Audiological Evaluation in Hypothyroid Patients and Effect of Thyroxine Replacement Therapy

Abstract

To do the audiological evaluation of patients with hypothyroidism and to assess status of hearing after thyroxin replacement therapy (TRT). Two groups were included: a hypothyroidism group (HG, n = 50), and a control group (CG, n = 50). Parameters studied: anominesic data, duration of hypothyroidism, comorbidities, cochleovestibular symptoms, biochemical and hormonal exams (TSH, FT4 and FT3), pure tone audiometry, impendence audiometry and BERA as where required. Mean age of the patients in HG was 26.5 ± 10.4 years. Male/Female ratio was 2.39. All HG patients had altered TSH values and 8% had diminished T4 values. Cochleovestibular symptoms were more common in hypothyroid patients (48%) than control (20%) p value. Pure Tone Audiometric threshold was found higher in 34% of cases. Sensorineural hearing loss was most common (76.46%) compared to conductive and mixed hearing loss. BERA showed significant prolonged absolute peak latency of wave III, inter peak latency (IPL) of wave I–III and reduced amplitude of wave Ia and Va. After thyroxine replacement therapy there was statistically significant improvement in hearing threshold in 46.42% ears (p  < 0.05), (if ≥ 5 dB hearing improvement consider as significant). The significant improvement was also found in BERA, in amplitude of wave Va. Site of involvement was at several levels, middle ear, cochlear or retro-cochlear. HG patients had more cochleovestibular symptoms, higher audiometric thresholds, increase in latency of wave III, IPL of I–III and reduced Ia and Va amplitude in the BERA. After TRT improvement in hearing threshold and BERA was found.

https://ift.tt/2IjVabS

Audiological Evaluation in Hypothyroid Patients and Effect of Thyroxine Replacement Therapy

Abstract

To do the audiological evaluation of patients with hypothyroidism and to assess status of hearing after thyroxin replacement therapy (TRT). Two groups were included: a hypothyroidism group (HG, n = 50), and a control group (CG, n = 50). Parameters studied: anominesic data, duration of hypothyroidism, comorbidities, cochleovestibular symptoms, biochemical and hormonal exams (TSH, FT4 and FT3), pure tone audiometry, impendence audiometry and BERA as where required. Mean age of the patients in HG was 26.5 ± 10.4 years. Male/Female ratio was 2.39. All HG patients had altered TSH values and 8% had diminished T4 values. Cochleovestibular symptoms were more common in hypothyroid patients (48%) than control (20%) p value. Pure Tone Audiometric threshold was found higher in 34% of cases. Sensorineural hearing loss was most common (76.46%) compared to conductive and mixed hearing loss. BERA showed significant prolonged absolute peak latency of wave III, inter peak latency (IPL) of wave I–III and reduced amplitude of wave Ia and Va. After thyroxine replacement therapy there was statistically significant improvement in hearing threshold in 46.42% ears (p  < 0.05), (if ≥ 5 dB hearing improvement consider as significant). The significant improvement was also found in BERA, in amplitude of wave Va. Site of involvement was at several levels, middle ear, cochlear or retro-cochlear. HG patients had more cochleovestibular symptoms, higher audiometric thresholds, increase in latency of wave III, IPL of I–III and reduced Ia and Va amplitude in the BERA. After TRT improvement in hearing threshold and BERA was found.

https://ift.tt/2IjVabS

Early Speech Perception Test Outcome in Children with Severe Sensorineural Hearing Loss with Unilateral Cochlear Implants Alone versus Bimodal Stimulation

Abstract

Bilateral stimulation of the auditory system has clear advantages over unilateral hearing. Hearing-impaired children are, therefore, generally fitted with hearing aids in both ears so that they can have the benefits of binaural hearing. Children who use acochlear implant in one ear and no acoustic stimulation in the opposite ear are at a definite disadvantage. This study was undertaken to determine the advantages of bimodal stimulation in pediatric population especially in terms of speech recognition. This study comprised of 30 children between 3 and 6 years of age with profound bilateral sensorineural hearing loss with cochlear implant in one ear and fitted with digital hearing aid in non-implanted ear. Speech recognition performance was compared in unilateral cochlear implant only and with bimodal hearing stimulation in the same set of children. A statistically significant difference was found between speech reception scores in children with a unilateral cochlear implant only and those with a cochlear implant in one ear and a hearing aid in the non implanted ear in quiet surroundings. It is suggested that the use of bimodal fitting be considered as an effective management method to obtain the advantage of binaural hearing in children who undergo unilateral cochlear implantation.

https://ift.tt/2wH1rx2

Early Speech Perception Test Outcome in Children with Severe Sensorineural Hearing Loss with Unilateral Cochlear Implants Alone versus Bimodal Stimulation

Abstract

Bilateral stimulation of the auditory system has clear advantages over unilateral hearing. Hearing-impaired children are, therefore, generally fitted with hearing aids in both ears so that they can have the benefits of binaural hearing. Children who use acochlear implant in one ear and no acoustic stimulation in the opposite ear are at a definite disadvantage. This study was undertaken to determine the advantages of bimodal stimulation in pediatric population especially in terms of speech recognition. This study comprised of 30 children between 3 and 6 years of age with profound bilateral sensorineural hearing loss with cochlear implant in one ear and fitted with digital hearing aid in non-implanted ear. Speech recognition performance was compared in unilateral cochlear implant only and with bimodal hearing stimulation in the same set of children. A statistically significant difference was found between speech reception scores in children with a unilateral cochlear implant only and those with a cochlear implant in one ear and a hearing aid in the non implanted ear in quiet surroundings. It is suggested that the use of bimodal fitting be considered as an effective management method to obtain the advantage of binaural hearing in children who undergo unilateral cochlear implantation.

https://ift.tt/2wH1rx2

A 37-year-old Nigerian woman with Apert syndrome – medical and psychosocial perspectives: a case report

Apert syndrome is a rare genetic disease that presents a diagnostic dilemma because of its similarity with other craniosynostosis syndromes. Currently, there is paucity of reports about adult patients in Afric...

