Cutaneous non-tuberculous mycobacteria in Western Sydney, Australia. Population study 1996–2013

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Adding sufentanil to ropivacaine in continuous thoracic paravertebral block fails to improve analgesia after video-assisted thoracic surgery: A randomised controlled trial

BACKGROUND The benefit of adding opioid to a local anaesthetic for continuous thoracic paravertebral analgesia after video-assisted thoracic surgery (VATS) is unclear. OBJECTIVES To analyse the analgesic efficacy of ropivacaine and sufentanil in combination compared with ropivacaine alone after VATS. DESIGN A randomised, double-blinded, single-centre clinical trial. SETTING A tertiary university hospital between March 2010 and April 2014. PATIENTS Ninety patients were recruited, two were not included leaving 88 randomised into two groups. Eighteen patients were excluded from analysis and 70 completed the study. INTERVENTION To receive thoracic paravertebral analgesia with either 2 mg ml−1 ropivacaine and 0.25 μg ml−1 sufentanil (ropivacaine + sufentanil group) or 2 mg ml−1 ropivacaine alone (ropivacaine group) for 48 h postoperatively. Infusion rate was set at 0.15 ml kg−1 h−1 in both groups. MAIN OUTCOME MEASURES The primary endpoint was the mean total amount of self-administered morphine by the patients in each group at 48 h postoperatively. RESULTS The mean ± SD total amount of self-administered morphine was not significantly different between groups (53.1 ± 27.2 mg in the ropivacaine + sufentanil group vs. 58.8 ± 34.3 mg in the ropivacaine group; P = 0.72). No significant differences were found between the two groups in either in pain scores at rest or during movement, in opioid-related adverse reactions, in patient satisfaction or length of hospital stay. CONCLUSION Adding 0.25 μg ml−1 sufentanil to 2 mg ml−1 ropivacaine in continuous thoracic paravertebral analgesia for VATS did not reduce morphine consumption or pain scores when compared with ropivacaine alone. We cannot recommend its use for routine clinical practice. Further studies analysing different concentrations and infusion rates of sufentanil are needed before a lack of efficacy can be confirmed. TRIAL REGISTRATION Clinical trial registrations: EudraCT: 2009-014832-38. ClinicalTrials.gov: NCT 01082744. Correspondence to Christian Bauer, MD, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service d'Anesthésie-Réanimation, 103 grande rue de la Croix-Rousse, 69004 Lyon, France Tel: +33 426732660; e-mail: christian.bauer@chu-lyon.fr 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/2ylyqmW). © 2018 European Society of Anaesthesiology

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Comparison of double intravenous vasopressor automated system using nexfin versus manual vasopressor bolus administration for maintenance of haemodynamic stability during spinal anaesthesia for caesarean delivery: A randomised double-blind controlled trial

BACKGROUND Hypotension is a common side effect of spinal anaesthesia during caesarean delivery and is associated with maternal and foetal adverse effects. We developed an updated double intravenous vasopressor automated (DIVA) system that administers phenylephrine or ephedrine based on continuous noninvasive haemodynamic monitoring using the Nexfin device. OBJECTIVE The aim of our present study is to compare the performance and reliability of the DIVA system against Manual Vasopressor Bolus administration. DESIGN A randomised, double-blind controlled trial. SETTING Single-centre, KK Women's and Children's Hospital, Singapore. PATIENTS Two hundred and thirty-six healthy women undergoing elective caesarean delivery under spinal anaesthesia. MAIN OUTCOME MEASURES The primary outcome was the incidence of maternal hypotension. The secondary outcome measures were reactive hypertension, total vasopressor requirement and maternal and neonatal outcomes. RESULTS The DIVA group had a significantly lower incidence of maternal hypotension, with 39.3% (46 of 117) patients having any SBP reading less than 80% of baseline compared with 57.5% (65 of 113) in the manual vasopressor bolus group (P = 0.008). The DIVA group also had fewer hypotensive episodes than the manual vasopressor bolus group (4.67 versus 7.77%; P 

http://ift.tt/2FkWdGO

The association between multiple pilomatrixomas and APC gene mutations

http://ift.tt/2DKuLoL

Synthetic DMARDs May Blunt Pneumococcal Vaccine Response in Systemic Sclerosis

Pneumococcal vaccination yields a satisfactory antibody response in patients with systemic sclerosis (SSc), but synthetic disease-modifying antirheumatic drugs (DMARDs) might reduce the vaccine response in these individuals, according to a report from Sweden.
Reuters Health Information

