SUNCT and SUNA: an Update and Review

Abstract

Purpose of Review

The purpose of this review is to provide an update on the clinical features, diagnosis, pathogenesis, epidemiology, and treatment of the rare primary headache disorders short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA). Together these entities are known as short-lasting unilateral neuralgiform headache attacks (SUNHA).

Recent Findings

Recent case reports of secondary SUNCT and SUNA due to medullary infarcts support the theory that the trigeminohypothalamic pathway is involved in the pathophysiology of SUNHA. While medical therapy for SUNHA has not significantly changed, surgical therapy for refractory SUNCT and SUNA has made advancements with a recent case series demonstrating the efficacy of deep brain stimulation.

Summary

We will discuss the pathophysiology of both the pain and the autonomic symptoms experienced in SUNCT and SUNA attacks as well the medical, procedural, and surgical options for treatment with emphasis on recent advances. Specific secondary causes reported in the recent literature will be discussed in brief.

https://ift.tt/2lqm0VY

CO 2 Laser for De-epithelialization in Tympanoplasty

Abstract

Tympanoplasty repairs tympanic membrane perforations but also covers an umbrella of procedures characterized by surgery of the mastoid bone. Tympanoplasty is widely regarded as a beneficial procedure with an over 90% graft closure success rate and an over 80% return to normal hearing range. Though surgical technique and graft type are important in determining surgical outcomes of the procedure, results are most greatly correlated with location of the perforation. Marginal perforations are associated with the most complications in reconstruction of the tympanic membrane, lack of vascularization and limited membrane area delaying the healing process (4). Lasers have been used in medical procedures dating back to the 1960s. The advantage of infrared lasers such as CO₂ are the precision of cutting and the smooth interaction with tissues (5). The CO₂ laser is absorbed by the tympanic membrane and does not damage the middle ear while visible lasers penetrate and can damage the ear drum (6). This retrospective study of 150 patients from 2013–2016 assesses and demonstrates the viability of using carbon dioxide laser as an alternative to the traditional method for de-epithelialization of tympanic perforation margins during tympanoplasty. By comparing closure rates and audiogram data, this study reveals parameters of use, benefits and adverse outcomes on healing and hearing restoration with the CO₂ laser-assisted method. Perforation closure rate of 91% and hearing improvement in 66% of patients was observed. Fourteen patients did not undergo closure of the tympanic membrane with an overwhelming majority of the 14 having large and marginal perforations.

https://ift.tt/2K5TQgN

Cochlear Implant in Prelingually Deaf Children: Our Experience

Abstract

Retrospective study of the prelingual cochlear implantation programme under government scheme done at medical college hospital in central India. Forty-two prelingually deaf children screened and sent for cochlear implantation at our centre From March 2015 to Feb 2018 were reviewed with respect to their age, sex, preimplantation hearing aid use, surgical technique for cochlear implantation, type of FDA (USA) approved cochlear implant, post operative speech therapy and its outcome with respect to categories of auditory perception and speech intelligibility scoring were compared for children younger than 4 years and older than 4 years. For outcome measurement non parametric statistical method was used for any significance between the two groups. There was a wide range of children implanted ranging from 2 to 7 years. Both varia and mastoidectomy and posterior tympanotomy method of cochlear implantations were done with good rate complete insertion and electrode activation. There was no significant difference between the two group with regard to CAP and SIR outcomes after 1 year. In order to get better outcomes with respect to the speech language development, there is need to strengthen the early identification and cochlear implantation before 4 years of age in government approved schemes.

https://ift.tt/2K37Ft7

Role of Preincisional Peritonsillar Infiltration of Bupivacaine in Postoperative Pain Relief in Tonsillectomy Patients

Abstract

Tonsillectomy is one of the most common surgical procedures carried out in ENT since ancient time, is associated with several morbidities in which the pain and bleeding being the commonest and can cause considerable delay in starting oral intake and discharge from the hospital. Different methods have been used to reduce posttonsillectomy pain including use of opioids, sucralfate and local anaesthetics. Local anaesthetics in the form of pre-incisional or post-incisional peritonsillar infiltration and also topical post-incisional spray or packing are some of the most effective methods for post-tonsillectomy pain management. In our hospital, a study was carried out for preincisional peritonsillar infiltration of 0.5% bupivacaine in tonsillectomy patients for post operative pain relief. Written informed valid consent was taken, all routine investigations were done. Pre anaesthetic check up was done and bupivacaine test dose was given, none of the patients showed allergic reactions. Our study showed that this is effective method of controlling post operative pain. Patients receiving bupivacaine showed lower pain scores 6 h post operatively. The mean pain scores for Bupivacaine group were 2.85, 5.52 and 7.04 versus 5.04, 7.04 and 7.61 in saline group at 2, 4, and 6 h post operatively (t value significant). Pre incisional peritonsillar infiltration of 0.5% bupivacaine significantly reduces postoperative pain till 6 h, thereby reducing the need of analgesics intraoperatively and post operatively. Oral intake was also earlier without any adverse effects in our study.

