Background: Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. Methods: In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl−) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. Results: Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [−1.0; 3.0] mmol/L; P
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Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Σάββατο 16 Ιουνίου 2018
Selection of Patients’ Recumbent Position Laterality According to Physician Handedness Bias Increases the Success Rate of Lumbar Puncture: A Multicenter Study
Background: Lumbar puncture (LP) is a medical procedure required during spinal anesthesia and for obtaining cerebrospinal fluid samples in the diagnosis of neurological disorders. The aim of this study was to assess the effects of physicians' handedness bias and the laterality of patients' recumbent position on the success rate of LPs. Methods and Patients: A prospective multicenter study including 36 physicians (18 left-handed and 18 right-handed) and 7200 patients was conducted in 6 medical centers. In each center, 1200 patients were randomized into group L (LPs performed by left-handed physicians) or group R (LPs performed by right-handed physicians). Each physician performed 200 cases of LPs, of which the laterality of the recumbent position (either on the left or right side) was decided after a second randomization. A successful LP was considered when the free flow of cerebrospinal fluid was observed upon the first attempt. Results: There was no significant difference in patient characteristics between groups L and R. Right-handed physicians had a significantly higher LP success rate with patients in the left lateral recumbent position (LRP) (1595/1800 vs. 1408/1800; odds ratio, 0.539; 95% confidence interval, 0.348-0.836; P=0.006). For left-handed physicians, the LP success rate was higher when patients were in the right LRP (1424/1800 vs. 1593/1800, odds ratio, 0.449; 95% confidence interval, 0.283-0.711; P=0.001). Patients' age, sex, height, and weight were not statistically related to LP success during multivariate analyses. Conclusions: Physicians handedness bias and patient laterality of recumbent position affects the success of LPs. Right-handed physicians have a greater chance of performing successful LPs when patients are in the left LRP, and vice versa. J.-L.Z. and Y.-R.S. contributed equally. Supported by the National Natural Science Foundation of China (81471241, 81271375, and 81171133), Shanghai Municipal Science and Technology Commission project (16411955300, 18441903300 and 18695841300), and Shanghai Minhang Natural Science Foundation (2014MHZ001). The authors have no conflicts of interest to disclose. Address correspondence to: Jin Hu, MD, PhD, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, P.R. China (e-mail: 286644104@qq.com). Received January 7, 2018 Accepted May 8, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
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https://ift.tt/2MuIWQ2
The causes and consequences of variation in human cytokine production in health
Melanie Schirmer | Vinod Kumar | Mihai G Netea | Ramnik J Xavier
https://ift.tt/2LWY0oN
Preoperative radiation and complication rates after double free flap reconstruction of head and neck cancer
In this study, we explore whether preoperative external beam radiation affects complication rates in patients that have undergone double simultaneous free tissue transfer for head and neck defects.
https://ift.tt/2My7WpS
Tired and Swollen: A Mono Mimic for Angioedema
Infectious mononucleosis (IM) secondary to Epstein-Barr virus (EBV) infection classically presents as a triad of cervical lymphadenopathy, fever and pharyngitis1 that is often accompanied by persistent fatigue. An uncommon presentation of early IM that has been reported rarely in the literature is periorbital edema. Here, we present a case of a 19 year-old female referred to allergy clinic for evaluation of angioedema. She was found to have periorbital swelling mistaken for angioedema and ultimately was diagnosed with IM despite lacking symptoms of the classic triad.
https://ift.tt/2JS37FX
Medical Treatment of Nasal Airway Obstruction
Nasal obstruction is a common, and potentially debilitating, problem. It is caused by a combination of structural factors and/or mucosal swelling/inflammation. The medical treatment of nasal obstruction is aimed at decreasing mucosal inflammation and edema and is generally guided by the underlying cause. Several different drug classes are commonly used in the treatment of nasal obstruction, each with different indications, and pros and cons to their use. This article discusses the most commonly used therapies for nasal obstruction. Current evidence on the efficacy and side effect profile of each therapy is reviewed.