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Low-Dose Trifluoperazine May Help Ease Morgellons Symptoms

Reuters Health Information

http://ift.tt/2DzuyEx

Azelaic Acid 15% Gel for the Reduction of Rosacea Lesions

A recent trial assessed the effects of azelaic acid 15% gel on inflammatory lesions of papulopustular rosacea in a real-world setting, with promising results.
Skin Therapy Letter

http://ift.tt/2Do8klK

Antibiotics, Antidepressants Dominate New FDA Watch List

Presence on list does not mean a drug has been linked to a risk, only that new safety information is available or potential risk has been identified and further review will be or has been completed.
Medscape Medical News

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Correction to: Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy: iMAP—an international interpretation of the MAP (Milk Allergy in Primary Care) guideline

In the original version of this article [1], published on 23 August 2017, an incorrect version of Additional file 4 has been used. The corrected version of Additional file 4 is given in this correction.

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Lichenoide Arzneimittelreaktionen

Zusammenfassung

Lichenoide Arzneimittelreaktionen sind im Vergleich zu morbilliformen Arzneimittelexanthemen und durch Medikamente ausgelöste Urtikaria selten und mit einzelnen Arzneimitteln bzw. Arzneimittelgruppen wie Goldpräparaten, Antimalariamedikamenten, β‑Blockern und ACE-Hemmern verbunden. Aktuelle Bedeutung hat ihre Verursachung durch Biologika bzw. Medikamente zur „immune checkpoint inhibition" wie TNF (Tumor-Nekrose-Faktor)-α-Antagonisten und Anti-PD-1(„anti-programme cell death protein 1")-Antikörper erlangt. Meistens manifestieren sie sich in Form eines Lichen planus mit bevorzugter Lokalisation in UV-Licht-abhängigen Hautatrealen, aber auch Schleimhautbeteiligungen bis hin zu bullösen Formen können auftreten.

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Terbinafine-induced liver injury may be asymptomatic: need for regular monitoring: reply from the authors

http://ift.tt/2DH8mcE

Opinion: Making Inactivated and Subunit-Based Vaccines Work

Viral Immunology , Vol. 0, No. 0.


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Development and Validation of the Cholinergic Urticaria Quality of Life Questionnaire: CholU-QoL

Abstract

Background

Cholinergic urticaria (CholU), a common form of chronic inducible urticaria, is characterized by itchy wheals that occur in response to physical exercise or passive warming. CholU patients frequently exhibit a high burden of disease. As of yet, no specific instrument is available to assess their disease-related quality of life (QoL) impairment.

Objective

The aim of this study was to develop and validate the first disease specific QoL instrument for CholU patients, the Cholinergic Urticaria Quality of Life Questionnaire (CholU-QoL).

Methods

Using a combined approach of literature search, semi-structured patient interviews and expert opinion we developed 96 potential CholU-QoL items. Subsequent item selection was performed by means of impact analysis complemented by an expert review for face validity. The resulting final CholU-QoL was then tested for levels of validity, reliability and influence factors in 88 CholU patients. In parallel, an US American-Canadian English version of the CholU-QoL was developed.

Results

The final 28-item CholU-QoL was found to have a 5-domain structure ('symptoms', 'functional life', 'social interaction', 'therapy', 'emotions') with excellent internal consistency. The CholU-QoL also showed a valid total score, and good levels of convergent validity, known-groups validity, as well as test-retest reliability. Multiple regression analysis found no significant drivers of the CholU-QoL total score.

Conclusions & Clinical Relevance

The CholU-QoL is the first disease specific QoL instrument for CholU and also the first specific QoL measure in the field of chronic inducible urticarias. It may serve as a valuable tool for clinical trials and improve routine patient management.

This article is protected by copyright. All rights reserved.

