral con resonancia.ResultadosLa maniobra de Epley ha mostrado una eficacia al primer intento del 74,6% para el canal posterior y del 100% para el superior. La eficacia de la maniobra de Lempert para el canal horizontal ha sido del 72,72% en los casos de canalolitiasis y del 58,33% en los de cupulolitiasis. Más complicado ha sido el tratamiento de los pacientes con más de un canal afectado y con antecedente quirúrgico en el mes previo.ConclusionesLas maniobras de reposicionamiento canalicular permiten alcanzar una tasa de éxito muy alta, obteniendo mejores resultados en el tratamiento del canal posterior. Hacen falta más estudios para confirmar la sospecha de que la cirugía previa pueda ser un factor de peor pronóstico.Introduction and objectivesBenign paroxysmal positional vertigo is the most common peripheral vertigo disease. The aim of this paper is to review the results obtained with the different specific particle repositioning manoeuvres, evaluating the possible risk factors linked to a poorer prognosis.MethodsOne hundred and seventy-six patients with a diagnosis of benign paroxysmal positional vertigo were reviewed retrospectively, of whom 150 had vertigo of the posterior canal, 20 had vertigo of the horizontal canal, 3 had vertigo of the superior canal, and 3 had a double vertigo. The Epley manoeuvre was used to treat the posterior and superior canals, and Lempert manoeuvre was used to treat the horizontal canal. An imaging study by nuclear magnetic resonance with gadolin was always used in refractory cases.ResultsThe Epley manoeuvre showed an efficacy of 74.6 and 100% at first attempt for posterior and superior canals respectively. The efficacy of the Lempert manoeuvre for the horizontal canal was 72.72% in the patients with canalolithiasis, and 58.33% in the patients with cupulolithiasis. The treatment of patients with more than one affected canal and a history of surgery in the previous month was more difficult.ConclusionsParticle repositioning manoeuvres show a very high success rate, allowing better results in the treatment of the posterior canal. We need more studies to confirm the suspicion that surgery may be a factor of poorer prognosis.



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Phelan-McDermid syndrome due to SHANK3 mutation in an intellectually disabled adult male: successful treatment with lithium

For 30 years, Phelan and co-workers described a syndrome characterised by neonatal hypotonia, global developmental delay, strongly impaired speech, sleep disturbances and hyperreactivity to sensory stimuli. This Phelan-McDermid syndrome (PMS), also presenting with symptoms from the autism spectrum and a higher risk of developing seizure disorders, may be caused by a deletion of chromosome 22q13 or by a mutation in the SHANK3 gene. Its core psychopathological phenotype comprises symptoms from the bipolar spectrum for which generally treatment with a mood-stabilising anticonvulsant in combination with an atypical antipsychotic seems to be most effective. In addition to two elsewhere published adolescent patients, we here describe in detail the history of an adult male patient with PMS caused by a SHANK3 mutation in whom successive treatment regimens with antipsychotics and mood-stabilising anticonvulsants were all ineffective. Ultimately, addition of lithium to existing olanzapine therapy led to enduring stabilisation of mood and behaviour.

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Breast pseudoaneurysm arising from core needle biopsy should be left well alone

A 45-year-old woman previously fit and well, developed a pseudoaneurysm of the breast following core needle biopsy. She was ultimately reassured and discharged without further intervention. Pseudoaneurysm is a rare complication of core needle biopsy which, contrary to previously published cases, can be managed conservatively.

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Human Metapneumovirus Infection: Pneumonia Risk Factors in Solid Organ Transplantation Patients and CT findings.

