Nasoseptal flap closure of the eustachian tube for recalcitrant cerebrospinal fluid rhinorrhea

http://ift.tt/2AVLO21

Easy insertion into the duct: The use of an angiocatheter as a sialendoscopy applicator

http://ift.tt/2iw3Q42

First bite syndrome following transcervical arterial ligation after transoral robotic surgery

Objective

To assess the incidence of first bite syndrome (FBS) in transoral robotic surgical (TORS) patients undergoing transcervical arterial ligation.

Methods

Retrospective case series of all patients diagnosed with FBS following prophylactic transcervical arterial ligation of branches of the external carotid system between March 2010 and December 2016 at a single academic center.

Results

Six patients with FBS after TORS with transcervical arterial ligation were evaluated, representing 7% of all patients who underwent neck dissection with concomitant transcervical arterial ligation (6 of 83). Median presentation of FBS was 63 days, with an average duration of 66 days. Treatment ranged from observation to botulinum toxin injection.

Conclusion

Patients who undergo transcervical arterial ligation to minimize bleeding complications following TORS are at risk of developing first bite syndrome.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2AVJcBa

The hospital otolaryngologist: The louisiana state university experience

Objectives/Hypothesis

To describe the implementation and impact of a hospital otolaryngologist in an academic medical center setting. Our hypothesis was that the hospital otolaryngologist would increase productivity of the Louisiana State University (LSU) faculty otolaryngologists and provide more timely access to inpatient otolaryngology services.

Study Design

Retrospective clinical and administrative database review.

Methods

A comparative database review was performed with data from the year predating the initiation of the hospitalist program (2013) to the first full year after initiation of the program (2014). A clinical database review including diagnoses and procedures was also performed.

Results

Overall outpatient clinic relative value units for the aggregated LSU faculty increased 16% (despite the fact that the direct outpatient contribution of the hospital otolaryngologist was negligible). Overall capture of inpatient consult codes increased 128%. The hospital otolaryngologist was responsible for 84.5% of inpatient consult codes. There was a 100% increase in outpatient consult codes for the LSU faculty, of which <1% was attributed to the otolaryngology hospitalist. No significant impact was seen on length of stay over the study interval. Clinical database review of the first 2 years of the program showed 3,707 total encounters with postoperative encounters the most common. Four hundred fifty-four inpatient procedures were logged. The most common surgical procedure was tracheostomy.

Conclusions

The otolaryngology hospitalist program is a viable clinical and economic model.

Level of Evidence

NA Laryngoscope, 2017

http://ift.tt/2ivPv7S

Hirano's cover–body model and its unique laryngeal postures revisited

Objectives/Hypothesis

In 1974, Minoru Hirano proposed his theory of voice production that is now known as the cover–body theory. He described the thyroarytenoid (TA) and cricothyroid (CT) muscles as the major determinants of vocal fold shape and stiffness, and theorized four typical laryngeal configurations resulting from unique TA/CT activations, with implications for the resulting voice quality. In this study, we directly observed the vocal fold medial surface shape under Hirano's unique TA/CT activation conditions to obtain a three-dimensional (3D) understanding of these laryngeal configurations during muscle activation.

Study Design

In vivo canine hemilarynx model.

Methods

Flesh points were marked along the medial surface of the vocal fold. Selective TA and CT activation were performed via respective laryngeal nerves. 3D reconstructions of the vocal fold medial surface were derived using digital image correlation.

Results

Low level TA and CT activation yielded anteroposterior lengthening and vertical thinning of the vocal fold. When TA activation is far greater than CT, the vocal fold shortens and thickens. With slightly greater TA than CT, activation the vocal length is maintained on average, whereas its vertical thickness decreases. With CT far greater than TA activation, the vocal fold lengthens and thins. In all conditions, glottal contour changes remained minimal.

Conclusions

Analysis of the 3D geometry of the vocal fold medial surface under Hirano's four typical laryngeal configurations revealed that the key geometric changes during TA/CT interactions lie within the anteroposterior length and the vertical thickness of the vocal fold.

Level of Evidence

NA Laryngoscope, 2017

http://ift.tt/2AUCETh

The national landscape of unplanned 30-day readmissions after total laryngectomy

Objectives/Hypothesis

Examine rates of readmission after total laryngectomy and determine primary etiologies, timing, and risk factors for unplanned readmission.

Study Design

Retrospective cohort study.

Methods

The Nationwide Readmissions Database was queried for patients who underwent total laryngectomy between January 2013 and November 2013. Patient-, procedure-, admission-, and institution-level characteristics were compared for patients with and without unplanned 30-day readmission. Outcomes of interest included rates, etiology, and timing of readmission. Multivariate logistic regression was used to identify predictors of 30-day readmission.

Results

There were 2,931 total laryngectomies performed in 2013 with an unplanned readmission rate of 17.5%. Postoperative fistula accounted for 13.7% of readmissions. The odds of readmission were elevated for patients undergoing concurrent procedures, including primary tracheoesophageal fistulization (adjusted odds ratio [aOR]: 2.44, 95% confidence interval [CI]: 1.15-5.18, P = .02) and/or pedicle graft or flap procedures (aOR: 1.73, 95% CI: 1.13-2.66, P = .01). Additionally, patients with comorbid coagulopathy (aOR: 3.04, 95% CI: 1.13-8.22, P = .03), liver disease (aOR: 2.48, 95% CI: 1.08-5.71, P = .03), and valvular heart disease (aOR: 3.18, 95% CI: 1.20-8.41, P = .02) had increased risk for unplanned 30-day readmission. Private insurance and longer lengths of stay were associated with decreased odds of readmission.

Conclusions

Nearly one-fifth of total laryngectomy patients are readmitted to the hospital within 30 days of discharge. Risk factors identified in this nationally representative cohort should be carefully considered during the postoperative period to reduce preventable readmissions after total laryngectomy.

Level of Evidence

2c Laryngoscope, 2017

http://ift.tt/2ixoJvN

Effect of topical nasal anesthetic on swallowing in healthy adults: A double-blind, high-resolution manometry study

Objective

Topical nasal anesthetic (TNA) is used when evaluating pharyngeal swallowing with high-resolution manometry (HRM). It is unclear if desensitizing the nasal mucosa improves procedure tolerability or affects pharyngeal pressure. This study evaluated the effects of TNA on comfort and pharyngeal pressure using HRM.