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Prevalence of High-Risk Human Papillomavirus in Tonsil Tissue in Healthy Adults

This retrospective, cross-sectional study examines the prevalence of oropharyngeal human papillomavirus and the spatial relationship between the virus and crypt biofilm in tonsil tissue of otherwise healthy adults.

http://ift.tt/2GjfEB4

Clinical reactivity of celery cultivars in allergic patients – Role of Api g 1

Abstract

Background

Celery (Apium graveolens L.) is a vegetable consumed worldwide. Celery stalks and celeriac roots are often ingredients in convenient food products like spice blends and soups.

Objective

In this study, we examined the allergenicity of distinct celeriac cultivars.

Methods

Sixteen celery allergic patients were identified using a double-blind, placebo-controlled food challenge (DBPCFC). Ten different celeriac cultivars were used for skin prick testing in the patients. Two cultivars were further applied for oral food challenges, their protein composition were analysed by immunoblotting, and contents of major allergen Api g 1 were quantified.

Results

From the 10 investigated celeriac cultivars, two cultivars elicited significantly different skin reactivity ('Anita': 5.0 [2.0 – 12.0] mm vs. 'Prinz': 7.0 [3.0 – 9.5] mm; p = 0.047). Moreover, 'Anita' induced fewer symptoms after a controlled oral celeriac challenge in 14 patient (p < 0.001). The protein profiles on 2DE protein gels showed distinct protein patterns and higher protein amounts of Api g 1 in 'Prinz' than in 'Anita'.

Conclusions & Clinical Relevance

Taken together, the data from this study suggest that cultivar Anita is better tolerated in celery allergic patients than 'Prinz'. Differences in the protein expression profile between the cultivars, particularly the different content of Api g 1, could cause the different allergenicity.

This article is protected by copyright. All rights reserved.

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Otolaryngologic Manifestations of Klippel-Feil Syndrome in Children

This review examines a series of children with Klippel-Feil syndrome to define the otolaryngologic diagnoses made and procedures performed in this challenging patient population.

http://ift.tt/2rKjY9l

Heart Failure and Hearing Loss Among Older Adults in the United States

This secondary analysis of the National Health and Nutrition Examination Survey examines the prevalence and correlates of hearing loss among older adults with and without heart failure in the United States.

http://ift.tt/2GinGu2

Persistent isoflurane-induced hypotension causes hippocampal neuronal damage in a rat model of chronic cerebral hypoperfusion

Abstract

Background

Postoperative cognitive dysfunction (POCD) is likely to occur in elderly people, who often suffer from cerebral hypoperfusion and white matter lesions even in the absence of cerebral infarctions.

Methods

Thirty-two adult male rats were randomly assigned to one of four groups: the cerebral normoperfusion + normotension group (n = 8), cerebral normoperfusion + hypotension group (n = 8), chronic cerebral hypoperfusion (CCH) + normotension group (n = 8), and CCH + hypotension group (n = 8). A rat model of CCH was developed via the permanent ligation of the bilateral common carotid arteries, but ligation was avoided in the cerebral normoperfusion groups. Two weeks later, the rats were intubated and mechanically ventilated under isoflurane anesthesia, and their mean arterial blood pressure was maintained over 80 mmHg (normotension) or below 60 mmHg (hypotension) for 2 h. After preparing brain slices, histological cresyl violet staining, ionized calcium binding adaptor molecule 1, a marker of microglial activation, or β amyloid precursor protein, a marker of axonal damage, were performed.

Results and conclusion

CCH per se caused microglial activation and axonal damage, which was not accentuated by hypotension. CCH alone did not cause neuronal damage, but CCH combined with hypotension caused significant neuronal damage in the hippocampal CA1 region. These results suggest that persistent hypotension during general anesthesia might cause neuronal damage in patients with CCH, such as elderly people, and contribute to prevention against POCD.

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The effect of in situ simulation training on the performance of tasks related to patient safety during sedation

Abstract

In many countries, procedural sedation outside of the operating room is performed by pediatricians. We examined if in situ sedation simulation training (SST) of pediatricians improves the performance of tasks related to patient safety during sedation in the Emergency Department (ED). We performed a single-center, quasi-experimental, study evaluating the performance of sedation, before-and-after SST. Sixteen pediatricians were evaluated during sedation as part of their usual practice, using the previously validated Sedation-Performance-Score (SPS). This tool evaluates physician behaviors during sedation that are conducive to safe patient outcomes. Following the sedation, providers completed SST, followed by a structured debriefing. They were then re-evaluated with the SPS during a subsequent patient sedation in the ED. Using multivariate regression, odds ratios were calculated for each SPS component, and were compared before and after the SST. Thirty-two sedations were performed, 16 before and 16 after SST. SPS scores improved from a median of 4 (IQR 2–5) to 6 (IQR 4–7) following SST (p < 0.0009, median difference 2, 95% CI 1–3). SST was associated with improved performance in four SPS components. The findings of this pilot study suggest that sedation simulation training of pediatricians improves several tasks related to patient safety during sedation.