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Prevalence of ALK gene alterations among the spectrum of plexiform spitzoid lesions
ALK gene rearrangements have been described in spitzoid lesions with plexiform growth pattern., ALK alterations characterize a significant subset of Spitz nevi and atypical Spitz tumors and can coexist with BRAF gene mutations., ALK immunohistochemistry represents a simple and relatively inexpensive ancillary technique to classify lesions with ALK gene alterations.
https://ift.tt/2LTe2jp
Clinical and Histopathological Features of Paraneoplastic Granuloma Annulare in Association with Solid Organ Malignancies: Case Control Study
Granuloma annulare (GA) is a granulomatous skin eruption rarely reported in association with solid organ, lymphoid, and blood malignancies., The clinical and histopathological features of paraneoplastic GA associated with solid organ malignancies are similar to classic GA., Cancer screening should be considered for patients with GA who display signs or symptoms concerning for underlying malignancy.
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Alternative Uses of Dermatoscopy In Daily Clinical Practice: An Update
Dermatoscopy is mainly used for the diagnosis of pigmented and non-pigmented skin tumours, The use of dermatoscopy beyond skin tumours is constantly increasing, Dermatoscopy may enhance the clinical diagnosis of various skin disorders, narrowing down the differential diagnosis and avoiding, in selected cases, unnecessary skin biopsy
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Overcoming heparin resistance in pregnant women with antithrombin deficiency: a case report and review of the literature
The risk of thromboembolic events during pregnancy in patients with antithrombin deficiency is increased. Preventing thromboembolic events during pregnancy in the case of antithrombin deficiency is still a mat...
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Intracranial complications of pediatric sinusitis: Identifying risk factors associated with prolonged clinical course
Publication date: September 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 112
Author(s): Alexander J. Schupper, Wen Jiang, Michael J. Coulter, Matthew Brigger, Javan Nation
ObjectiveIntracranial extension is one of the most serious and morbid complications of pediatric sinusitis. Managing this complication continues to be challenging even after widespread pneumococcal vaccination adoption. We aim to identify risk factors associated with complicated clinical courses, and to assess for altering microbial communities and increased antibiotic resistance.MethodsA retrospective review was conducted of sinus procedures performed at a single institution for acute sinusitis with intracranial extension, and 16 cases were identified. Variables collected included patient demographics, vaccination status, laboratory results, imaging data, antibiotic therapy, sinus and intracranial cultures, perioperative and surgical reports, and hospital course.ResultsThe average patient age was 11.9 years, and 75% were male. The dominant microbial organisms were gram positive in 93.8% (15/16) of cases and 37.5% (6/16) were anaerobic. There were no cases of resistant bacterial growth, and only one case of Streptococcus pneumoniae. Increased antibiotic therapy duration was associated with anaerobic and polymicrobial sinus cultures. A significant increase in length of hospital stay was identified in polymicrobial sinus cultures and frontal sinus involvement. Intracranial abscess re-accumulation was associated with sinus cultures positive for fusobacterium (p = 0.036), polymicrobial infections (p = 0.034), and involvement of brain parenchyma (p = 0.036). Patients with frontal sinus involvement required a greater number of surgical procedures for abscess drainage (p = 0.046). An anaerobic intracranial culture was associated with an increased number of revision craniotomies (p < 0.001). Parenchymal involvement of the infection was associated with an increased number of surgical complications.ConclusionsFrontal sinus involvement, and anaerobic and polymicrobial sinus cultures were predictive of a more severe infection requiring more surgical interventions, prolonged intravenous antibiotic treatment and overall hospital length of stay. Streptococcus pneumoniae was not prevalent in our series, and there seems to be a shift in the microbial profile of this patient subset, compared to previous studies, which can likely be attributed to the adoption of pneumococcal vaccinations. Sinus cultures were more predictive of a complicated clinical course compared to intracranial cultures, suggesting the importance of a thorough sinus debridement and obtaining directed sinus cultures.