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In Response

No abstract available

https://ift.tt/2rDkpzy

A Contemporary Analysis of Medicolegal Issues in Obstetric Anesthesia Between 2005 and 2015

BACKGROUND: Detailed reviews of closed malpractice claims have provided insights into the most common events resulting in litigation and helped improve anesthesia care. In the past 10 years, there have been multiple safety advancements in the practice of obstetric anesthesia. We investigated the relationship among contributing factors, patient injuries, and legal outcome by analyzing a contemporary cohort of closed malpractice claims where obstetric anesthesiology was the principal defendant. METHODS: The Controlled Risk Insurance Company (CRICO) is the captive medical liability insurer of the Harvard Medical Institutions that, in collaboration with other insurance companies and health care entities, contributes to the Comparative Benchmark System database for research purposes. We reviewed all (N = 106) closed malpractice cases related to obstetric anesthesia between 2005 and 2015 and compared the following classes of injury: maternal death and brain injury, neonatal death and brain injury, maternal nerve injury, and maternal major and minor injury. In addition, settled claims were compared to the cases that did not receive payment. χ2, analysis of variance, Student t test, and Kruskal-Wallis tests were used for comparison between the different classes of injury. RESULTS: The largest number of claims, 54.7%, involved maternal nerve injury; 77.6% of these claims did not receive any indemnity payment. Cases involving maternal death or brain injury comprised 15.1% of all cases and were more likely to receive payment, especially in the high range (P = .02). The most common causes of maternal death or brain injury were high neuraxial blocks, embolic events, and failed intubation. Claims for maternal major and minor injury were least likely to receive payment (P = .02) and were most commonly (34.8%) associated with only emotional injury. Compared to the dropped/denied/dismissed claims, settled claims more frequently involved general anesthesia (P = .03), were associated with delays in care (P = .005), and took longer to resolve (3.2 vs 1.3 years; P

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The Perioperative Care of the Transgender Patient

An estimated 25 million people identify as transgender worldwide, approximately 1 million of whom reside in the United States. The increasing visibility and acceptance of transgender people makes it likely that they will present in general surgical settings; therefore, perioperative health care providers must develop the knowledge and skills requisite for the safe management of transgender patients in the perioperative setting. Extant guidelines, such as those published by the World Professional Association for Transgender Health and the University of California San Francisco Center of Excellence for Transgender Health, serve as critical resources to those caring for transgender patients; however, they do not address their unique perioperative needs. It is essential that anesthesia providers develop the knowledge and skills necessary for safely managing transgender patients in the perioperative setting. This review provides an overview of relevant terminology, the imperative for the provision of culturally sensitive care, and guidelines for preoperative, intraoperative, and postoperative management of the transgender patient. Accepted for publication February 27, 2018 Funding: This research was funded in part through the National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748. The authors declare no conflicts of interest. All authors were substantial contributors to the conception of the article, were active participants in the drafting and revision of the article, approved the final version of the article, and agree to be accountable for all aspects of the work. Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines: This article adheres to the appropriate EQUATOR guidelines Standards for QUality Improvement Reporting Excellence (SQUIRE) 2.0. Reprints will not be available from the authors. Address correspondence to Luis Etienne Tollinche, MD, FASA, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065. Address e-mail to tollincl@mskcc.org. © 2018 International Anesthesia Research Society

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Effects of Intraoperative Opioid Use on Recurrence-Free and Overall Survival in Patients With Esophageal Adenocarcinoma and Squamous Cell Carcinoma

BACKGROUND: Perioperative opioid use is associated with poor survival in patients with esophageal squamous cell carcinoma. The most common histological type of esophageal cancer in western countries is adenocarcinoma. The objective of this study was to evaluate the association between intraoperative opioid consumption and survival in patients with adenocarcinoma and squamous cell carcinoma of the esophagus. METHODS: Records of patients who had undergone esophageal cancer surgery between January 2000 and January 2017 were reviewed. Comparisons were made between patients who received high versus low intraoperative doses of opioids. Groups were divided using the recursive partitioning method. Multicovariate Cox proportional hazards models were fitted to evaluate the impact of intraoperative opioid use on recurrence-free survival (RFS) and overall survival (OS). RESULTS: For patients with esophageal squamous cell carcinoma, the univariable analysis indicated that lower opioid dosages (

https://ift.tt/2KlbeuH

Misconceptions Surrounding Penicillin Allergy: Implications for Anesthesiologists