Methods

A double-blinded study was conducted with 20 healthy participants ( = 27 years). Participants performed five saliva and five 10-mL swallows during two exams with ManoScan HRM ESO catheter (Medtronic, Minneapolis, MN) randomized under placebo (nonanesthetic lubricant) and anesthetized (0.4 mL of 2% viscous lidocaine hydrochloride) conditions. Comfort was rated using a 100-mm visual analog scale (VAS). Pharyngeal HRM amplitude and timing were analyzed.

Results

VAS ratings were similar under placebo (mean = 38.4, standard deviation [SD] = 19.92) and TNA conditions (mean = 33.78, SD = 18.9), with no significant differences between placebo and anesthetized conditions (t[19] = 1.23, P = 0.23) or tolerability at first and second procedure (t[19] = 1.38, P = 0.18). Lower maximum and mean pharyngeal pressure were found for the TNA condition when compared to placebo (dry: maximum [−15.45 mmHg, standard error (SE) = 5.06 mmHg, P = 0.021]; mean [−5.22 mmHg, SE = 1.58 mmHg, P = 0.005]), and (liquid: maximum [−14.79 mmHg, SE = 5.01 mmHg, P = 0.010]; mean [−2.79 mmHg, SE = 1.99 mmHg, P = 0.008]).

Conclusion

This double-blind, randomized study is the first to investigate effects of TNA on tolerability and pharyngeal pressure using HRM. Results indicate TNA offered no significant difference in procedure comfort while affecting the magnitude of pharyngeal swallowing.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2AVUuFw

When should you perform injection medialization for pediatric unilateral vocal fold immobility?

http://ift.tt/2AVJ9Fu

Healthcare disparities in pediatric otolaryngology: A systematic review

Objectives

Multiple studies have reported healthcare disparities in particular settings and conditions within pediatric otolaryngology, but a systematic examination of the breadth of the problem within the field is lacking. This study's objectives are to synthesize the available evidence regarding healthcare disparities in pediatric otolaryngology, highlight recurrent themes with respect to etiologies and manifestations, and demonstrate potential impacts from patient and provider standpoints.

Methods

A qualitative systematic review of the PubMed, Ovid, and Cochrane databases for articles focusing on racial, ethnic, or socioeconomic disparities related to pediatric otolaryngology conditions or settings was conducted. United States-based studies of any design or publication date with analysis of children 0 to 18 years old were included.

Results

Of 711 abstracts identified, 39 met inclusion criteria. Manual review of references from these articles yielded 22 additional studies, for a total of 61. Disparities were identified in nearly every subspecialty within pediatric otolaryngology, with otologic conditions the most frequently studied (33 of 61). The most commonly cited disparities involved low socioeconomic status (25 of 61), inadequate insurance (23 of 61), nonwhite race (21 of 61), and barriers to accessing care (21 of 61). Only six articles found no disparities regarding the condition examined in their study.

Conclusion

Through a variety of study topics, designs, and settings, a growing body of literature documents disparities across the spectrum of pediatric otolaryngology care. The etiologies and manifestations of such disparities are myriad. This evidence suggests the need for interventions to address these disparities at various professional and institutional levels, ideally with methodological rigor to assess the effectiveness of such interventions. Laryngoscope, 2017

http://ift.tt/2iw3OJs

Comparison of pediatric adenoidectomy techniques

Objectives

Evaluate the effects of electrocautery, microdebrider, and coblation techniques on outpatient pediatric adenoidectomy costs and complications.

Study Design

Observational retrospective cohort study.

Methods

An observational cohort study was performed in a multihospital network using a standardized accounting system. Children < 18 years of age who underwent outpatient adenoidectomy were included from January 2008 to September 2015. Cases with additional procedures were excluded. The cohorts were divided into children who underwent electrocautery, microdebrider, or coblator adenoidectomy. Data regarding costs, postoperative complications, and revision surgeries were analyzed.

Results

A total of 1,065 cases of adenoidectomy were performed with electrocautery (34.9%), microdebrider (26.1%), and coblation (39.0%). There was an increased after direct cost associated with the microdebrider, $833 (standard deviation [SD] $363) and the coblator, $797 (SD $262) compared to the electrocautery, $597 (SD $361) (P < 0.0001). There was a greater overall operating room (OR) time associated with use of the microdebrider (mean 28.7, SD 11.0 minutes) compared with both the electrocautery (mean 24.7, SD 8.1 minutes) and coblator (mean 26.2, SD 9.8 minutes) (P < 0.0001). No significant difference was found with regard to complication rates. The incidence of repeat adenoidectomies was significantly greater for microdebrider (9.7%) compared to electrocautery (2.7%; P = 0.0002) and coblator (5.3%; P = 0.0336) techniques.

Conclusion

These results suggest that adenoidectomy with electrocautery is significantly less expensive than microdebrider and coblator, with no differences in complication rates or surgical times among the techniques. Microdebrider adenoidectomy was associated with a longer overall OR time and a higher rate of adenoid regrowth, requiring revision surgery.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2AUGHPs

Impact of an oral appliance on obstructive sleep apnea severity, quality of life, and biomarkers

Objective/Hypothesis

To investigate outcomes including efficacy, quality of life, and levels of inflammatory markers of a mandibular advancement device (MAD) for moderate-to-severe obstructive sleep apnea (OSA).

Study Design

Case-control study.

Methods

Patients with apnea-hypopnea index (AHI) ≥ 15/hr who only accepted MAD therapy (study group) or who refused any treatment (control group) were recruited. At baseline and at 6 months, polysomnography, Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), C-reactive protein (CRP), interleukin 1β, interleukin 6, and tumor necrosis factor α (TNF-α) were assessed in both groups.