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Turkish Adaptation of the Pediatric Voice Related Quality of Life Survey: A validity and reliability study
Publication date: August 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 111
Author(s): Rahşan Çinar, Çağıl Gökdoğan, Yusuf Kemal Kemaloğlu, Metin Yılmaz
ObjectivesChildhood voice disorders have increased in recent years reduce not only communication of the child, but also; the quality of life by affecting the socio-emotional state.MethodsIn the study, it is aimed to test validity and reliability of Pediatric Voice Related Quality of Life Survey (PVRQOL)'s Turkish adaptation. A total of 223 individuals aged between 2 years and 18 years, with and without voice problems were involved in this study.ResultsStatistically significant differences were found between study and control groups for total score and sub domain scores for PVRQOL (p < 0,001). Total score of quality of life was higher in the control group. Cronbach alpha coefficient for overall PVRQOL was 0,922; dimension of physical function was 0,894 and socio-emotional domain was 0,804. In the test-retest reliability test, overall PVRQOL was found to be 0,732; physical functional sub domain was 0,734; socio-emotional sub domain was 0,721. The validity of the questionnaire was determined by factor analysis.ConclusionThe results suggest that the Turkish version of the PVRQOL has reliability and validity, and may play a crucial role in evaluating children with voice disorders.
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Including auditory tube function on models is relevant to assess water exposure after tympanostomy tubes–Multiphase computerized fluid dynamics model
Source:International Journal of Pediatric Otorhinolaryngology, Volume 111
Author(s): Joao Subtil, Nuno Martins, Teresa Nunes, Didia Covas, Paulo Vera-Cruz, Richard Voegels, Joao Paco
IntroductionMyringotomy with tympanostomy tube is the most common otologic surgery and some patients are still advised to avoid water. However, there is no evidence supporting this, with published papers questioning the need for this advice.MethodsA Multiphase Computational Fluid Dynamics (CFD) model was created using computerized tomography images of a child's healthy ear. It was then used to study the flow of fluids through the external ear, tympanic cavity, and auditory tube, with and without submersion.ResultsThe model accurately described the behavior of the air retained in the patient's nasopharynx and tympanic cavity. A simulated elevation of pressure in the external auditory canal without submersion, without increase of pressure in the nasopharynx, demonstrated that fluids promptly crossed the tympanostomy tube into the middle ear. However, simulated elevation of pressure in the external auditory canal with concurrent elevation of air pressure in the nasopharynx during submersion did not lead to passive tube opening nor to any detectable flow through the tympanostomy tube.ConclusionsIn the model, submersion increases pressure in the nasopharynx which offsets the pressure in the external auditory canal. So, in the absence of a pressure gradient, no passive tubal opening took place, and no air or fluid flow was detected through the transtympanic tube.This model now includes the exhaust function of the auditory tube in the model and shows its relevance.
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What Is the Relationship Between Eosinophilic Esophagitis (EoE) and Aeroallergens? Implications for Allergen Immunotherapy
Abstract
Purpose of Review
Observations suggesting that aeroallergens trigger eosinophilic esophagitis (EoE) in a subset of patients raise questions about the implications this finding has on the evaluation and management of patients with EoE, including a potential role for allergen immunotherapy.
Recent Findings
The majority of studies evaluating the potential role of aeroallergens as provocateurs of EoE have addressed this issue by assessing the seasonal variation in EoE diagnosis and/or symptom onset or worsening, with mixed results. For various reasons, reaching accurate conclusions based on this methodology is potentially fraught with error. In addition, studies examining the even harder to assess role of perennial aeroallergens in triggering EoE are lacking. Although clearly not the majority, there may be a subset of patients with EoE and allergic rhinitis in whom exposure to aeroallergens to which they are sensitized contributes to esophageal eosinophilia either through direct chronic esophageal mucosal contact with pollen allergens or from repetitive exposure of the esophageal mucosa to pollen allergens, mediators, and eosinophils in swallowed nasal secretions. Therefore, evaluation for and optimal treatment of comorbid allergic rhinitis in EoE patients are clearly indicated. Recognition of the potential role of aeroallergens as triggers of EoE also raises the question of whether allergen immunotherapy might be an effective form of EoE treatment. Reports of sublingual immunotherapy (SLIT) inducing EoE support the notion that aeroallergens can trigger EoE, but negate this approach as a potential form of EoE therapy. In fact, the use of SLIT is contraindicated in patients with EoE. The literature regarding the role of subcutaneous immunotherapy (SCIT) in patients with EoE is limited. Current evidence indicates that it should not be typically recommended; however, SCIT might benefit a subset of patients with EoE and uncontrolled allergic rhinitis on conventional therapies in whom SCIT would otherwise be indicated for allergic rhinoconjunctivitis, particularly in those with sensitizations to pollens containing allergens that cross react with food allergens.