Administration of preoperative antimicrobial prophylaxis, often with a cephalosporin, is the mainstay of surgical site infection prevention guidelines. Unfortunately, due to prevalent misconceptions, patients labeled as having a penicillin allergy often receive alternate and less-effective antibiotics, placing them at risk of a variety of adverse effects including increased morbidity and higher risk of surgical site infection. The perioperative physician should ascertain the nature of previous reactions to aid in determining the probability of the prevalence of a true allergy. Penicillin allergy testing may be performed but may not be feasible in the perioperative setting. Current evidence on the structural determinants of penicillin and cephalosporin allergies refutes the misconception of cross-reactivity between penicillins and cefazolin, and there is no clear evidence of an increased risk of anaphylaxis in cefazolin-naive, penicillin-allergic patients. A clinical practice algorithm for the perioperative evaluation and management of patients reporting a history of penicillin allergy is presented, concluding that cephalosporins can be safely administered to a majority of such patients. Accepted for publication March 30, 2018. 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 (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Leon Vorobeichik, MD, Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Room M3-200, Toronto, ON M4N 3M5, Canada. Address e-mail to l.vorobeichik@mail.utoronto.ca. © 2018 International Anesthesia Research Society

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A modified CO2/O2 Guedel airway improves capnographic accuracy compared with a CO2/O2 nasal cannula: An infant manikin study

BACKGROUND Capnography via a CO2/O2 nasal cannula is commonly used for respiratory monitoring during sedation. However, signal disturbances are frequently encountered, especially in young children. OBJECTIVE Sampling ports placed closer to the trachea have been shown to result in improved signal quality. In a manikin model of a 6-month-old infant we compared capnography from a modified Guedel airway with a CO2 port located at the tip with that from a CO2/O2 nasal cannula. DESIGN A comparison study using an artificial model of a breathing 6-month-old infant. SETTING Department of Paediatrics, Inselspital Bern, Switzerland, from March 2016 to June 2016. MATERIAL Modified CO2/O2 Guedel airway. INTERVENTIONS Capnography using a modified CO2/O2 Guedel airway or a CO2/O2 nasal cannula was performed for tidal volumes of 20 to 80 ml (in steps of 20 ml), respiratory rates of 20 to 60 min−1 (in steps of 10 min−1) and with different O2 flows (0 to 2 l min−1, in steps of 0.5 l). MAIN OUTCOME MEASURES Comparison of differences between tracheal and device CO2. Secondary outcomes included the effect of various respiratory settings and O2 flows on the CO2 difference. RESULTS The tracheal to device CO2 difference was significantly smaller when using a modified CO2/O2 Guedel airway vs. a CO2/O2 nasal cannula: Mean ± SD, 16.8 ± 4.9 vs. 24.1 ± 5.9 mmHg, P less than 0.0001. An O2 flow of 0.5 to 2 l min−1 did not influence the tracheal to device CO2 difference with the modified CO2/O2 Guedel airway in contrast to the CO2/O2 nasal cannula where there were significant differences (P 

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Duration of the action of rocuronium in patients with BMI of less than 25: An observational study

BACKGROUND The duration of rocuronium in patients with BMI more than 30 kg m−2 is prolonged. Whether the reverse is true when BMI is less than 18.5 kg m−2 is unclear. OBJECTIVE The objective of this study was to investigate whether a BMI less than 25 kg m−2 affects the duration of rocuronium in doses adjusted for actual body weight. DESIGN A prospective, observational, single-centre study. SETTING The operating room of a teaching hospital from 1 June 2008 to 30 June 2015. PATIENTS Thirty patients with American Society of Anesthesiologists physical status I or II who were scheduled to undergo elective surgery (BMI 

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Placebo versus low-dose ketamine infusion in addition to remifentanil target-controlled infusion for conscious sedation during oocyte retrieval: A prospective, double-blinded, randomised controlled trial

BACKGROUND Currently, there is no gold standard for monitored anaesthesia care during oocyte retrieval. OBJECTIVE In our institution, the standard is a conscious sedation technique using a target-controlled infusion (TCI) of remifentanil, titrated to maintain a visual analogue pain score less than 30 mm. This protocol is well accepted by patients but is associated with frequent episodes of respiratory depression. The main objective of this study was to evaluate whether the addition of a continuous intravenous infusion of ketamine could reduce these episodes. DESIGN Controlled, randomised, prospective, double-blinded study. SETTING The current study was conducted in a tertiary-level hospital in Brussels (Belgium) from December 2013 to June 2014. PATIENTS Of the 132 women undergoing oocyte retrieval included, 121 completed the study. INTERVENTION After randomisation, patients received either a ketamine infusion (40 μg kg−1 min−1 over 5 min followed by 2.5 μg kg−1 min−1) or a 0.9% saline infusion in addition to the variable remifentanil TCI. MAIN OUTCOME MEASURES The primary outcome was the number of respiratory depression episodes. Effect site target remifentanil concentrations, side effects, pain score, patient satisfaction and incidence of pregnancy were also recorded. RESULTS No significant difference in the incidence of respiratory events was noted (pulse oximetry oxygen saturation 

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Immunosuppression is associated with clinical features and relapse risk of B cell posttransplant lymphoproliferative disorder: A retrospective analysis based on the prospective, international, multicenter PTLD-1 trials