https://ift.tt/2Ke08ei

Superior vena cava syndrome presenting as position-dependent periorbital oedema

Description 

A 54-year-old woman presented to our dermatology clinic with a 2 months history of periorbital oedema, more prominent after lying down in horizontal position. Her face and throat felt swollen. She experienced dyspnoea on exertion, fatigue and had lost 6 kg of weight. Treatment with antihistamines and oral prednisone were ineffective. She smoked one pack of tobacco per week. Medical history and family history were unremarkable. She did not use any medications. Physical examination revealed prominent periorbital oedema and facial swelling (figure 1). Chest radiograph revealed a pathologically enlarged right hilum, broadened mediastinum and modest pleural effusion (figure 2). Diagnosis of superior vena cava syndrome (SVCS) was made and the patient was referred to the pulmonologist.

Figure 1

Prominent periorbital oedema and facial swelling after lying down the night before as a presenting symptom of superior vena cava syndrome.

...

https://ift.tt/2loGui0

Acute locked superior shoulder dislocation in a patient with cuff tear arthropathy

In the field of traumatic shoulder dislocations, this report of a 61-year-old female patient discusses the case of an acute locked superior shoulder dislocation in conjunction with a chronic rotator cuff arthropathy resulting from a low-energy fall on the outstretched and abducted arm. Radiological assessment revealed a complex combination of associated bony injuries including a fracture of the upper part of the glenoid and an impaction fracture of the inferior articular surface of the humeral head. Closed reduction and immobilisation were not successful in obtaining joint stability. This unique report highlights the clinical importance of accurate management of bony injuries in traumatic shoulder dislocation.

https://ift.tt/2yu8IRJ

Renal pelvicalyceal rupture secondary to extraperitoneal pelvic packing (EPP) in the unstable trauma patient

Presented here is the case of an 86-year-old man who was found to have right-sided pelvicalyceal rupture and anuric renal failure, secondary to obstructive uropathy caused by life-saving extraperitoneal pelvic packing (EPP) in the settling of severe trauma. In efforts to control haemorrhage in this haemodynamically unstable patient, EPP placement deviated from the recognised method of three extraperitoneal packs bilaterally with seven surgical packs placed. Progress postoperative imaging revealed right-sided hydroureteronephrosis with obstruction evident at the level of the extraperitoneal pelvic packs, identified by delayed contrast excretion from the preceding CT angiography imaging. Urology performed bilateral retrograde pyelograms at his relook laparotomy, timed after removal of his extraperitoneal packs and haemostasis, which showed impression of the surgical pack on the distal ureter but no persisting obstruction or short-term complications. Anuric renal failure improved, and renal function returned to near premorbid levels on day 4 postoperatively.

https://ift.tt/2lrkx1P

Massive faecal impaction leading to abdominal compartment syndrome and acute lower limb ischaemia

Abdominal compartment syndrome (ACS) is associated with significant morbidity and mortality requiring prompt treatment. We report a rare case of a 57-year-old man who developed acute lower limb ischaemia, severe metabolic acidosis and renal impairment from massive faecal impaction of unknown aetiology resulting in ACS causing occlusion of the right common iliac artery. This was treated with faecal disimpaction, which eventually resulted in slow but full recovery.

https://ift.tt/2tq1oR7

Laparoscopic revisional surgery for an unusual complication of Roux-en-Y gastric bypass

With the worldwide epidemic of obesity, there has been an increase in the numbers of primary and revisional procedures of bariatric surgery such as the Roux-en-Y gastric bypass (RYGBP). Nevertheless, this type of surgery is not exempt from complications. An excessive length of non-functional Roux limb proximal to the jejunojejunostomy can cause abnormal upper gastrointestinal symptoms after laparoscopic RYGBP. We present the case of a female patient who presented these unspecific abdominal symptoms after laparoscopic RYGBP who underwent laparoscopic resection in order to reduce the length of the dilated blind loop responsible for the symptoms.