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Case 3-2018: A 5-Month-Old Boy with Hypoglycemia

Presentation of Case. Dr. Micaela R. Atkins (Pediatrics): A 5-month-old boy was admitted to the pediatric intensive care unit (ICU) of this hospital for evaluation of suspected hypoglycemia. The patient was born at another hospital after 40 weeks 4 days of gestation. His mother had had a positive…

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The development of gene therapy for Niemann-Pick Type C disease

Hughes, Michael; (2017) The development of gene therapy for Niemann-Pick Type C disease. Doctoral thesis (Ph.D), UCL (University College London).

http://ift.tt/2najrYA

Tongues on fire: on the origins and transmission of a system of tongue diagnosis

Holroyde-Downing, Nancy; (2017) Tongues on fire: on the origins and transmission of a system of tongue diagnosis. Doctoral thesis (Ph.D), UCL (University College London). Green open access

http://ift.tt/2DCyCVw

Enacting Virtue

Hampson, Margaret Róisín; (2017) Enacting Virtue. Doctoral thesis (Ph.D), UCL (University College London). Green open access

http://ift.tt/2ndYewG

Radio Frequency Ablation and Pulsed Radiofrequency for Treating Peripheral Neuralgias

Abstract

Purpose of Review

Peripheral nerve pain is common among patients with typical management including the use of pain medications, neuropathic agents, steroid injections, and nerve blocks. Additionally, the use of pulsed radiofrequency (PRF) and radiofrequency ablation (RFA) can be used in the management of chronic peripheral nerve pain. Previous studies investigating the effectiveness of RFA and PRF, typically case reports, have demonstrated that peripheral nerve RFA and PRF have the potential to provide relief of chronic pain for long duration. Our study aimed at testing efficacy of RFA/PRF for treating peripheral neuralgia. This was a retrospective review. We identified 16 patients who received 17 RFAs/PRFs. Outcomes of interest collected included pain scores before and after procedures, percent improvement in pain after each procedure, and duration of improvement until the time of data collection. In addition, demographic data including age, sex, and nerves involved were collected.

Recent Findings

Eleven patients (12 RFAs/PRFs) (80%) reported improvement after their procedure. Pain scores improved significantly from 6.3 ± 2.3 before each procedure to 3.6 ± 2.7 after each procedure (p = 0.003). Eleven patients (12 RFAs/PRFs) reported an average improvement of 60.8% ± 35% after their procedure with an average duration of improvement of 128.8 ± 106.8 days.

Summary

RFA and PRF can be used to treat chronic peripheral pain after conservative methods fail to do so. Large clinical trials are needed to confirm our finding.

http://ift.tt/2rEHaFK

Food Pyramid for Kids: Nutrition 101

 

You may know your child eats relatively well, but is she getting enough fruits? Should you be offering more vegetables? We parents fuss a lot over what we're feeding our kids. But did you know they have an internal barometer of sorts? Kids do a pretty decent job of getting the calories and nutrients they need. Here's how you help them along.

The post Food Pyramid for Kids: Nutrition 101 appeared first on ChildrensMD.

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Comparative study of Helicobacter pylori eradication rates of concomitant therapy vs modified quadruple therapy comprising proton-pump inhibitor, bismuth, amoxicillin, and metronidazole in Korea

Abstract

Background

The standard triple Helicobacter pylori regimen now shows unacceptably low treatment success in Korea. Administration of the concomitant therapy for 10 days, which has a high cure rate, is recommended as an alternative first-line treatment in areas of high clarithromycin resistance including Korea. Recently, modified bismuth-containing quadruple therapy with amoxicillin (PAM-B therapy) showed excellent results, regardless of dual clarithromycin and metronidazole resistance. This study compared the concomitant therapy with PAM-B therapy as a first-line treatment for H. pylori infection.