Background Current guideline recommendations for immunosuppression reduction after diagnosis of posttransplant lymphoproliferative disorder (PTLD) include stopping antimetabolites, reducing calcineurin inhibitors and maintaining corticosteroids. However, the effect of immunosuppression on PTLD relapse risk after up-to-date therapy is unclear. Methods This is a retrospective analysis of immunosuppression, patient baseline characteristics and relapse risk measured as landmark time to progression (TTP) starting 1 year after start of therapy in 159 patients with B cell PTLD after solid organ transplantation treated in the prospective, international, multicenter PTLD-1 trials with either sequential treatment (rituximab followed by CHOP chemotherapy) or risk-stratified sequential treatment (rituximab followed by rituximab or R-CHOP immunochemotherapy). Results Patient baseline characteristics at diagnosis of PTLD differed significantly depending on immunosuppression before diagnosis. Compared to immunosuppression before diagnosis, significantly fewer patients received an antimetabolite or a calcineurin inhibitor (CNI) after diagnosis of PTLD. Relapse risk measured as landmark TTP was significantly higher for patients on corticosteroids compared to all others (p=0.010) as well as for patients on ciclosporin compared to those on tacrolimus (p=0.002), but similar for those on antimetabolites compared to all others (p=0.912). In a Cox regression analysis of landmark TTP, corticosteroid-containing immunosuppression after diagnosis of PTLD (p=0.002, hazard ratio (HR) 11.195) and age (p=0.001, HR 1.076/year) were identified as independent, significant risk factors for PTLD relapse. Conclusions In the prospective PTLD-1 trials, corticosteroid use after diagnosis of PTLD is associated with an increased risk of relapse whereas the use of antimetabolites is not. These findings require prospective validation. Correspondence: Ralf Ulrich Trappe, DIAKO Hospital Bremen, Department of Internal Medicine II: Hematology and Oncology, Gröpelinger Heerstr. 406-408, 28239 Bremen, Germany, e-mail: rtrappe@gwdg.de Authorship HZ and RUT designed the study. RUT is the principal investigators and takes primary responsibility for the paper. RUT, SC and DD coordinated the research. HR, NB, SC, VL, FM, DD, PM, JMZ, MD, UD, PR, GV, MS, AH, TT, EB, IAH, CT, EVDN and OG recruited significant numbers of patients. HZ and RUT collected, analyzed and interpreted the data. IA served as reference pathologists. HZ, NB, DD, MD, SC, FM, JMZ, HR, and RUT wrote the paper. All authors had full access to the final version of the manuscript and agreed to publication. Disclosures H. Zimmermann reports grants form Roche, and nonfinancial support from Celgene Amgen, and Roche, outside the submitted work. F. Morschhauser reports personal fees from Celgene, Genentech/Roche, Gilead, and Janssen, outside the submitted work. P. Mollee reports grants from Celgene and Janssen as well as advisory boards membership for Celgene, Janssen, Amgen and BMS, outside the submitted work. J.M. Zaucha reports personal fees from Roche, Amgen, and Takeda, all outside the submitted work. M. Dreyling reports grants and personal fees from Roche, outside the submitted work. P. Reinke reports personal fees or travel support from Teva, Thermo Fisher, Pfizer, Astellas, Amgen, Baxalta, MSD, Pluristem, and Novartis, outside the submitted work. U. Dührsen reports and personal fees from Roche, outside the submitted work. M. Subklewe reports institutional grants from Roche, Amgen and OBT and personal fees or travel support from Amgen, Pfizer, Seattle Genetics, Gilead and Celgene, outside the submitted work. I.A. Hauser reports nonfinancial support from Astellas and Alexion as well as personal fees from Novartis, Roche, Chiesi, Sanofi, Hexal, and Teva, outside the submitted work. V. Leblond reports personal fees from Roche, Gilead, Janssen and Novartis, outside the submitted work. S. Choquet reports grants from Roche France and Chugai during the conduct of the study. R.U. Trappe reports grants from Hoffmann-La Roche, Amgen, Chugai France and Novartis during the conduct of the study; ongoing grants from Roche, and nonfinancial support from Abbvie, Celgene, Takeda, Teva, Janssen, Roche and Gilead, all outside the submitted work. All other authors declared no conflicts of interest. Funding The PTLD-1 trials were planned and initiated in 2003 and amended in 2006 as an investigator-initiated trial by the German and French PTLD Study Groups. In 2004, F Hoffmann-La Roche, AMGEN and Chugaï France granted financial support. Novartis provided funding for an analysis of the effect of immunosuppression on PTLD outcomes. The companies were neither involved in protocol design nor in data collection, analysis or interpretation. They had no role in writing the manuscript and were not involved in the decision to submit for publication. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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A Novel Technique in The Treatment of Lymphoceles After Renal Transplantation: C-arm Cone Beam CT-Guided Percutaneous Embolization of Lymphatic Leakage Following Lymphangiography