Results

At baseline, the study group (n = 30) showed a higher percentage of rapid eye movement sleep and higher CRP levels (P < .05) than the control group (n = 10). At 6 months, the MAD significantly improved AHI and lowest oxygen saturation (P < .01), non–rapid eye movement (N)1 and N3 sleep stages (P < .05), ESS score (P < .05), FOSQ total score (P < .01), interleukin 1β (P < .05), and TNF-α (P < .01) compared with the untreated group. In the overall, moderate, and severe OSA groups, 63.3%, 75%, and 50%, respectively, achieved at least good response.

Conclusions

Use of a MAD significantly improved polysomnographic parameters, quality of life, and some inflammatory markers (CRP, IL-β, and TNF-α) in a significant proportion of patients with moderate OSA and in some patients with severe OSA. Hence, a MAD may be a viable alternative therapy in patients with moderate-to-severe OSA who refuse continuous positive airway pressure.

Level of Evidence

3b Laryngoscope, 2017

http://ift.tt/2izgVtB

Referral patterns from emergency department to otolaryngology clinic

Objectives/Hypothesis

Patients who present to the emergency department (ED) with various otolaryngologic disorders are frequently referred to an otolaryngologist for follow-up care. Our aim was to further characterize this group as it has not been well described in the literature.

Study Design

Cross-sectional retrospective study.

Methods

We reviewed the charts of patients seen during an 18-month period in an urban public hospital trauma center adult ED and referred to an otolaryngology clinic for follow-up care.

Results

Seven hundred thirty-eight patients were seen and referred; the most common diagnoses made by ED providers were peripheral vertigo (12%), otitis externa (8%), and nasal fractures (8%). Nine percent of patients were evaluated during their ED visit by an otolaryngology provider. Three hundred seventy-two (50%) patients returned for their otolaryngology clinic visit; facial trauma patients were least likely to return. The most common diagnoses made by otolaryngology providers were otitis externa (12%), peripheral vertigo (12%), and nasal fractures (7%). There was 50% concordance between patients' diagnoses made by ED and otolaryngology providers. The most common differences were otitis media versus otitis externa (10%) and acute pharyngitis versus laryngopharyngeal reflux (8%). During 37% of follow-up visits, an in-office procedure was performed, most commonly flexible fiberoptic laryngoscopy, cerumen removal, and nasal endoscopy.

Conclusions

Our analysis reports comprehensive characteristics of this referral group, identifying potential areas for improvement in patient management, resident education and efficiency. Otolaryngologists covering EDs should be familiar with this population in terms of types of cases that may affect their practices.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2AVUe9w

Laser treatment of cutaneous angiokeratomas: A systematic review

Abstract

Angiokeratomas can present therapeutic challenges, especially in cases of extensive lesions, where traditional surgical methods carry high risks of scarring and hemorrhage. Argon, pulsed dye (PDL), neodymium-doped yttrium aluminum garnet (Nd:YAG), copper vapor, potassium titanyl phosphate, carbon dioxide, and erbium-doped yttrium aluminum garnet (Er:YAG) lasers have emerged as alternative options. To review the use and efficacy of lasers in treating angiokeratomas. A PubMed search identified randomized clinical trials, cohort studies, case series, and case reports involving laser treatment of cutaneous angiokeratomas. Twenty-five studies were included. Quality ratings were assigned using the Oxford Centre for Evidence-Based Medicine scheme. Several laser modalities are effective in treating multiple variants of angiokeratomas. Vascular lasers like PDL, Nd:YAG, and argon are the most studied and of these, PDL offers the safest side effect profile. Nd:YAG may be more effective for hyperkeratotic angiokeratomas. Combination treatment with multiple laser modalities has also demonstrated some success. Lasers are a promising treatment option for angiokeratomas, but current use is limited by the lack of treatment guidelines. There are limited high quality studies comparing laser treatments to each other and to non-laser options. Additional studies are needed to establish guidelines and to optimize laser parameters.

http://ift.tt/2z1slwl

Monopolar radiofrequency treatment in Asian skin: An update

http://ift.tt/2B5s64T

Cosmeceutical effect of ethyl acetate fraction of Kombucha tea by intradermal administration in the skin of aged mice

Summary

Background/purpose

Natural ingredients have been always an interesting approach to prolong youthful appearance of skin. One of the natural compounds is Kombucha tea (KT), which has been mainly used as an energy drink in Asian countries for a long time. Previous reports indicated that it has pharmaceutical and favorable wound repairing effects. The beneficial properties of KT are thought to be mainly due to the presence of fermentation products such as flavonoids and other polyphenols with inhibition of hydrolytic and oxidative enzymes and anti-inflammatory effects. These properties prompted us to study the anti-aging potential of KT and investigate its effective fraction in aged mice,

Methods

Kombucha tea was fractionated into chloroform, butanol, and ethyl acetate, and flavonoid content was determined. Young and old mice were used as control. KT ethyl acetate fraction (KEAf), which had the highest flavonoid content, was intradermally administered to old mice.

Results

Administration of KEAf significantly increased the collagen content, NAD⁺/NADH level, and concomitantly improved skin connective tissue abnormalities in the aged skin. No sensitivity or irritation was observed.

Conclusion

This finding suggested that KEAf can be a suitable candidate as a cosmetic product to improve aging-related skin abnormalities and regeneration of aged skin.

http://ift.tt/2mJtczS

Skin care and cosmeceuticals: Attitudes and trends among trainees and educators

Summary

Introduction

Patients often seek skin care recommendations from their dermatologist. The objective of this study was to determine the degree of education dermatology residents receive on skin care and cosmeceutical products, the source of education, and the attitude of trainees and their educators toward skin care and cosmeceuticals.

Methods

A cross-sectional survey of dermatology residents and faculty via an online survey administered June 2015 and August 2015, respectively.

Results

In total, 104 dermatology residents and 50 dermatology faculty members completed the survey. Among the dermatology residents and faculty, equal distribution was represented across the country. The majority of residents and faculty (62% and 69%, respectively) report discussing skin care with up to 25% of their patients. Among resident participants, 76.5% "agree or strongly agree" that skin care and cosmeceutical education should be part of their education and the majority of residents (74.5%) report their education has been "too little or nonexistent" during residency. In contrast, the majority of the faculty (60%) reports their resident education is "just the right amount or too much" (P < .001).