https://ift.tt/2lnjuzR

Gorlin-Goltz syndrome: first reported case of bullae in the lungs complicated with tension pneumothorax

A 13-year-old girl was referred by her general practitioner with acute worsening exertional dyspnoea and sudden onset of left-sided chest pain. There was no associated trauma, palpitations or syncope. Clinical examination revealed that the left lung was hyper-resonant on percussion with reduced air entry on auscultation. Chest X-ray showed a left tension pneumothorax. She was treated conservatively with chest drain. Follow-up X-ray revealed multiple bullae within her left lung. Unfortunately, she redeveloped a pneumothorax and was sent to a tertiary centre. She was under the care of the paediatric cardiothoracic surgeons who organised a CT thorax and performed a lobectomy to remove the bullae. She was discharged from the tertiary centre and currently being followed up under the care of the paediatrician in the district general hospital. She have not developed any further pneumothoraxes.

https://ift.tt/2yE3dA7

Posterior root medial meniscus reconstruction: an option in chronic posterior root meniscal injury management

Posterior root medial meniscus (PRMM) tears have shown to be biomechanically equivalent to complete meniscectomy. Drawbacks from PRMM tears repair are unsatisfactory healing rates. In this case report, we outlined a PRMM reconstruction with gracilis graft healing outcome in chronic PRMM tear case, based on clinical and MRI evaluation. A 60-year-old man reported a chief complaint of increasing pain on the right knee joint in the last 1 year after a deep-flexion injury. On MRI investigation, we confirmed the chronic PRMM tear as Osteoarthritis Kellgren-Lawrence grade II. Then, we planned to perform a PRMM reconstruction with gracilis graft per arthroscopy. At the 6-month MRI evaluation, we found healing of the attached PRMM on its footprints, with intact graft transition from the meniscus to the tibial bone tunnel.

https://ift.tt/2ll2KZX

Symptomatic dyspnoea addressed by excision of ossified anterior longitudinal ligament

Ossification of the anterior longitudinal ligament (OALL) in cervical spine is known to cause dysphagia. However, dyspnoea and obstructive sleep apnoea (OSA) due to OALL is a rare entity. A 50-year-old man presented to our clinic 2 years after anterior cervical discectomy and fusion (ACDF) with complaints of dysphagia, dyspnoea and difficulty in sleeping supine. The clinico-neurological examination of patient was normal without any long tract signs. The diagnosis of OALL was made on plain lateral radiographs. Ultrasonic bone cutter was used to convert sessile osteophyte mass into a pedunculated mass. It was then disconnected from the anterior aspect of vertebral bodies with a chisel. The patient showed immediate relief from dysphagia and OSA. Dyspnoea improved over a week and the postoperative change in voice responded well to speech therapy. To the best of our knowledge, this is the first report of dyspnoea due to OALL after ACDF.

https://ift.tt/2ytbeHF

Long-term control of laryngeal plasma cell mucositis with systemic immunosuppression

Plasma cell mucositis (PCM) is a rare non-neoplastic plasma cell proliferative disorder of the mucous membranes, which typically presents as soft tissue lesions involving oral, upper airway or genital mucosa. Laryngeal involvement resulting in stridor has been reported in four other cases previously, with three requiring tracheostomy. We present a case of supraglottic stenosis in a 53-year-old woman presenting with dysphonia and stridor, requiring surgical resection on three occasions accompanied by tracheostomy on two occasions; biopsy was consistent with PCM. Due to relapsing disease activity, high-dose prednisolone and mycophenolate mofetil were commenced with prednisolone eventually being ceased. After 2 years of mycophenolate mofetil therapy, the patient's disease has been controlled without need for further surgical intervention. This is the first reported case of prolonged symptomatic improvement with the use of systemic immunosuppressive therapy with mycophenolate mofetil in PCM.

https://ift.tt/2lnjrEb

Tuning B cell responses to antigens by cell polarity and membrane trafficking

Publication date: September 2018
Source:Molecular Immunology, Volume 101
Author(s): Felipe del Valle Batalla, Ana-María Lennon-Dumenil, María-Isabel Yuseff
The capacity of B lymphocytes to produce specific antibodies, particularly broadly neutralizing antibodies that provide immunity to viral pathogens has positioned them as valuable therapeutic targets for immunomodulation. To become competent as antibody secreting cells, B cells undergo a series of activation steps, which are triggered by the recognition of antigens frequently displayed on the surface of other presenting cells. Such antigens elicit the formation of an immune synapse (IS), where local cytoskeleton rearrangements coupled to mechanical forces and membrane trafficking orchestrate the extraction and processing of antigens in B cells. In this review, we discuss the molecular mechanisms that regulate polarized membrane trafficking and mechanical properties of the immune synapse, as well as the potential extracellular cues from the environment, which may impact the ability of B cells to sense and acquire antigens at the immune synapse. An integrated view of the diverse cellular mechanisms that shape the immune synapse will provide a better understanding on how B cells are efficiently activated.