Background We aimed to evaluate the efficacy of percutaneous embolization following lymphangiography using C-arm cone-beam computed tomography (CBCT) performed at the site of lymphatic leakage in patients with postrenal transplant lymphocele. Methods Between July 2014 and August 2017, 13 patients not responding to percutaneous ethanol sclerotherapy and conservative treatment for recurrent lymphocele following renal transplant were included. The mean age of the patients was 56.38 ± 9.91 (range: 36 to 70) years and it comprised 9 men and 4 women. All patients underwent intranodal lymphangiography. C-arm CBCT-guided percutaneous embolization was performed in patients with confirmed lymphatic leakage. Patients who had no lymphatic leakage underwent drainage with fibrin glue injection. Results Lymphatic leakage was observed in 9 patients following lymphangiography and they underwent CBCT-guided percutaneous N-butyl-2-cyanoacrylate (NBCA) embolization. The volume of lymphatic drainage reduced to less than 10 cc in 8 patients. One patient who was not responding to embolization was treated surgically, after percutaneous drainage and fibrin glue injection. Lymphatic leakage wasn't observed in 4 patients following lymphangiography. Of these, 3 patients showed a reduction in the amount of ymphatic drainage following the lymphangiography. All 4 patients underwent percutaneous drainage and fibrin glue injection. One patient didn't respond to the treatment and was treated surgically. Pre and post lymphangiography and embolization, the volume of lymphatic drainage was 113,07±21,75 ml, and 53,84±30,96 ml respectively, and statistically significant decrease was detected. (p

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Response to commentary

No abstract available

https://ift.tt/2KjZclg

Coagulation Defects in the Cirrhotic Patient Undergoing Liver Transplantation

Patients with cirrhosis undergoing liver transplantation have unique challenges with regard to the prevention and management of thrombosis and hemorrhage. Patients with cirrhosis have an unstable balance of the coagulation system due to defects in both prothrombotic and antithrombotic components. These changes make laboratory monitoring challenging, prophylaxis against bleeding and thrombosis controversial, and therapy for the same uncertain. When cirrhotic patients undergo liver transplantation they frequently have significant transfusion requirements. Emerging evidence may help aid in predicting which recipients will have the greatest blood product requirements, but the ideal blood product regimen to support them through the surgical procedure remains elusive. After these patients receive a liver they are at risk for both venous and arterial thrombotic complications. Unique to liver transplantation is the possibility of acquiring an inherited defect in coagulation, most commonly leading to a predisposition to thrombosis. Further high quality prospective studies focusing on the management of cirrhotic patients are needed to better guide clinicians. Correspondence: Corresponding author/reprints: Constantine J. Karvellas MD SM FRCPC, Associate Professor of Medicine, Division of Gastroenterology (Liver Unit), Division of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Phone: (780) 248-1555, Fax: (780) 492-5643, Email: dean.karvellas@ualberta.ca Conflict of interest: None Financial support: None Authorship: Both authors contributed to writing this manuscript. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Development of a Predictive Model for Deceased Donor Organ Yield

No abstract available

https://ift.tt/2KlGJV9

Determination of Minimal Hemoglobin Level Necessary for Normothermic Porcine Ex situ Liver Perfusion

Background In current studies of ex situ liver perfusion there exists considerable variability in perfusate composition, including the type of oxygen carrier. Herein we aim to clarify the minimal hemoglobin level necessary during normothermic porcine ex situ liver perfusion. Methods Livers procured from 35- 45 Kg domestic pigs were connected to our experimental ex situ circuit (n=10). In the treatment group, perfusate was sequentially diluted hourly to predetermined hemoglobin levels. At the end of each hemoglobin dilution, perfusate samples were analyzed for liver transaminases, lactate dehydrogenase, total bilirubin, and lactate levels. Liver oxygen consumption was measured. In the control group, livers were perfused continually for a duration of 24 hours at target hemoglobin levels of 30 and 20 g/L. Results Rising liver transaminases, significantly higher lactate (p

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Detection of Complement-Binding Donor-Specific Antibodies, not IgG-Antibody Strength nor C4d Status, at Antibody-Mediated Rejection Diagnosis is an Independent Predictor of Kidney Graft Failure

Background Antibody-mediated rejection (ABMR) remains associated with reduced kidney graft survival and no clear prognostic marker is available. Methods We investigated whether donor-specific antibodies (DSA) ability to bind C1q in comparison with ABMR C4d status, both indirect signs of complement activation, improve risk stratification at time of ABMR. Hence, among 467 patients in whom ≥1 graft biopsy was performed between 2008 and 2015, we included 56 with ABMR according to Banff'15 criteria. Using concurrent sera, we prospectively identified DSA by single-antigen beads (IgG and C1q) assays. Results ABMR C4d (+) (n=28) was associated with preformed DSA (P=0.007), while DSA C1q (+) (n=25) cases had stronger IgG-DSA (P

https://ift.tt/2KlvCfb

Revascularization Time in Liver Transplantation: Independent Prediction of Inferior Short- and Long-term Outcomes by Prolonged Graft Implantation

Background Strategies for successful transplantation are much needed in the era of organ shortage and there has been a resurgence of interest on the impact of revascularization time (RT) on outcomes in liver transplantation (LT). Methods All primary LT performed in Birmingham between 2009 and 2014 (n=678) with portal reperfusion first were stratified according to RT (

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Differential impact of T-bet and IFNγ on pancreatic islet allograft rejection