Conclusions

Skin care and cosmeceutical recommendations are often discussed in dermatology visits. Dermatology residents feel that education on these products should be a part of their residency training.

http://ift.tt/2zjTfUp

Magnesium sulfate and ophthalmic artery Doppler velocimetry in patients with severe preeclampsia: a case series

In the present study, we used Doppler velocimetry in the ophthalmic artery to evaluate the hemodynamic status of the intracranial vasculature. This is the first time in the literature that indices of ophthalmi...

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Clinical Thyroidology for the Public – Highlighted Article

From Clinical Thyroidology for the Public: Overall, thyroid blood testing has steadily increased over the past few decades, corresponding with rising healthcare costs. Many thyroid tests are overused and may be inappropriate for the type of thyroid condition suspected. Read More….

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Standardised noxious stimulation-guided individual adjustment of remifentanil target-controlled infusion to prevent haemodynamic responses to laryngoscopy and surgical incision: A randomised controlled trial

BACKGROUND The surgical plethysmographic index (SPI) is one of the available indexes of the nociception–antinociception (NAN) balance. Individually adjusting the NAN balance to prevent somatic responses to noxious stimulation remains a challenge. OBJECTIVES To assess whether guiding remifentanil administration according to the SPI response to a calibrated noxious stimulus (NANCAL) can blunt the haemodynamic response to tracheal intubation and surgical incision. DESIGN Prospective randomised multicentre controlled study. SETTING Two Belgian university hospitals from January 2014 to April 2015. PATIENTS After ethic review board approval and informed consent, 48 American Society of Anesthesiologists I or II adult patients scheduled for surgery under general anaesthesia were enrolled. INTERVENTIONS Patients were randomly assigned to a SPI group, where remifentanil effect-site concentration was adjusted according to NANCAL, or a control group, where it was fixed at 4 ng ml−1. Propofol concentration was always adjusted to maintain the bispectral index close to 40. NANCAL consisted of a 100 Hz, 60 mA electrical tetanic stimulation during 30 s at the wrist before tracheal intubation and before surgical incision. MAIN OUTCOME MEASURES The primary endpoint was the efficacy of the NANCAL-guided remifentanil administration to prevent the haemodynamic response to tracheal intubation and surgical incision. The secondary aim was to compare the ability of SPI, analgesia nociception index, pupil diameter and mean arterial pressure response to NANCAL to predict the haemodynamic response to tracheal intubation and surgical incision. RESULTS Our SPI response to NANCAL-based correcting scheme for remifentanil administration was not superior to a fixed remifentanil concentration at blunting the haemodynamic response to tracheal intubation or surgical incision. Among all tested NAN balance indices, only mean arterial pressure had significant predictive ability with regard to the haemodynamic response to surgical incision. CONCLUSION Further research is needed to define the best NANCAL stimulus and the best remifentanil correcting scheme to help individualised tailoring of antinociception for each specific subpopulation of surgical patients. TRIAL REGISTRATION Clinicaltrials.gov NCT: 02884310; http://ift.tt/2B2PCiQ. Correspondence to Aline Defresne, MD, Department of Anaesthesia and Intensive Care Medicine, CHR Citadelle, Bd du 12eme de Ligne, 1, 4000 Liege, Belgium E-mail: adefresne@chu.ulg.ac.be © 2017 European Society of Anaesthesiology

http://ift.tt/2z0fN8n

End-of-treatment positron emission tomography after uniform first-line therapy of B cell posttransplant lymphoproliferative disorder identifies patients at low risk of relapse in the prospective German PTLD registry

Background Fluorine-18 fluorodeoxyglucose (18F-FDG) - positron-emission tomography (PET) is a recommended standard in the staging and response assessment of 18F-FDG-avid lymphoma. Posttransplant lymphoproliferative disorder (PTLD) can be detected by 18F-FDG-PET at diagnosis with high sensitivity and specificity. However, the role of response assessment by end of treatment (EOT)-PET has only been addressed in small case series. Methods We performed a retrospective, multi-center study of 37 patients with CD20-positive posttransplant lymphoproliferative disorder (PTLD) after solid organ transplantation (SOT) treated with uniform, up-to-date first-line protocols in the prospective German PTLD registry who had received EOT-18F-FDG-PET between 2006 and 2014. Median follow-up was 5.0 years. Any nonphysiological 18F-FDG uptake (Deauville score greater 2) was interpreted as PET-positive. Results By computed tomography (CT) final staging, 18 out of 37 patients had a complete response (CR), 18 had a partial response and 1 patient had stable disease. EOT PET was negative in 24/37 patients and positive in 13/37. The positive predictive value of EOT PET for PTLD relapse was 38% and the negative predictive value 92%. Time to progression (TTP) and progression-free-survival (PFS) were significantly longer in the PET negative group (p=0.019 and p=0.013). In the 18 patients in a partial response by CT staging, we noted highly significant differences in overall survival (p=0.001), TTP (p=0.007), and PFS (p

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Lung transplantation as a therapeutic option in acute respiratory distress syndrome

Background Lung transplantation (LTPL) is considered as a salvage therapeutic option in patients with end-stage lung disease. However, there is a lack of sufficient data on the use of LTPL in patients with acute respiratory distress syndrome (ARDS). While there are few case reports on lung transplant for ARDS, no case series exist up to date. The aim of this study was to evaluate the clinical outcomes of patients with ARDS in accordance with the LTPL status. Methods Patients who had severe ARDS (PaO2/FiO2 ratio ≤ 100 mmHg with positive end expiratory pressure ≥ 5 cmH2O) and were listed for LTPL with no underlying end-stage lung disease were included in this single-center retrospective study. Demographic and clinical data of the patients were collected and analyzed. Results Fourteen patients were listed for LTPL due to severe ARDS. All patients received mechanical ventilation, and 12 (86%) patients underwent extracorporeal membrane oxygenation. Of the nine patients who underwent LTPL, eight (89%) survived, whereas only one patient (20%) out of those who did not receive LTPL survived. The median survival time of the patients who underwent LTPL was 1996 days (interquartile range (IQR), 872–2239), compared with 49 days (IQR, 872–2239) in patients who did not undergo LTPL. The median survival time after LTPL was 64 months (IQR, 28–72). The three-year survival rate of the recipients was 78%. Conclusions LTPL may be considered as a therapeutic option in a select group of patients with severe ARDS. However, the irreversibility of the patient's lung status should be considered. Correspondence to: Seung-Il Park, M.D.: Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea, E-mail: sipark@amc.seoul.kr, Sang-Bum Hong, M.D.: Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea, E-mail:sbhong@amc.seoul.kr Seung-Il Park, M.D. and Sang-Bum Hong, M.D. equally contributed to this study. Contributions: Conception and design: SH, SP, TS; Acquisition, analysis and interpretation: YC, SL, SC, HK, YK, DK, KD, IC; Drafting the manuscript for important intellectual content: YC, SH, SP, TS. Conflicts of interest: The authors declare no conflicts of interest. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Incidence and Risk Factors of Intracranial Hemorrhage in Liver Transplant Recipients