Method

Subjects infected with H. pylori and naïve to treatment were performed a head-to-head comparison between 10-day concomitant therapy [rabeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg twice daily] and 14-day PAM-B therapy [rabeprazole 20 mg, amoxicillin 1 g, metronidazole 750 mg, and tripotassium dicitrato bismuthate 600 mg (elemental bismuth 240 mg) twice daily]. Six weeks after treatment, H. pylori eradication was assessed.

Results

Two hundred and seventy subjects were randomized. Both regimens achieved high cure rates: 83.0% (112/135) and 88.1% (119/135) by the intention-to-treat analysis and 95.5% (106/111) and 96.6% (114/118) by the per-protocol analysis, respectively. The intention-to-treat and per-protocol analyses revealed no statistically significant difference in the eradication rate (P = .299 and P = .743, respectively). Rates of adverse events were similar between groups (25.2% vs 23.0%, P -value: .776) Adverse events, which resulted in poor compliance, occurred in six patients of each group, but there were no serious complications.

Conclusions

PAM-B therapy is as effective as concomitant therapy for eradicating H. pylori with comparative safety. PAM-B therapy is regarded as a promising alternative to standard triple therapy for a first-line eradication in Korea.

http://ift.tt/2DI4jfg

Cisplatin Plus Radiotherapy vs Durvalumab Plus Radiotherapy Followed by Durvalumab vs Durvalumab Plus Radiotherapy Followed by Tremelimumab and Durvalumab in Intermediate Risk HPV-Positive Oropharyngeal SCC

Condition:   Oropharyngeal Squamous Cell Carcinoma
Interventions:   Radiation: Radiation;   Drug: Cisplatin;   Drug: Durvalumab;   Drug: Tremelimumab
Sponsors:   Canadian Cancer Trials Group;   AstraZeneca
Not yet recruiting

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Filaggrin gene mutations may influence the persistence of food allergies in Japanese primary school children

Abstract

Mutations in FLG are the underlying cause of ichthyosis vulgaris and are an important predisposing factor for atopic dermatitis (AD).¹ In 2011, FLG mutations were reported to increase the risk of peanut allergy², and they have been proven to increase the risk of other food sensitizations and allergies.^3,4 In this study, we comprehensively screened 411 children in Japan for 10 Japanese-population-specific FLG mutations and suggested that FLG mutations influence the persistence of food allergies (FAs).

This article is protected by copyright. All rights reserved.

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Neurochemistry of the Hepatic Encephalopathy

Hadjihambi, Anna; (2017) Neurochemistry of the Hepatic Encephalopathy. Doctoral thesis (Ph.D), UCL (University College London). Green open access

http://ift.tt/2DBLjjk

Confocal microscopy in adult women with acne

Abstract

Background

Acne is an inflammatory disease of the pilosebaceous follicle, affecting 41–54% of adult women, with a particular form that involves the mandible.

Methods

We characterized infundibulum morphology in two groups of adult women using reflectance confocal microscopy. First, we investigated acne visually "healthy zones" on the forehead in 15 adult women with diffuse acne and compared with acne-free controls. We then compared healthy forehead and affected mandibular zone in 15 acne patients with mandibular involvement. Exposed results had a P < 0.05.

Results

Seven hundred and ninety-one follicles were observed on apparently healthy skin of 15 adult women with acne, with a larger diameter, thicker (68%), and hyper keratinized (65%) follicle border, and more keratin plugs (44%) than in controls. In the second group of 15 adult women with mandibular acne, we compared 569 follicles in the mandibular zone and 475 on forehead. In the mandibular area, follicles were significantly larger, thicker (76%), more hyper keratinized (72%), with more keratin plugs (47%) and increased inflammation (23%) compared with the forehead area. In the mandibular area, 0.2% of follicles showed isolated inflammation without hyper keratinization, and 15.3% had both thickened borders with an onion-like appearance and keratin plugs associated with inflammation.

Conclusions

Hyper keratinization was higher in healthy skin of adult women with acne compared with controls, confirming that microcomedo is crucial in the development of acne lesions. We also demonstrate that the repartition of comedones and microcomedones is inhomogeneous with a great number in the mandibular area where acne lesions are located.