Background T-cell-mediated graft rejection is mostly correlated with potent Th1 responses. However, since IFNγ-/- mice reject their graft as efficiently as wild-type (WT) mice, the exact contribution of IFNγ and its transcription factor T-bet remains a matter of debate. Here, we address this question in the context of pancreatic islet allograft to better inform the molecular pathways that hampers islet survival in vivo. Methods Pancreatic islets from BALB/c mice were transplanted in WT, IFNγ-/- or T-bet-/- C57BL/6 mice. Graft survival and the induction of effector and cytotoxic T cell responses were monitored. Results Rejection of fully mismatched islet allografts correlated with high expression of both IFNγ and T-bet in WT recipients. However, allogeneic islets were permanently accepted in T-bet-/- mice, in contrast to IFNγ-/- hosts. Long-term survival correlated with decreased CD4+ and CD8+ T cell infiltrates, drastically reduced donor-specific IFNγ and TNFα responses and very low expression of the cytotoxic markers granzyme B, perforin and FasLigand. In addition, in vitro and in vivo data pointed to an increased susceptibility of T-bet-/- CD8+ T cell to apoptosis. These observations were not reported in IFNγ-/- mice, which have set up compensatory effector mechanisms comprising an increased expression of the transcription factor Eomes and cytolytic molecules as well as TNFα- but not IL-4 nor IL-17-mediated allogeneic responses. Conclusion Anti-islet T cell responses require T-bet but not IFNγ-dependent programs. Our results provide new clues on the mechanisms dictating islet rejection and may help refining the therapeutic/immunosuppressive regimens applied in diabetic patients receiving islets or pancreas allografts. *These authors equally contributed to this work. Corresponding author: Dr. Sylvaine You, INSERM U1016 – Institut Cochin, Bâtiment Cassini, 123 Bd de Port Royal, 75014 Paris, France. E-mail: sylvaine.you@inserm.fr Authorship A.B and Z.D. designed experiments, performed experiments, analyzed and interpreted the data. T.G, F.V. and E.P. performed experiments and analyzed the data. L.C. provided critical advice and help in writing the manuscript. S. Y. designed and directed the study, analyzed the data and wrote the manuscript. Disclosure The authors declare no conflicts of interest. Funding: This work was supported by grants from the RISET consortium (Reprogramming the Immune System for the Establishment of Tolerance) from the European Commission (FP6), Institutional funding from INSERM and University Paris Descartes, the Fondation CENTAURE, and the Fondation DAY SOLVAY. A. Besançon was supported by a doctoral fellowship from INSERM by a price from the Société Française d'Endocrinologie et Diabétologie Pédiatrique (SFEDP, grant from NOVONORDISK). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Contemporary Strategies and Barriers to Transplantation Tolerance

The purpose of this review is to discuss immunologic tolerance as it applies to solid organ transplantation and to identify barriers that hinder the achievement of this long-term goal. First, the definition of tolerance and an introduction of mechanisms by which tolerance exists or can be achieved will be discussed. Next, a review of contemporary attempts at achieving transplant tolerance will be described. Finally, a discussion of the humoral barriers to transplantation tolerance and potential ways to overcome these barriers will be presented. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Address all correspondence and requests for reprints to: Stuart J. Knechtle, MD, Executive Director, Duke Transplant Center, 207 Research Dr., Jones 365, Durham, NC 27710, U.S.A. Phone: 919-613-9687; Fax: 919-684-8716; E-mail: stuart.knechtle@dm.duke.edu. Jean Kwun, DVM, PhD, Duke Transplant Center, 207 Research Dr., Jones 362, Durham, NC 27710, U.S.A. Phone: 919-668-6792; Fax: 919-684-8716; E-mail: jean.kwun@duke.edu (SJK and JK share the corresponding authorship for this work) Disclosure: The authors declare no conflicts of interest. Funding: The work in this paper is supported in part by grants: NIH U19 AI051731 (S.K.), NIH 1U19AI131471 (S.K.) and AHA Enduring Hearts Foundation Research Award 15SDG25710165 (J.K.). Author Contribution B.E. conceived the idea and wrote the manuscript. P.S. conceived the idea, wrote the manuscript, and devised the figure. K.F. and J.Y. participated in manuscript cowriting and critical revision. J.K. and S.K. conceived the idea and wrote the manuscript. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Early and late hepatitis B reactivation following IFN- or DAA-based therapy of recurrent hepatitis C in anti-HBc-positive liver transplant recipients

No abstract available

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Caspase Inhibition: Optimizing Grafts for Transplantation

No abstract available

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Preventing Antibody Mediated Rejection during Transplantation: the Potential of Tfr Cells

No abstract available

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T follicular regulatory cells and antibody responses in transplantation

De novo donor specific antibody (DSA) formation is a major problem in transplantation, and associated with long-term graft decline and loss as well as sensitisation, limiting future transplant options. Forming high-affinity, long-lived antibody responses involves a process called the germinal center (GC) reaction, and requires interaction between several cell types, including GC B cells, T follicular helper (Tfh) and T follicular regulatory (Tfr) cells. Tfr cells are an essential component of the GC reaction, limiting its size and reducing nonspecific or self-reactive responses. An imbalance between helper function and regulatory function can lead to excessive antibody production. High proportions of Tfh cells have been associated with DSA formation in transplantation; therefore Tfr cells are likely to play an important role in limiting DSA production. Understanding the signals that govern Tfr cell development and the balance between helper and regulatory function within the GC is key to understanding how these cells might be manipulated to reduce the risk of DSA development. This review discusses the development and function of Tfr cells and their relevance to transplantation. In particular how current and future immunosuppressive strategies might allow us to skew the ratio between Tfr and Tfh cells to increase or decrease the risk of de novo DSA formation. Transplant Research Immunology Group, Nuffield Dept Surgical Sciences, Level 6 John Radcliffe Hospital, Oxford OX3 9DU. Email: lizwallin@doctors.org.uk Telephone +44 (0)1865 222508, fax +44 (0)1865 768876 EFW was supported by a Kidney Research UK/MRC Clinical Fellowship and declares no conflict of interest. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Primary Graft Dysfunction: The Devil is in the details

No abstract available

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Live Donor Kidney Transpalntation: Altruism Alone is not Always Enough!