Background Intracranial hemorrhage after liver transplantation is an infrequently reported complication but one which can have devastating consequences. Methods We performed a retrospective cross-sectional analysis of all liver transplants performed between January 2010 and June 2015 at a single high-volume institution using a prospectively maintained electronic database and query of the electronic medical record. Cases of intracranial hemorrhage were adjudicated as either spontaneous intraparenchymal (IPH) or extra-axial (EAH) hemorrhages. Patients with confirmed intracranial hemorrhage were compared with all other liver transplant recipients. Risk factors were identified by univariate analysis and logistic regression models for IPH and EAH. Results Thirty-one (5.2%) of 595 liver transplant recipients developed an intracranial hemorrhage within 12 months of transplantation, 15 IPH and 16 EAH. The majority of intracranial hemorrhages were diagnosed within 1 month of transplantation. Eight (26%) intracranial hemorrhage patients died during hospitalization. Fourteen (45%) intracranial hemorrhage patients died within 1 year of transplantation and 1-year mortality was greater than in patients without intracranial hemorrhage (11.2%, p

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Lung Isolation in the Patient With a Difficult Airway

One-lung ventilation is routinely used to facilitate exposure for thoracic surgical procedures and can be achieved via several lung isolation techniques. The optimal method for lung isolation depends on a number of factors that include (1) the indication for lung isolation, (2) anatomic features of the upper and lower airway, (3) availability of equipment and devices, and (4) the anesthesiologist's proficiency and preferences. Though double-lumen endobronchial tubes (DLTs) are most commonly utilized to achieve lung isolation, the use of endobronchial blockers offer advantages in patients with challenging airway anatomy. Anesthesiologists should be familiar with existing alternatives to the DLT for lung isolation and alternative techniques for DLT placement in the patient with a difficult airway. Newer technologies such as videolaryngoscopy with or without adjunctive fiberoptic bronchoscopy may facilitate intubation and lung isolation in difficult airway management. Accepted for publication October 3, 2017. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Randal S. Blank, MD, PhD, Department of Anesthesiology, Thoracic Anesthesia, University of Virginia Health System, PO Box 800710-0710, Charlottesville, VA 22908. Address e-mail to rsb8p@virginia.edu. © 2017 International Anesthesia Research Society

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Ultrasound-Assisted Versus Fluoroscopic-Guided Lumbar Sympathetic Ganglion Block: A Prospective and Randomized Study

BACKGROUND: Fluoroscopy (FL)-guided lumbar sympathetic ganglion block (LSGB) is widely performed to diagnose and manage various diseases associated with sympathetically maintained pain. Recently, numerous ultrasound (US)-assisted procedures in pain medicine have been attempted, showing an advantage of low radiation exposure. This randomized, prospective trial compared the procedural outcomes and complications between FL-guided and US-assisted LSGBs. METHODS: Fifty LSGBs were randomly divided into 2 groups: FL-guided (FL group) or US-assisted (US group) LSGB group. Both groups received FL-guided or US-assisted LSGB with 10 mL of 0.25% levobupivacaine. The primary end point was the total procedure time. Secondary outcomes were success rate, imaging time, onset time (based on temperature rise), dosage of radiation exposure, other procedure-related outcomes, and complications. RESULTS: Total procedure time and success rate were not statistically different between the 2 groups, whereas imaging time of the US group was longer than that of the FL group (P = .012). The onset time was faster in the US group (P = .019), and bone touching during the procedure was less frequent in the US group (P = .001). Moreover, radiation exposure was significantly lower in the US group than in the FL group (P

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Perioperative Noninvasive Blood Pressure Monitoring

The most commonly monitored variable for perioperative hemodynamic management is blood pressure. Several indirect noninvasive blood pressure monitoring techniques have been developed over the last century, including intermittent techniques such as auscultation (Riva-Rocci and Korotkoff) and oscillometry (Marey) and continuous techniques. With the introduction of automated noninvasive blood pressure devices in the 1970s, the oscillometric technique quickly became and remains the standard for automated, intermittent blood pressure measurement. It tends to estimate more extreme high and low blood pressures closer to normal than what invasive measurements indicate. The accuracy of the oscillometric maximum amplitude algorithm for estimating mean arterial pressure is affected by multiple factors, including the cuff size and shape, the shape of the arterial compliance curve and arterial pressure pulse, and pulse pressure itself. Additionally, the technique typically assumes a consistent arterial compliance and arterial pressure pulse, thus changes in arterial compliance and arrhythmias that lead to variation in the pressure pulse can affect accuracy. Volume clamping, based on the Penaz principle, and arterial tonometry provide continuous tracking of the arterial pressure pulse. The ubiquitous use of blood pressure monitoring is in contrast with the lack of evidence for optimal perioperative blood pressure targets. Accepted for publication September 27, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Kai Kuck, PhD, Department of Anesthesiology, University of Utah Medical School, 30 N 1900 E Room 3c444, Salt Lake City, UT 84132. Address e-mail to kai.kuck@hsc.utah.edu. © 2017 International Anesthesia Research Society

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How to Survive in Anaesthesia, 5th ed