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Prevalence and predictors of depressive symptoms among attendees of a tertiary care dermatology clinic in Muscat, Oman

Abstract

Background

Various studies have suggested that depression is more prevalent among patients with skin disorders than in the general population. Most of the studies addressing this subject involve Euro-American populations.

Objectives

The present study aimed to estimate the prevalence of depressive symptoms among patients with dermatological disorders and, then, to decipher the clinical–demographic factors associated with depressive symptoms.

Methods

A cross-sectional analytical study was conducted among a random sample of patients attending a dermatology clinic in Muscat. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms. A logistic regression model was used to find the adjusted and unadjusted odds ratios (ORs).

Results

A total of 260 patients participated in this study, with a response rate of 81%. The prevalence of depression symptoms was 24%. According to regression analysis, family history of depression, comorbid medical disorders, and treatment with topicals or isotretinoin were significant predictors of depression (OR = 9.41, 95% confidence interval [CI]: 2.27–39.05, P = 0.002; OR = 2.0, 95% CI: 1.2–3.21, P = 0.05; OR = 2.28, 95% CI: 1.09–4.76, P = 0.028; and OR = 2.78; 95% CI: 1.08–7.19, P = 0.035, respectively).

Conclusion

This study indicates that depressive symptoms are common among patients with dermatological disorders in Oman, particularly in those with a family history of depression and medical comorbidities, and those who use a specific dermatological medication. Screening for depression in patients attending dermatology clinics is essential in order to detect and promptly treat patients suffering from depression.

http://ift.tt/2Ebl3JT

Monocle tumor as tonsillar squamous cell carcinoma metastasis: resolution after chemotherapy treatment

http://ift.tt/2DzJ8ZJ

Long-term pediatric skin eruption-related hospitalizations in offspring conceived via fertility treatment

Abstract

Background

Although concerns have been raised regarding the long-term health risks of offspring conceived following fertility treatments, limited information is available regarding their health status beyond the neonatal period. We aimed to evaluate the risk of long-term eruptive dermatological morbidity among children born following fertility treatments as compared to those conceived spontaneously.

Methods

A population-based cohort study was conducted, including all singleton deliveries occurring between the years 1991 and 2014 at a single tertiary medical center. Fetuses with congenital malformations and multiple gestations were excluded. Children delivered following fertility treatment pregnancies and spontaneous pregnancies were compared. Hospitalizations of the offspring up to the age of 18 years involving cutaneous eruptions were evaluated. A Kaplan–Meier survival curve was used to compare cumulative morbidity incidence and a Cox regression model to control for confounders.

Results

During the study period, 242,187 singleton deliveries met the inclusion criteria, 1.8% of which were following fertility treatments (n = 4324). Eruptive dermatological morbidity of the offspring up to the age of 18 years was significantly more common in the fertility treatment group (1.5%) as compared to spontaneous pregnancies (1.1%; P = 0.023). The Kaplan–Meier survival curve demonstrated a significantly higher cumulative incidence of eruptive dermatological morbidity following fertility treatments (log-rank P = 0.007). Using the Cox regression model, while controlling for multiple confounders, fertility treatment was noted as an independent risk factor for long-term pediatric eruptive dermatological morbidity (adjusted HR = 1.43, CI 1.12–1.83, P = 0.004).

Conclusion

Singletons conceived via fertility treatments appear to be at an increased risk for long-term eruptive dermatological morbidity.

http://ift.tt/2E6ZyK3

A Brodie’s abscess with soft tissue collection—complicating an already difficult diagnosis

Abstract

A healthy 14-year-old boy with a 3-month history of thigh pain and swelling is referred to a specialist centre with an uncertain diagnosis. After extensive tests and imaging a Brodie's abscess is diagnosed. The abscess is complicated by a fistula (cloaca) through the cortical bone of the femur, resulting in a large complex soft tissue collection. This is a presentation, we are unaware has been documented in any literature. After specialist multi-team combined management (Paediatric Trauma and Orthopaedic and Paediatric Infectious Diseases), the patient undergoes two surgical procedures, and extensive antibiotic cover. The patient makes a good recovery with no long lasting sequelae to date.

http://ift.tt/2rE0eE4

Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report

Abstract

A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.