No abstract available

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ISHLT Primary Graft Dysfunction incidence, risk factors and outcome: a UK National Study

Background Heart transplantation (HTx) remains the most effective long-term treatment for advanced heart failure. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication. In 2014, a consensus statement released by ISHLT established diagnostic criteria for PGD. We studied the incidence of PGD across the UK. Methods We analysed the medical records of all adult patients who underwent heart transplantation between October 2012-October 2015 in the 6 UK heart transplant centers Preoperative donor and recipient characteristics, intraoperative details and posttransplant complications were compared between the PGD and non PGD groups using the ISHLT definition. Multivariable analysis was performed using logistic regression. Results The incidence of ISHLT PGD was 36%. Thirty-day all-cause mortality in those with and without PGD was 31(19%) vs 13(4.5%) (p=0.0001). Donor, recipient and operative factors associated with PGD were: recipient diabetes mellitus (p=0.031), recipient preoperative BIVAD(p

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Caspase inhibition during cold storage improves graft function and histology in a murine kidney transplant model

Background Prolonged cold ischemia is a risk factor for delayed graft function of kidney transplants, and is associated with caspase-3 mediated apoptotic tubular cell death. We hypothesized that treatment of tubular cells and donor kidneys during cold storage with a caspase inhibitor before transplant would reduce tubular cell apoptosis and improve kidney function after transplant. Methods Mouse tubular cells were incubated with either DMSO or Q-VD-OPh during cold storage in saline followed by rewarming in normal media. For in vivo studies, donor kidneys from C57BL/6 mice were perfused with cold saline, DMSO (vehicle), or QVD-OPh. Donor kidneys were then recovered, stored at 4°C for 60 minutes, and transplanted into syngeneic C57BL/6 recipients Results Tubular cells treated with a caspase inhibitor had significantly reduced capsase-3 protein expression, caspase-3 activity, and apoptotic cell death compared to saline or DMSO (vehicle) in a dose-dependent manner. Treatment of donor kidneys with a caspase inhibitor significantly reduced serum creatinine, and resulted in significantly less tubular cell apoptosis, brush border injury, tubular injury, cast formation, and tubule lumen dilation compared to DMSO and saline-treated kidneys. Conclusion: Caspase inhibition resulted in decreased tubular cell apoptosis and improved renal function after transplantation. Caspase inhibition may be a useful strategy to prevent cold ischemic injury of donor renal grafts. Trevor L. Nydam, MD, Robert Plenter, Swati Jain, Authors contributed equally to this work. Address for Correspondence: Alkesh Jani, University of Colorado Denver Division of Renal Diseases and Hypertension, 12700 East 19th Avenue, C281, Aurora, Colorado 80045: Email address: Alkesh.jani@ucdenver.edu Authorship TN participated in performance of the research, research design, writing the paper and data analysis; RP participated in performance of the research, writing the paper and data analysis; SJ participated in performance of the research, writing the paper and data analysis; SL participated in data analysis and AJ participated in performance of the research, research design, writing the paper and data analysis. Disclosures The authors of this manuscript have no conflicts of interest to disclose as described by Transplantation. Funding This work was supported by a T32 award 5T32DK007, in addition to a 135 VA Merit Award 1I01BX001737 to AJ and the 2014 American Society of Transplant Surgeons –Astellas Faculty Development Award to TN. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Impact of Early Initiated Everolimus on the Recurrence of Hepatocellular Carcinoma after Liver Transplantation