No abstract available

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Two-Year Follow-Up Survey: Views of US Anesthesiologists About Health Care Costs and Future Practice Roles

Anesthesiologists' perspectives on US health care finance reform are increasingly germane to recent policy reforms. The aim of this follow-up survey was to examine how anesthesiologists' views of health care costs and future practice roles have changed since 2014. Six thousand randomly chosen active members of the American Society of Anesthesiologists were again surveyed and were also asked several new questions regarding specialties and perioperative management. Results showed an increase in self-reported understanding of the perioperative surgical home. Government, insurance companies, and pharmaceutical companies saw an increase in perceived "major responsibility" for cost reduction. Respondents vastly preferred that patient care under the perioperative surgical home be multidisciplinary. Accepted for publication September 1, 2017. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Joseph B. Rinehart, MD, Department of Anesthesiology & Perioperative Care, University of California, Irvine, 101 The City Dr S, Orange, CA 92868. Address e-mail to jrinehar@uci.edu. © 2017 International Anesthesia Research Society

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Reducing Maternal Mortality in Papua New Guinea: Contextualizing Access to Safe Surgery and Anesthesia

Papua New Guinea has one of the world's highest maternal mortality rates with approximately 215 women dying per 100,000 live births. The sustainable development goals outline key priority areas for achieving a reduction in maternal mortality including a focus on universal health coverage with safe surgery and anesthesia for all pregnant women. This narrative review addresses the issue of reducing maternal mortality in Papua New Guinea by contextualizing the need for safe obstetric surgery and anesthesia within a structure of enabling environments at key times in a woman's life. The 3 pillars of enabling environments are as follows: a stable humanitarian government; a safe, secure, and clean environment; and a strong health system. Key times, and their associated specific issues, in a woman's life include prepregnancy, antenatal, birth and the postpartum period, childhood, adolescence and young womanhood, and the postchildbearing years. Accepted for publication September 8, 2017. Funding: None. The author declares no conflicts of interest. This review was undertaken as part of work completed by Associate Professor Dennis at the University of Sydney as part of the completion of her Master of International Public Health. Reprints will not be available from the author. Address correspondence to Alicia T. Dennis, MBBS, PhD, MIPH, PGDipEcho, FANZCA, Department of Anaesthesia, The Royal Women's Hospital, The University of Melbourne, Locked Bag 300, Corner Grattan St & Flemington Rd, Parkville, Victoria 3052, Australia. Address e-mail to alicia.dennis@thewomens.org.au. © 2017 International Anesthesia Research Society

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Alkalinized Lidocaine Preloaded Endotracheal Tube Cuffs Reduce Emergence Cough After Brief Surgery: A Prospective Randomized Trial

BACKGROUND: Alkalinized lidocaine in the endotracheal tube (ETT) cuff decreases the incidence of cough and throat pain on emergence after surgery lasting more than 2 hours. However, alkalinized lidocaine needs 60–120 minutes to cross the ETT cuff membrane; therefore, its usefulness in shorter duration surgery is unknown. This prospective double-blind randomized controlled trial tested the hypothesis that alkalinized lidocaine would reduce the incidence of emergence cough after surgeries lasting 90 minutes before intubation with either 2 mL of 2% lidocaine and 8 mL of 8.4% bicarbonate (group AL) or 10 mL of normal saline (group S). Cuffs were emptied immediately before intubation. After intubation, either 2 mL of 2% lidocaine (AL) or 2 mL of saline (S) were injected into the cuff. Additional 8.4% bicarbonate (AL) or saline (S) was injected into the cuff until there was no air leak. Anesthesia was maintained using desflurane, rocuronium, and either fentanyl or sufentanil to maintain vital signs within 20% of baseline values. Opioids administered in prophylaxis of extubation cough were proscribed. A standardized "no touch" emergence technique was used. A blinded assessor noted any cough above 0.2 minimum alveolar concentration (MAC) of expired desflurane. At 0.2 MAC, once every 30 seconds, the patient was instructed to open his eyes and extubation occurred once a directed response was noted. RESULTS: A total of 213 patients were randomized and 100 patients in each group completed the experimental protocol. The incidence of extubation cough in group AL was 12%, significantly lower (1-sided P = .045) than the 22% incidence in group S. The 1-tailed risk ratio for cough in group AL was 0.55 (0–0.94, P = .045). Total amount of opioids administered (P = .194), ETT cuff preloading times (P = .259), and extubation times (P = .331) were not significantly different between groups. The average duration of surgery was 59 ± 28 minutes in group AL and 52 ± 29 minutes in group S (P = .057). CONCLUSIONS: Alkalinized lidocaine in the ETT cuff significantly decreased general anesthesia emergence cough after surgeries with an average duration of slightly

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The Science of Local Anesthesia: Basic Research, Clinical Application, and Future Directions

Local anesthetics have been used clinically for more than a century, but new insights into their mechanisms of action and their interaction with biological systems continue to surprise researchers and clinicians alike. Next to their classic action on voltage-gated sodium channels, local anesthetics interact with calcium, potassium, and hyperpolarization-gated ion channels, ligand-gated channels, and G protein–coupled receptors. They activate numerous downstream pathways in neurons, and affect the structure and function of many types of membranes. Local anesthetics must traverse several tissue barriers to reach their site of action on neuronal membranes. In particular, the perineurium is a major rate-limiting step. Allergy to local anesthetics is rare, while the variation in individual patient's response to local anesthetics is probably larger than previously assumed. Several adjuncts are available to prolong sensory block, but these typically also prolong motor block. The 2 main research avenues being followed to improve action of local anesthetics are to prolong duration of block, by slow-release formulations and on-demand release, and to develop compounds and combinations that elicit a nociception-selective blockade. Accepted for publication October 16, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Markus W. Hollmann, MD, PhD, Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. Address e-mail to m.w.hollmann@amc.uva.nl. © 2017 International Anesthesia Research Society

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Improvement of the Elevated Tryptase Criterion to Discriminate IgE- From Non–IgE-Mediated Allergic Reactions