http://ift.tt/2GeNNSm

Spontaneous closure of multiple enterocutaneous fistula due to abdominal tuberculosis using negative pressure wound therapy: a case report

Abstract

Enterocutaneous fistula (ECF) is one of the most challenging abdominal complications, for surgeons and other healthcare members, which involves significant morbidity and potentially mortality. Despite advancements in both operative and non-operative therapy, fistula-related complications are still unavoidable. Negative pressure wound therapy (NPWT) had been used years to treat chronic wound, to decrease tissue edema, improve circulation, promote healthy granulation tissue and inhibit bacterial growth. We report a 29-year-old male with complicated ECF due to abdominal tuberculosis, that was healed after treated using NPWT. This was the first ECF patient in our hospital treated using NPWT.

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Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty: A Pharmacokinetic Study to Determine Safety Following Fixed-Dose Administration

Background and Objectives The primary aim of this study was to examine the pharmacokinetics of ropivacaine in patients undergoing elective total knee arthroplasty with local infiltration analgesia as the primary analgesic method. We also sought to determine the incidence of biochemical toxicity through measurement of plasma ropivacaine concentrations over the first 24 hours postoperatively. Methods This was a prospective, observational study of 15 patients undergoing elective total knee arthroplasty. Local infiltration analgesia was administered by standard technique with 300 mg ropivacaine and epinephrine 5 μg/mL. Total ropivacaine concentrations were taken at specified time intervals in the 24 hours after tourniquet release and analyzed by liquid chromatography–mass spectrometry. Results Fifteen patients were enrolled into the study. The median peak ropivacaine concentration was 0.57 μg/mL, with a range of 0.32 to 0.88 μg/mL, and occurred between 6 and 24 hours. Age (P = 0.04), weight (P = 0.04), creatinine (P = 0.02), and female sex (P = 0.03) were important predictors of peak concentration. Age (P = 0.02), female sex (P = 0.01), and baseline α1 acid glycoprotein concentrations (P = 0.03) were important predictors for the area under the curve from a ropivacaine concentration versus time plot. Conclusions The peak total ropivacaine concentration was below quoted toxic concentrations (2.2 μg/mL) in all patients. This peak occurred later than has previously been described in those undergoing neuraxial or peripheral nerve block, occurring between 6 and 24 hours. The influence of age, weight, and renal function on systemic ropivacaine concentration should be considered when planning local infiltration analgesia. Female sex is a factor that has not previously been associated with peak ropivacaine concentrations. Accepted for publication August 28, 2017. Address correspondence to: Reuben J. Miller, MBChB, Department of Anaesthesia and Pain Medicine, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand (e-mail: reuben.j.miller@gmail.com). The authors declare no conflict of interest. This research was funded in part by the Counties Manukau Health TUPU fund and the South Auckland Anaesthetic Research Trust. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Epidural Hematoma Following Cessation of a Direct Oral Anticoagulant: A Case Report

Objective In this case report, we describe a case of epidural hematoma following epidural analgesia in a patient with recent cessation of a direct oral anticoagulant (DOAC). Case Report An 89-year-old woman requiring upper abdominal surgery presented with multiple comorbidities, including a prior cerebrovascular accident resulting in a left-sided hemiparesis and atrial fibrillation requiring anticoagulation with rivaroxaban. In accordance with our departmental guidelines at the time of procedure, rivaroxaban was discontinued 4 days preoperatively. A thoracic epidural was placed at T8/9 immediately prior to induction. Venous thromboembolism prophylaxis was provided with compression devices, and every-12-hour unfractionated heparin initiated 5.5 hours after epidural placement. On postoperative day 2, the patient was noted to have a bilateral motor block, and imaging demonstrated a thoracic epidural hematoma extending from T6 to T11. Preexisting neurological deficits may have delayed detection. With patient agreement, neurosurgery recommended observation rather than surgical decompression because the patient was a poor surgical candidate and limited neurologic recovery was expected. The patient had modest motor recovery over the next few months. Conclusions Guidelines for cessation of DOACs prior to neuraxial techniques are based on pharmacologic half-lives rather than accumulated experience. This case adds to the experience of neuraxial analgesia complications while following these guidelines. Patient risk may be increased by the combination of recent cessation of a DOAC, as well as the cumulative effect of multiple small risk factors. Continued vigilance and reporting of cases of epidural hematomas will enhance our understanding and ultimately improve patient care. Elderly patients and/or patients with prior neurological deficits may present further challenges for early detection and require frequent assessments with comparison to baseline status. Accepted for publication October 4, 2017. Address correspondence to: Melanie Jaeger, MD, FRCPC, Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, Canada, K7L 2V7 (e-mail: jaegerm@kgh.kari.net). No funding was acquired for preparation or publication of this article. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Case of psoriatic arthritis mutilans whose finger dysfunction was successfully ameliorated by surgical intervention during infliximab treatment