Background Many centers implement everolimus-based immunosuppression in liver transplant patients with hepatocellular carcinoma. We aimed to explore the potential impact of early initiated everolimus on tumor recurrence after liver transplantation. Methods This study included 192 patients with hepatocellular carcinoma undergoing liver transplantation among who 64 individuals were prospectively enrolled (2012-2015) and received early initiated everolimus (ie, started between postoperative day 15 to 21), while the remaining 128 patients acted as historical controls without everolimus. Propensity score matching was performed to ensure comparability. Multivariate Cox's regression and competing risks analysis were used to control for potential confounders. Results Patients with and without everolimus were comparable in terms of number of nodules (p=0.37), total tumor diameter (p=0.44), Milan criteria fulfillment (p=0.56) and histological differentiation (p=0.61), but there were increased microvascular invasion rates in the everolimus group (26.5% vs 13.3%; p=0.026). Tumor recurrence rates were similar with and without everolimus (10.9% vs 9.9% at 36 months respectively; p=0.18). After controlling for microvascular invasion among other potential confounders, everolimus had no significant impact on tumor recurrence, neither in the multivariate Cox regression (RR=3.23; p=0.09), nor in the competing risks analysis for tumor recurrence-death (RR=1.02; p=0.94). Patients receiving everolimus had reduced tacrolimus trough concentrations and lower serum creatinine within the first 18 months post-LT. Conclusion Everolimus may not be universally prescribed to prevent tumor recurrence in liver transplant patients with hepatocellular carcinoma. Future randomized trials should be focused on patients with histological features of increased tumor aggressiveness, in whom the potential benefit would be higher. These authors contributed equally to the present manuscript, Manuel Rodríguez-Perálvarez, PhD and Marta Guerrero, MD. CORRESPONDENCE INFORMATION: Prof. Manuel de la Mata, MD, PhD. Head of Department of Hepatology and Liver Transplantation at the Reina Sofía University Hospital, Córdoba, Spain. Address: Avda/Menéndez Pidal s/n, Postal code 14004, Córdoba, Spain. E-mail: mdelamatagarcia@gmail.com. Manuel De la Mata and Manuel Rodríguez-Perálvarez conceived the original idea and designed the study. Lydia Barrera, Gustavo Ferrín, María D. Ayllón, Gonzalo Suárez-Artacho, Carmen Bernal and Juan M. Pascasio enrolled patients and acquired the data. Manuel Rodríguez-Perálvarez, Marta Guerrero and Antonio Poyato analyzed the data. Manuel Rodríguez-Perálvarez and Marta Guerrero drafted the manuscript. Jose L. Montero, Javier Briceño, Javier Padillo, Luis M. Marín-Gómez and Manuel De la Mata critically revised the manuscript for important intellectual content. DISCLOSURE: The authors have no conflict of interest to disclose regarding the present manuscript. FUNDING: The present study was supported by the Instituto de Salud Carlos III (FIS PI11-02867 and PI14/01469) and co-funded by FEDER. Additional funding was granted by the Andalusian Society for Organ Transplantation (SATOT). M.R-P is a recipient of the Physician Scientist Fellowship awarded by the European Association for the Study of the Liver (EASL). The financial sources listed above had no vested interest in the results of the study. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Copyright

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2





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Contributors

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2





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Contents

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2





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Forthcoming Issues

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2





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Practice Management: Successfully Guiding Your Group into the Future

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2
Author(s): Amr E. Abouleish, Stanley W. Stead




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Overlapping Surgery

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2
Author(s): Amanda J. Morris, Joseph A. Sanford, Edward J. Damrose, Samuel H. Wald, Bassam Kadry, Alex Macario

Teaser

A keystone of operating room (OR) management is proper OR allocation to optimize access, safety, efficiency, and throughput. Access is important to surgeons, and overlapping surgery may increase patient access to surgeons with specialized skill sets and facilitate the training of medical students, residents, and fellows. Overlapping surgery is commonly performed in academic medical centers, although recent public scrutiny has raised debate about its safety, necessitating monitoring. This article introduces a system to monitor overlapping surgery, providing a surgeon-specific Key Performance Indicator, and discusses overlapping surgery as an approach toward OR management goals of efficiency and throughput.


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Quality Reporting

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2
Author(s): DeLaine Schmitz, Matthew T. Popovich

Teaser

Since the 1990s, the use of quality measures in healthcare has grown exponentially. Practices must maintain current knowledge of measures that affect their clinicians locally and understand how assessment of these medical professionals affects the priorities and quality activities of practices and facilities. Because quality measures are increasingly used by hospital administrators, health plans, and payers, practices are being asked to shoulder the additional burdens of collecting and reporting data to various entities. Part of the solution to this increased burden often includes contracting with vendors and outside experts, as well as identifying effective local physician and practice champions.


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Comprehensive Preoperative Assessment and Global Optimization

Publication date: June 2018
Source:Anesthesiology Clinics, Volume 36, Issue 2
Author(s): Neil N. Shah, Thomas R. Vetter

Teaser

To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.


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A Case of Medialized Lateral Maxillary Sinus Wall: A Pillar of Support

The number of maxillofacial trauma (MFT) cases attended in the Emergency Department is progressively increasing in trend, owing to the rising statistics of motor-vehicle accidents (MVAs) and urban assaults in addition to occupational-related injuries. Prompt and thorough assessment is important for accurate diagnosis and paramount treatment plans. We will be discussing a case of unusual presentation of an orbital floor fracture post-MVA which was treated conservatively based on the clinical assessments during follow-ups, supported by radiological findings. We will also briefly discuss the different radiological modalities available in assessing MFT and late presentation of enophthalmos.

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Hunter Syndrome Diagnosed by Otorhinolaryngologist

Hunter syndrome is a lysosomal disease characterized by deficiency of the lysosomal enzyme iduronate-2-sulfatase (I2S). It has an estimated incidence of approximately 1 in 1,62,000 live male births. We report a case of Hunter syndrome diagnosed by an otorhinolaryngologist. To our knowledge, this is the first study diagnosed by an otorhinolaryngologist despite the fact that otorhinolaryngological symptoms manifest at a young age in this disease. The patient was a 4-year-old boy. He underwent adenotonsillectomy. Intubation was difficult, and he had some symptoms which are reasonable as a mucopolysaccharidosis. The otorhinolaryngologist should play an integral role in the multidisciplinary approach to the diagnosis and management of many children with MPS (mucopolysaccharidoses) disorders.

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