Background: Human metapneumovirus (HMPV) is a newly detected pathogen which can cause lower respiratory tract disease. Clinical characteristics, computed tomography (CT) findings, and outcomes of HMPV pneumonia in solid organ transplantation (SOT) patients have not been well demonstrated. Methods: Between January 2010 and February 2016, clinical and imaging findings of 59 patients receiving SOT (types of organ: 37 kidney, 16 liver, 4 heart and 2 pancreas and kidney) who had HMPV infection detected in nasopharyngeal or bronchoalveolar lavage by reverse transcription polymerase chain reaction were retrospectively evaluated. Results: Most (90%) of the patients were detected between March and June. In the 59 SOT patients with upper respiratory tract infection (URI), 29 (49%) progressed to lower respiratory tract disease (LRD) after a median of 7 days (range, 2-31 days). Co-infection was noted in 39% of patients. In Cox proportional hazards analysis, low lymphocyte count ( 10 mg/dL (HR, 2.93, 95% CI, 1.19-7.21, P=0.02) at URI diagnosis were associated with HMPV pneumonia. On CT, HMPV pneumonia presented as bilateral ill-defined centrilobular nodules, consolidation and ground-glass opacities, while lymphadenopathy or effusion is not common. There were no significantly different imaging CT findings between patients with HMPV infection alone and those with co-infection. Conclusions: HMPV pneumonias were detected in nearly half of SOT patients showing URI symptoms with positive HMPV, and low lymphocyte count and high CRP at URI diagnosis were significant factors associated with HMPV pneumonia. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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The Importance in Using Serially Measured TAC Clearance Values, Especially during the Early Posttransplant Period.

No abstract available

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The Authors' Reply.

No abstract available

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Chronic liraglutide administration fails to suppress postprandial glucagon levels in type 1 diabetic islet allograft recipients with graft dysfunction.

No abstract available

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Heart rate variability: implications for perioperative anesthesia care.

Purpose of review: Heart rate variability (HRV) is a measure of the balance between both the parasympathetic and sympathetic nervous system and may provide useful information for anesthesia care providers. HRV may offer predictive information about critically ill and operative patients. Further, HRV collection provides real-time information of patient autonomic nervous system status and may allow tailoring of the analgesia for patients in the ICU and operating room. Recent findings: Reduced and abnormal resting HRV predict sudden and nonsudden cardiac death. Recent evidence shows that decreased HRV correlates with worsened outcomes in both trauma patients and patients with sepsis, as well as the risk of developing hypotension after induction of general anesthesia and placement of intrathecal local anesthesia. In addition, HRV appears to provide an accurate assessment of the nociception-analgesia balance in deeply sedated ICU patients and those under general anesthesia. Summary: No study has assessed the prognostic value of preoperative HRV in patients presenting for surgery. Use of HRV for patient risk stratification and intraoperative analgesia management may allow tailored perioperative care and improved outcomes. If intraoperative HRV data leads to decreased perioperative opioid use, opioid-related adverse events, a serious perioperative issue, may be decreased. Clinical Trials Registration: Not applicable Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Difficult airway management and training: simulation, communication, and feedback.

Purpose of review: Successful and sustainable training and learning of the management of difficult and normal airway is essential for all clinically active anesthesiologists. We emphasize the importance of a continuously updated learning and training environment based on actual knowledge, best available equipment, standardized procedures, and educational theory. Recent findings: In the past, most of the training were based on 'learning by doing' under the supervision of superiors or experienced colleagues. This has been recognized as insufficient and training has evolved to its recent level by structuring it into technical, methodological, and behavioral components. Additionally, a large part of it has been shifted away from learning on patients to simulated scenarios in designated environments. The contents, structure, components, and succession of components have been refined according to the steadily evolving and available instruments. Increasingly, team interaction and behavioral aspects gained more attention and became part of standardized education units that are tailored to the learners' clinical role and level of experience. Summary: We present the details of the Zurich Airway Training and Simulation program, which has been constantly updated to the actual state of knowledge and available equipment. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Perioperative management of cardiac rhythm assist devices in ambulatory surgery and nonoperating room anesthesia.