https://ift.tt/2MIPKtu

Amyotrophic lateral sclerosis: The complement and inflammatory hypothesis

Publication date: Available online 20 June 2018
Source:Molecular Immunology
Author(s): Anne-Lene Kjældgaard, Katrine Pilely, Karsten Skovgaard Olsen, Stephen Wørlich Pedersen, Anne Øberg Lauritsen, Kirsten Møller, Peter Garred
Amyotrophic lateral sclerosis (ALS) is a devastating, neurodegenerative motor neuron disease. The aetiology of ALS remains an enigma which hinders the design of an effective treatment to prevent, postpone, or reverse the pathophysiological changes occurring during the aggressive progression of this disease.During the last decade, basic research within the innate immune system, and in particular the complement system, has revealed new, important roles of the innate immune system during development, homeostasis, and ageing within as well as outside the central nervous system. Several lines of evidence indicate that aberrant activation of the complement system locally in the central nervous system as well as systemically may be involved in the pathophysiology of ALS. This exciting new knowledge could point towards the innate immune system as a potential target of medical intervention in ALS. Recently, the historic perception of ALS as a central neurodegenerative disease has been challenged due to the significant amount of evidence of a dying-back mechanism causing the selective destruction of the motor neurons, indicating that disease onset occurs outside the borders of the blood-brain-barrier. This review addresses the function of the innate immune system during ALS. We emphasize the role of the complement system and specifically suggest the involvement of ficolin-3 from the lectin pathway in the pathophysiology of ALS.



https://ift.tt/2yvPgE0

Hsp90/Sec22b promotes unconventional secretion of mature-IL-1β through an autophagosomal carrier in porcine alveolar macrophages during Mycoplasma hyopneumoniae infection

Publication date: September 2018
Source:Molecular Immunology, Volume 101
Author(s): Zhenzhen Zhang, Yanna Wei, Beibei Liu, Yuzi Wu, Haiyan Wang, Xing Xie, Zhixin Feng, Guoqing Shao, Qiyan Xiong
Interleukin-1β (IL-1β) is a critical inflammatory regulator in response to Mycoplasma hyopneumoniae infection. However, the mechanism involved in the secretion of IL-1β during Mycoplasma hyopneumoniae infection is unclear. In this study, we demonstrated that Mycoplasma hyopneumoniae infection increased the secretion of mature-IL-1β (m-IL-1β), but not pro-IL-1β, in porcine alveolar macrophages. Moreover, Mycoplasma hyopneumoniae infection promoted the generation of autophagosomes, which attributed to the unconventional secretion of m-IL-1β. Further results revealed that Hsp90 was required for the entry of m-IL-1β into autophagosomes during Mycoplasma hyopneumoniae infection. The fusion of m-IL-1β-containing autophagosome and plasma membranes was regulated by Sec22b and independent of lysosomal dysfunction. In conclusion, we provide evidence that Hsp90/Sec22b promotes the unconventional secretion of IL-1β through an autophagosomal carrier during Mycoplasma hyopneumoniae infection. The elucidation of the molecular and cellular machinery in Mycoplasma hyopneumoniae infected mammalian cells in this study suggests avenues for further study and applications and paves the way for novel therapeutic strategies to prevent tissue damage in mycoplasma-associated diseases.



https://ift.tt/2tdzYi3

Complement analysis in the era of targeted therapeutics

Publication date: Available online 20 June 2018
Source:Molecular Immunology
Author(s): Zoltán Prohászka, Michael Kirschfink, Ashley Frazer-Abel
Complement immunobiology, and with it complement analysis, has undergone a renaissance in the past decade. Classically, complement analysis was limited number of testing C3, C4 in a routine laboratory with the possible addition of CH50 with all other analysis being performed at only few highly esoteric laboratories. This diagnostics expanding beyond specialized laboratories is the result of the growing recognition of the role played by complement dysfunction in many more diseases and disorders and the concomitant increase in interest in complement targeting therapeutics. In response, laboratories specializing in complement analysis have joined with the International Complement Society and the IUIS to coordinate efforts to standardize and improve complement testing, ongoing efforts that have already borne fruit. A recognition of the power of complement analysis has brought forward new testing but also realization of the importance of post-draw specimen handling to limit ex vivo activation, as well as the sometimes large difference between testing laboratory results. The increased usefulness of complement analysis and efforts to standardize and expand it means the future is strong for complement analysis.