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Impact of a new simplified disability scoring system for adult patients with localized scleroderma

Abstract

Localized scleroderma (LoS) involves dermal but not internal inflammation and fibrosis. Cosmetic changes often impact quality of life (QOL), however, impairment of activities of daily living (ADL) in LoS patients has not been investigated. To determine what factor(s) are associated with ADL in adult patients with LoS, we performed a retrospective observational study in 177 Japanese adult LoS patients using a novel LoS disability score based on Barthel's indices of ADL: feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfers, mobility and stairs. LoS disability scores increased in proportion to the number of affected body parts but were not correlated to age and duration of illness. The presence of leg lesions significantly impaired ADL of LoS patients compared with lesions on other body parts. Patients treated with systemic medications, who tended to have multiple lesions, presented higher LoS disability scores than those without systemic treatments. Our study proposes that physicians evaluate ADL, not only QOL, in LoS patients. Our findings using LoS disability scoring indicate that multiple affected body parts and leg lesions are risk factors for ADL impairment.

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Current developments in phototherapy for psoriasis

Abstract

Phototherapy utilizes the beneficial effects of ultraviolet (UV) wavelengths to affect immunoregulatory functions. UV light phototherapy using narrowband UV-B (NB-UVB) and bath-psoralen UV-A (bath-PUVA) therapy are well-established treatments for psoriasis. Dual-action mechanisms of UV phototherapy have been identified: apoptosis and immune suppression. NB-UVB depletes pathogenic T cells by inducing apoptosis and regulatory T cells. Other wavelengths are also utilized for phototherapy, namely 308-nm excimer light and 312-nm flat-typed NB-UVB. Excimer light (308-nm) therapy effectively targets the affected skin without unduly exposing other areas and increases the levels of regulatory T cells. Phototherapy improves impaired resting regulatory T cells and increases activated regulatory T cells in patients with psoriasis. Intensive studies of phototherapy effects have led to several improvements in the design, protocols, and light sources, such as UV light-emitting diodes, thereby providing several options for patients with refractory skin disease, such as psoriasis.

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Case with anaphylactic shock induced by heparin-lock flush injection

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Birth Order and Pediatric Allergic Disease: A Nationwide Longitudinal Survey

Abstract

Background

Environmental factors seem to be related to the incidence of allergic disease. Children with a later birth order are often exposed to environments where pathogens and endotoxins can be found, and thus have a higher risk of developing infectious diseases. Therefore, birth order is regarded as an indicator that reflects postnatal environment. However, longitudinal studies are limited on this subject. This study sought to elucidate the relationships between birth order and allergic disease.

Methods

From a nationwide longitudinal study that followed children born in 2001 (n=47,015), we selected doctors' visits for three types of allergic disease—bronchial asthma, food allergy, and atopic dermatitis—from infancy to 12 years of age and conducted binomial log-linear regression analysis to evaluate the associations between birth order and these diseases. We adjusted for child and parental factors and estimated risk ratio (RR) and 95% confidence interval (CI) for each outcome.

Results

The associations between birth order and bronchial asthma were diverse; later birth order increased the risk in early childhood, but decreased the risks during school age. For example, the adjusted RR comparing third-born or higher and first-born children was 1.19 (95% CI, 1.05 to 1.35) between 30 and 42 months of age, but was 0.76 (95% CI, 0.65 to 0.89) between 10 and 11 years. Later birth order was generally protective for food allergy but increased the risk of atopic dermatitis.

Conclusion

The influence of birth order depended on the type of allergic disease and the childhood period. Childhood is unique in terms of physical and immunological development, and the immune response to the postnatal environment in childhood appears to be heterogeneous.

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