Purpose of review: Patients with cardiac implantable electronic devices (CIEDs) frequently undergo various surgical procedures and in the past perioperative management involved only placing magnet over the device. New programming features, development of implantable cardiac defibrillator (ICD), cardiac resynchronization therapy, and increasing complexity of the operating room equipment have led to new sources of electromagnetic interference (EMI). A comprehensive understanding of the CIED is necessary to provide a timely and optimal care to the patients. Recent findings: Technological advancements and direct implantation of the transvenous implantable cardiac defibrillators into the heart have led to less clear lines between the pacemakers and the ICD. Subcutaneous ICD as well as the leadless transcatheter deployed intracardiac pacemaker development has complicated the issue further. Summary: Rapidly developing technologies and increasing number of patients with these devices coming for noncardiac surgeries necessitate continuous education of the anesthesia team regarding perioperative management of such devices. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Thyroid High-Impact Articles

FREE ACCESS through October 12, 2017.
Read now:

Latest Impact Factor: 5.515
The Official Journal of: American Thyroid Association

Clinical Implications of Immunoglobulin G4 to Graves' Ophthalmopathy
Sung Hoon Yu, Jun Goo Kang, Chul Sik Kim, Sung-Hee Ihm, Moon Gi Choi, Hyung Joon Yoo, Seong Jin Lee

Idiopathic Low Ovarian Reserve Is Associated with More Frequent Positive Thyroid Peroxidase Antibodies
Chien-Wen Chen, Ya-Li Huang, Chii-Ruey Tzeng, Rui-Lan Huang, Chi-Huang Chen

Treatment of Swedish Patients with Graves' Hyperthyroidism Is Associated with Changes in Acylcarnitine Levels
Mahmoud Al-Majdoub, Mikael Lantz, Peter Spégel

Defining Radioiodine-Refractory Differentiated Thyroid Cancer: Efficacy and Safety of Lenvatinib by Radioiodine-Refractory Criteria in the SELECT Trial
Naomi Kiyota, Bruce Robinson, Manisha Shah, Ana O. Hoff, Matthew H. Taylor, Di Li, Corina E. Dutcus, Eun Kyung Lee, Sung-Bae Kim, Makoto Tahara

Comparison of the Seventh and Eighth Editions of the American Joint Committee on Cancer/Union for International Cancer Control Tumor-Node-Metastasis Staging System for Differentiated Thyroid Cancer
Mijin Kim, Won Gu Kim, Hye-Seon Oh, Suyeon Park, Hyemi Kwon, Dong Eun Song, Tae Yong Kim, Young Kee Shong, Won Bae Kim, Tae-Yon Sung, Min Ji Jeon

The post Thyroid High-Impact Articles appeared first on American Thyroid Association.

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Schwannoma of external auditory canal

Schwannomas of the external auditory canal are extremely rare and only a few cases have been reported in the literature. Herein, we report a case of schwannoma of the external ear canal in a 41-year male. Clinicians should consider the possibility that the schwannoma may originate in the external auditory canal mimicking other more frequently observed lesions.

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Electroneurography in the acute stage of facial palsy as a predictive factor for the development of facial synkinesis sequela

We investigated whether the value of ENoG is a predictive factor for the development of facial synkinesis in patients with facial palsy.

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The role of regulatory B cells in allergen immunotherapy.

Purpose of review: Allergen immunotherapy (AIT) is currently the only curative treatment available for allergic diseases, and has been used in clinical practice for over a century. Induction and maintenance of immune tolerance to nonhazardous environmental and self-antigens is essential to maintain homeostasis and prevent chronic inflammation. Regulatory B (BREG) cells are immunoregulatory cells that protect against chronic inflammatory responses primarily through production of anti-inflammatory cytokines such as IL-10, transforming growth factor-[beta], and IL-35. The importance of BREG cells has been extensively demonstrated in the context of autoimmune diseases. Data showing their role in the regulation of allergic responses are slowly accumulating. This review summarizes recent findings relevant to the topic of BREG cells and their potential role in AIT. Recent findings: BREG cells support AIT in models of allergic airway inflammation and intestinal inflammation through induction of regulatory T (TREG) cells. In humans BREG frequency increases during venom immunotherapy while the phenotype of allergen-specific B cells changes. Mechanisms of BREG-mediated tolerance to allergens include IL-10-mediated suppression of effector T cell, including TH2 responses, induction of TREG cells, IL-10-mediated inhibition of Dendritic cell maturation, modulation of T follicular helper responses, and production of anti-inflammatory IgG4 antibodies. Summary: Current evidence supports a potential role for BREG cells in induction and maintenance of allergen tolerance during AIT. A better understanding of the role of B cells and BREG cells in AIT could open potential new windows for developing targeted therapies specifically focused on promoting BREG responses during AIT. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Comparing hemophagocytic lymphohistiocytosis in pediatric and adult patients.