BACKGROUND: Differentiating between immunoglobulin E (IgE)-dependent and IgE-independent hypersensitivity reactions may improve the etiologic orientation and clinical management of patients with allergic reactions in the anesthesia setting. Serum tryptase levels may be useful to discriminate the immune mechanism of allergic reactions, but the diagnostic accuracy and optimal cutpoint remain unclear. We aimed to compare the diagnostic accuracy of tryptase during reaction (TDR) alone and the TDR/basal tryptase (TDR/BT) ratio for discriminating IgE- from non–IgE-mediated allergic reactions, and to estimate the best cut point for these indicators. METHODS: We included 111 patients (45% men; aged 3–99 years) who had experienced an allergic reaction, even though the allergic reaction could be nonanaphylactic. Allergy tests were performed to classify the reaction as an IgE- or non–IgE-mediated one. The area under the curve (AUC) of the receiver operating characteristic analysis was performed to estimate the discriminative ability of TDR and TDR/BT ratio. RESULTS: An IgE-mediated reaction was diagnosed in 49.5% of patients, of whom 56% met anaphylaxis criteria. The median (quartiles) TDR for the IgE-mediated reactions was 8.0 (4.9–19.6) and 5.1 (3.5–8.1) for the non–IgE-mediated (P = .022). The median (quartiles) TDR/BT ratio was 2.7 (1.7–4.5) in IgE-mediated and 1.1 (1.0–1.6) in non–IgE-mediated reactions (P

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Anesthesia Medication Handling Needs a New Vision

No abstract available

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Effects of Increasing Airway Pressures on the Pressure of the Endotracheal Tube Cuff During Pelvic Laparoscopic Surgery

BACKGROUND: Tracheal tube cuff pressures exceeding the perfusion pressures of the tracheal mucosa have been associated with complications such as sore throat, tracheal mucosa ulcers, tracheal rupture, and subglottic stenosis. Despite appropriate inflation, many factors can increase the tracheal cuff pressure during mechanical ventilation. This prospective observational cohort study was designed to test the hypothesis that during a clinical model of decreasing respiratory compliance, the pressure within the endotracheal tube cuff will rise in direct relationship to increases in the airway pressures. METHODS: Twenty-eight adult obese patients (BMI ≥30 kg/m2) scheduled for elective laparoscopic gynecologic procedures were enrolled. All patients received general anesthesia utilizing endotracheal tubes with low-pressure high-volume cuffs. After baseline adjustment of the cuff pressure to 25 cm H2O, the airway pressures and endotracheal cuff pressures were continuously measured using pressure transducers connected to the anesthesia circuit and cuff pilot, respectively. Data on cuff and airway pressures, mechanical ventilation parameters, intraabdominal pressures, and degree of surgical table inclination were collected throughout the anesthetic procedure. General linear regression models with fixed and random effects were fit to assess the effect of increases in airway pressures on cuff pressure, after adjusting for covariates and the clustered structure of the data. RESULTS: The mean (standard deviation) age and body mass index were 42.2 (8.8) years and 37.7 (5.1) kg/m2, respectively. After tracheal intubation, the cuffs were overinflated (ie, intracuff pressures >30 cm H2O) in 89% of patients. The cuff pressures significantly changed after concomitant variations in the airway pressures from a mean (standard error) value of 29.6 (1.30) cm H2O before peritoneal insufflations, to 35.6 (0.68) cm H2O after peritoneal insufflation, and to 27.8 (0.79) cm H2O after peritoneal deflation (P

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Epidural Space Identification With Loss of Resistance Technique for Epidural Analgesia During Labor: A Randomized Controlled Study Using Air or Saline—New Arguments for an Old Controversy

BACKGROUND: The best technique to identify the epidural space for labor analgesia is still unclear despite the publication of various randomized controlled studies and meta-analyses. Our aim was to assess the superiority of the saline loss of resistance (SLOR) technique over the air loss of resistance (ALOR) technique with respect to the quality of the block. METHODS: Consenting parturients admitted to our obstetric suite for spontaneous or induced labor were randomized to receive epidural analgesia using either the ALOR or SLOR technique. Our primary outcome was to compare the impact of the SLOR and ALOR technique on pain score improvement measured 30 minutes after administration of epidural block. Our secondary outcomes included the density of motor blockade and analgesic efficacy measured at 30 minutes. Primary and secondary outcomes were compared using the Student t test and Mann-Whitney U test. Statistical significance was set at P

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Case 14431: A Case of Dyspnea and Weakness

ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR CASE 14431 A CASE OF DYSPNEA AND WEAKNESS Medical Department First admission. A German-American salesman sixty years old entered January 24…

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Case 14432: How Long is an Apparently Cured Streptococcus Sepsis Still Dangerous?

CASE 14432 HOW LONG IS AN APPARENTLY CURED STREPTOCOCCUS SEPSIS STILL DANGEROUS? Surgical Department A married New England woman thirty-three years old entered through the Emergency Ward July 28 complaining of pain in the right upper quadrant with chills and fever. Two months before admission she…

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Case 14421: General Glandular Enlargement Lasting Thirty Years or More

ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES CASE 14421 GENERAL GLANDULAR ENLARGEMENT LASTING THIRTY YEARS OR MORE Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR Medical Department An American stationary fireman forty-three years old entered…

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Case 14422: Possibilities in the Treatment of a Case of Advanced Pulmonary Tuberculosis

Dr. Cabot : I don't know. I don't think that can be due to this disease. A Student : How do you account for glands decreasing in size? Dr. Cabot : X-ray treatment accounts for it. Perhaps also he had some terminal infection. Any terminal infection that we can name tends to make the glands and…

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Case 14281: Jaundice and Ascites in a Boy of Eighteen

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Case 14282: Fever, Weakness and Pain in the Right Axilla

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Case 14272: Cause of Diarrhea?

fed the patient passed through the ulcer of the ileum into this abscess cavity in the abdominal wall, and from there out through the umbilicus. Except for this abscess cavity it was a typical dry type of tuberculous peritonitis with widespread adhesions and the surfaces studded with tubercles. The…

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Case 14271: Ascites at Seventeen Months

ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR CASE 14271 ASCITES AT SEVENTEEN MONTHS Medical Department A girl baby seventeen months old entered March 20. The complaints were abdominal distention…