Summary
The purpose of this review is to discuss the current literature examining the role of aeroallergens in triggering EoE with a focus on the potential clinical implications of this finding on managing patients with EoE.
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Oncogenic drivers in 11q13 associated with prognosis and response to therapy in advanced oropharyngeal carcinomas
Source:Oral Oncology, Volume 83
Author(s): M.C. Barros-Filho, L.A. Reis-Rosa, M. Hatakeyama, F.A. Marchi, T. Chulam, C. Scapulatempo-Neto, U.R. Nicolau, A.L. Carvalho, C.A.L. Pinto, S.A. Drigo, L.P. Kowalski, S.R. Rogatto
ObjectivesTo identify potential molecular drivers associated with prognosis and response to treatment in advanced oropharyngeal squamous cell carcinomas (OPSCC).Materials and methodsThirty-three OPSCC biopsies from untreated Brazilian patients were evaluated for human papilloma virus genotyping, genome wide copy number alterations and gene expression profiling. Data were integrated using CONEXIC algorithm. Validation with TCGA dataset and confirmation by RT-qPCR of candidate genes were performed.ResultsHigh-risk HPV positive cases, detected in 55% of advanced OPSCC, were associated with better outcome. Losses of 8p11.23-p11.22, 14q11.1-q11.2 and 15q11.2, and gains of 11q13.2 and 11q13.2-q13.3 were detected as recurrent alterations. Gains of 3q26.31 and 11q13.2 and losses of 9p21.3 were exclusively detected in HPV-negative tumors. Two clusters of expression profiles were observed, being one composed mostly by HPV positive cases (83%). HPV-positive enriched cluster showed predominantly immune response-related pathways. Integrative analysis identified 10 modulators mapped in 11q13, which were frequently cancer-related. These 10 genes showed copy number gains, overexpression and an association with worse survival, further validated by TCGA database analyses. Overexpression of four genes (ORAOV1, CPT1A, SHANK2 and PPFIA1) evaluated by RT-qPCR confirmed their association with poor survival. Multivariate analysis showed that PPFIA1 overexpression and HPV status are independent prognostic markers. Moreover, SHANK2 overexpression was significantly associated with incomplete response to treatment.ConclusionThe integrative genomic and transcriptomic data revealed potential driver genes mapped in 11q13 associated with worse prognosis and response to treatment, giving fundamentals for the identification of novel therapeutic targets in OPSCC.
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Risk of plate removal in free flap reconstruction of the mandible
Source:Oral Oncology, Volume 83
Author(s): C. Burton Wood, Justin R. Shinn, Shaunak N. Amin, Sarah L. Rohde, Robert J. Sinard
ObjectivesTo evaluate the factors associated with need for removal of fixation plates in mandibular free flap reconstruction.MethodsThis retrospective cohort analysis reviews patients undergoing mandibular free flap reconstruction at a tertiary care center from 2005 to 2016. Patients requiring removal of fixation plates were identified through electronic medical records. Factors including demographics, adjuvant therapy, surgical site infection (SSI) and fistula rates were compared. Removal rates based on flap type were determined.ResultsBetween 2004 and 2016, 307 patients underwent osteocutaneous mandibular free flap reconstruction. 83 required removal of their fixation plates (27%). Age, tobacco use, and BMI were similar between patients requiring removal versus not requiring removal. Primary indications for removal were plate exposure (n = 41), and/or chronic drainage (n = 31), infection (n = 25), and pain (n = 17). Patients undergoing removal were significantly more likely to have had adjuvant radiation therapy (OR 2.09, CI 1.82–3.81), surgical site infection (OR 13.9, CI 5.15–43.2), and post-operative fistula (OR 13.0, 6.85–24.8). 35% of all fibula flaps (n = 52), 21% of osteocutaneous radial forearm (n = 21), and 11% of osteocutaneous scapular flaps (n = 6) required removal. 90% of patients (n = 75) had resolution of their symptoms following hardware removal.ConclusionSurgical site infection and fistula are strongly associated with the need for plate removal. Fibular free flaps carry the highest rate of plate removal. Plate removal leads to resolution of plate-associated symptoms in a majority of cases.
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