Purpose of review: Hemophagocytic lymphohistiocytosis (HLH) has long been thought of primarily as a pediatric disease. However, this syndrome may occur secondary to underlying malignancies, infections, and autoimmune diseases, in adult patients. Here, we seek to highlight similarities and differences between pediatric and adult HLH, knowledge gaps, and areas of active research. Recent findings: Malignancy is a more frequent driver of HLH in adults, present in nearly half. Prognosis is poor as compared with nonmalignant HLH. Prognosis in adults is generally worse than pediatric patients, suggesting that age and other comorbid illnesses not surprisingly affect the outcome of HLH. Diagnostic and treatment approaches are more variable in adults, likely contributing to poorer outcomes. The frequency of mutations in HLH-causing genes is higher than had been anticipated in adults, although with a higher frequency of uniallelic and hypomorphic mutations than in children. Summary: Optimizing diagnostic criteria for earlier detection may benefit both children and adults. Standardizing treatment approaches in adults will be more difficult because of the variability in triggering illnesses, but a more standardized or algorithmic approach will likely be beneficial. More research into the role of uniallelic and hypomorphic mutations in adults is necessary, to understand treatment and prognostic implications. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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NLRC4 inflammasomopathies.

Purpose of review: The purpose of the review is to highlight developments in autoinflammatory diseases associated with gain-of-function mutations in the gene encoding NLR-family CARD-containing protein 4 (NLRC4), the NLRC4-inflammasomopathies. Recent findings: Three years since the identification of the first autoinflammation with infantile enterocolitis (AIFEC) patients, there is an improved understanding of how the NLRC4 inflammasome and interleukin 18 (IL-18) contribute to gut inflammation in myeloid and also intestinal epithelial cells. This information has opened new therapeutic avenues to treat AIFEC patients with targeted agents like recombinant IL-18 binding protein and antiinterferon-[gamma] antibodies. Additional phenotypes traditionally associated with NLRP3 mutations like familial cold autoinflammatory syndrome and neonatal onset multisystem inflammatory disease (NOMID), have now also been associated with gain-of-function NLRC4 mutations. Finally, NLRC4 somatic mosaicism has now been identified in a NOMID and an AIFEC patient, a finding emphasizing nontraditional modes of inheritance in autoinflammatory diseases. Summary: The NLRC4 inflammasomopathies constitute a growing autoinflammatory disease category that spans a broad clinical spectrum from cold urticaria to NOMID and the often fatal disease AIFEC. Rapid case identification with biomarkers like elevated serum IL-18 concentrations and early intervention with targeted immunomodulatory therapies are key strategies to improving outcomes for AIFEC patients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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A tongue mass

Publication date: Available online 28 September 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): A. Nurdoğan




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Deregulation of selected microRNAs in sinonasal carcinoma: Value of miR-21 as prognostic biomarker in sinonasal squamous cell carcinoma

Abstract

Background

Tumors occurring in the sinonasal area are characterized by unfavorable outcome due to difficult diagnosis, treatment, and prognosis of the disease corresponding with the anatomic complexity of the area.

Methods

We used quantitative real-time polymerase chain reaction (PCR) to compare relative expression of miR-21, miR-141, and miR-200c in 70 formalin-fixed, paraffin-embedded samples of sinonasal carcinoma tissue (majority of squamous cell carcinoma [SCC] samples) with 17 control samples of sinonasal tissue.