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Case 14192: A Persistent Bullous Eruption

ing is said about emaciation. She does not seem to have had cough any length of time. There is no reason to suspect tuberculosis except for the râles. They are perfectly proper to hear over a pneumonia. Miss Painter : She is recorded as well nourished. Dr. Cabot : Should we consider a pulmonary…

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Case 14191: Coma

ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES CASE 14191 COMA Medical Department An unmarried Irish-American woman sixtyseven years old entered the hospital March 17 in coma. The history is limited to a few facts obtained from a brother who did not live with…

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Case 14162: Epigastric Pain, Conflicting Symptoms, Subsequently Elucidated

that without a hypertrophied heart he could have died from his kidneys, without more definite evidence of an acute nephritis. CASE 14162 EPIGASTRIC PAIN, CONFLICTING SYMPTOMS, SUBSEQUENTLY ELUCIDATED Medical Department A married Canadian woman fifty-eight years old came to the Out-Patient…

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Case 14161: Dyspnea without Obvious Cause

ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR CASE 14161 DYSPNEA WITHOUT OBVIOUS CAUSE Medical Department A Canadian teamster fifty-two years old entered February 2 complaining of difficulty in…

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Case 14152: Early Symptoms of Neuritis; Subsequent Involvement of Spinal Cord. Anacidity. Blood Not Consistent with Primary Anemia. Improvement Both before and after Taking Liver

· tive blood culture means something, negative means nothing. A Physician : Does not a fixation of gravity mean chronic nephritis, or can it occur from kidney infarcts? Dr. Cabot : I think I can remember here cases where we have been shown at post-mortem extensive infarctions or emboli Avithout…

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Case 14151: Hematuria, Dyspnea and Acute Arthritis

ANTE-MORTEM ANDPOST-MORTEMRECORDS AS USEDIN WEEKLY CLINICO-PATHOLOGICALEXERCISES Edited by R. C. Cabot, M.D. F.M.PAINTER,A.B.ASSISTANTEDITOR CASE 14151 HEMATURIA, DYSPNEA AND ACUTE ARTHRITIS Medical Department A married colored Avoman twenty-four years old was sent from the Out-Patient Department…

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Case 14092: An Obscure Abdominal Situation

' ' Pneumocooci predominant. ' ' That means nothing. That temperature is very low. One Avonders if he closed his mouth. I should not take it too seriously. "Pressure signs developed in the left back." That is the lingo of 1910. It means that in the left back there was a patch of dullness and…

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Case 14091: Recurrent Multiple Arthritis

ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR CASE 14091 RECURRENT MULTIPLE ARTHRITIS Medical Department First admission. An American schoolboy fourteen years old entered May 16 complaining of…

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Case 14011: Fever and Cheyne-Stokes Breathing at Seventy-Eight

ANTE-MORTEM AND POST-MORTEM RECORDSAS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR CASE 14011 FEVER AND CHEYNE-STOKES BREATHING AT SEVENTY-EIGHT Medical Department A Nova Scotian seventy-eight years old, formerly a teamster, was…

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Case 14012: Operation with Confusing Findings

Arteriosclerosis. Post-operative enucleation of the left eye for glaucoma. Bronchopneumonia. DR. RICHARD C. CABOT's DIAGNOSIS Pneumococcus meningitis. Hypertrophy of heart. Pneumonia. ANATOMIC DIAGNOSES 1. Primary fatal lesion. Pneumococcus meningitis. 2. Secondary or terminal lesions. Enucleation…

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Case 13542: Was the Patient Misinformed?

Dentón's is by far the most detailed and careful work that has been done, I think, on the pathology of pellagra. He Avorked on very fresh material. The changes in the cord have been described by various people, but there is nothing very characteristic about them. Dr. Cabot : Are esophageal lesions…

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Case 13541: A Case with Anasarca, Cyanosis, Symmetrical Dermatitis, Diarrhea, Mass in the Abdomen and Psychosis

CaseRecords of the MassachusettsGeneralHospital ANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES Edited by R. C. Cabot, M.D. F. M. PAINTER, A.B. ASSISTANT EDITOR CASE 13541 A CASE WITH ANASARCA, CYANOSIS, SYMMETRICAL DERMATITIS, DIARRHEA, MASS IN THE ABDOMEN AND…

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Impaired permeability and antimicrobial barriers in type 2 diabetes skin are linked to increased serum levels of advanced glycation end-product

Abstract

Background

The incidence of type 2 diabetes mellitus (DM) has been increasing rapidly, and the disease has become a serious sociomedical problem. Many skin problems, such as xerosis, pruritus, skin infections, and delayed wound healing, that might be related to chronic impairment of skin barrier function decrease the quality of life in DM patients. However, the status of the permeability and antimicrobial barrier of the skin in DM remains unknown.

Objective

This study aimed to elucidate skin barrier impairment in type 2 DM patients and its patho-mechanisms using classic animal models of type 2 DM.

Methods

Functional studies of the skin barrier and an analysis of stratum corneum (SC) lipids were compared between type 2 DM patients and age- and sex-matched non-diabetes controls. Also, functional studies on the skin barrier, epidermal lipid analyses, and electron microscopy and bio-molecular studies were performed using type 2 DM animal models, db/db and ob/ob mice.

Results

Type 2 DM patients presented with epidermal barrier impairments, including SC hydration, which was influenced by blood glucose control (HbA1c level). In the lipid analysis of SC, ceramides, fatty acids, and cholesterol were significantly decreased in type 2 DM patients compared with controls. Type 2 DM murine models presented with severe hyperglycemia, impairment of skin barrier homeostasis, decreases in epidermal proliferation and epidermal lipid synthesis, decreases in lamellar body (LB) and epidermal anti-microbial peptides (AMPs), an increase in receptors for advanced glycation end-product (AGE) in the epidermis, and an increase in serum AGE.

Conclusion

Impairment of the skin barrier was observed in type 2 DM, which results in part from a decrease in epidermal proliferation. Serum AGE and its epidermal receptors were increased in type 2 diabetic mice which display impaired skin barrier parameters such as epidermal lipid synthesis, LB production, epidermal AMP, and SC lipids.

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