Results

Our data showed significant upregulation of miR-21 in sinonasal cancer tissue. Expression levels of miR-141 and miR-200c were below detectable levels in both sinonasal cancer samples and healthy tissue. Kaplan-Meier analysis with log-rank survival showed that patients with SCC with high expression of miR-21 (highest quartile) had impaired survival close to reaching statistical significance (P = .0630).

Conclusion

Our results suggest that miR-21 upregulation is involved in tumorigenesis of sinonasal carcinoma and that it is associated with poor prognosis. Thus, miR-21 could be used as a valuable prognostic biomarker.

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The effect of agomelatine and melatonin on sleep-related eating: a case report

Sleep-related eating may occur in the context of mental illness, sleep disorders, or psychopharmacological treatment. Frequently, sleep-related eating leads to severe weight gain and, so far, there are no trea...

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Response to Krieger et al. Re: “TSHR/IGF-1R Cross-Talk, Not IGF-1R Stimulating Antibodies, Mediates Graves' Ophthalmopathy Pathogenesis” (Thyroid 2017;27:746–747)

Thyroid , Vol. 0, No. 0.


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Thyroid Nodule Diagnostic Markers in the Face of the New NIFTP Category: Time for a Reset?

Thyroid , Vol. 0, No. 0.


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Use of reflectance confocal microscopy to evaluate 5-fluorouracil 0.5% /salicylic acid 10% in the field-directed treatment of sub-clinical lesions of actinic keratosis: sub-analysis of a Phase III, randomised, double-blind, vehicle-controlled trial

Abstract

Background

Actinic keratosis (AK) is a common skin disorder that can progress to invasive squamous-cell carcinoma. AK can present as clinical (visible) or sub-clinical (invisible) lesions within areas of chronic sun damage. The importance of treating sub-clinical AK is gaining support. We present a sub-analysis of a previously published Phase III, double-blind, vehicle-controlled study (NCT02289768), to assess 5-fluorouracil (5-FU) 0.5% /salicylic acid 10% treatment of sub-clinical AK lesions, based on reflectance confocal microscopy (RCM).

Objective

To determine the efficacy of 5-FU 0.5% /salicylic acid 10% as field-directed treatment for sub-clinical AK lesions using RCM.

Methods

For inclusion in this sub-analysis, patients had to have at least three sub-clinical AK lesions within a 25 cm² area of skin. Sub-clinical AK lesions were diagnosed according to the presence of three key RCM criteria: architectural disarray; keratinocyte atypia and pleomorphism at the basal, spinous and granular layer. Sub-clinical AK lesions were evaluated by RCM at baseline, after 4, 6 and 12 weeks of 5-FU 0.5% /salicylic acid 10% treatment or vehicle, and 8 weeks following the end of treatment.

Results

Twenty-seven patients were included: 17 (mean age = 72.2 years, standard deviation [SD] = 6.3) received 5-FU 0.5% /salicylic acid 10% treatment and 10 (mean age = 76.4 years, SD = 3.9) received vehicle. Eight weeks following the end of treatment, the mean number of sub-clinical lesions declined (from 3.0 at baseline) to 0.3 (95% confidence interval [CI] 0.06–0.57) for the 5-FU 0.5% /salicylic acid 10% group and 1.6 (95% CI 0.52–2.68) in the vehicle group (reductions of 90% [95% CI 72.1–107.1] vs. 47% [95% CI 24.8–69.5], respectively; P = 0.005). The proportion of patients receiving 5-FU 0.5% /salicylic acid 10% showing complete clearance of three pre-selected sub-clinical AK lesions was numerically greater than in the vehicle group (69% vs. 40%, respectively; P = 0.183).

Conclusion

To the best of our knowledge, this is the first randomised, vehicle-controlled study investigating 5-FU 0.5% /salicylic acid 10% treatment for sub-clinical AK lesions. The present data suggest some treatment efficacy for sub-clinical AK lesions detected using RCM. However, this sub-analysis was not sufficiently powered and should be reproduced in a larger, subsequent cohort.

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