https://ift.tt/2tqIk5t

Chilaiditi Syndrome: A Case Report Highlighting the Intermittent Nature of the Disease

Background. Chilaiditi syndrome is a phenomenon where there is an interposition of the colon between the liver and the abdominal wall leading to clinical symptoms. This is distinct from Chilaiditi sign for which there is radiographic evidence of the interposition, but is asymptomatic. Case Presentation. Here, we present the case of a patient who, despite having clinical symptoms for a decade, had a delayed diagnosis presumably due to the interposition being intermittent and episodic. Conclusions. This case highlights the fact that Chilaiditi syndrome may be intermittent and episodic in nature. This raises an interesting question of whether previous case reports, which describe complete resolution of the syndrome after nonsurgical intervention, are perhaps just capturing periods of resolution that may have occurred spontaneously. Because the syndrome may be intermittent with spontaneous resolution and then recurrence, patients should have episodic follow-up after nonsurgical intervention.

https://ift.tt/2I9CTNn

Zufallsbefund eines Dens invaginatus in der digitalen Volumentomographie

Laryngo-Rhino-Otol
DOI: 10.1055/a-0640-9305

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Full text

https://ift.tt/2MG0LMe

Nasal Obstruction Considerations in Sleep Apnea

Obstructive sleep apnea (OSA) is a highly prevalent condition in the context of the global obesity epidemic with significant medical comorbidities and psychosocial implications. The first-line treatment of OSA is continuous positive airway pressure (CPAP). There is evidence to demonstrate an association between nasal obstruction and OSA. Therefore, medications and surgical interventions to address nasal obstruction may play a role in the treatment of OSA. In addition, surgical correction of nasal obstruction has been shown to improve CPAP tolerance and compliance.

https://ift.tt/2K7qETH

Diagnostic yield of MRI of the brain and IAC in patients with neurotologic complaints

Quantify number of MRI scans obtained in a tertiary neurotology practice and identify likelihood of pathologic findings.

https://ift.tt/2K7R6iX

Olfactory cleft dilatation

Publication date: Available online 20 June 2018
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): R. Jankowski, D.T. Nguyen, P. Gallet, C. Rumeau
The surgical technique of olfactory cleft dilatation consists in transmucosal lateral fracture-dislocation of the lateral wall of each olfactory cleft (i.e., of the turbinate wall of the ethmoid, composed, from anterior to posterior, of the middle, superior and supreme turbinates), in order to get access to the recess hosting the human olfactory mucosa and to the roof of the olfactory cleft (i.e., cribriform plate), with minimal trauma to the mucosa. Olfactory cleft dilatation is indicated for dysosmia secondary to constitutional stenosis of the olfactory clefts due to abnormal development of the ethmoid. Constitutional stenosis of the olfactory clefts should be differentiated from inflammatory obstruction and other diseases of the olfactory clefts, and especially from respiratory epithelial adenomatoid hamartoma, which enlarges the olfactory clefts and must be treated by resection. The technique of olfactory cleft dilatation is illustrated by three surgical cases. There was clear improvement in dysosmia in all three cases, without any complications. The place of constitutional olfactory cleft stenosis needs still to be defined in both diagnosis and treatment of dysosmia.



https://ift.tt/2K4qhcc

French Society of ENT (SFORL) guidelines (short version): Audiometry in adults and children

Publication date: Available online 19 June 2018
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): V. Favier, C. Vincent, É. Bizaguet, D. Bouccara, R. Dauman, B. Frachet, F. Le Her, C. Meyer-Bisch, S. Tronche, F. Sterkers-Artières, F. Venail
IntroductionFrench Society of ENT (SFORL) good practice guidelines for audiometric examination in adults and children.MethodsA multidisciplinary working group performed a review of the scientific literature. Guidelines were drawn up, reviewed by an independent reading group, and finalized in a consensus meeting.ResultsAudiometry should be performed in an acoustically controlled environment (<30dBA); audiometer calibration should be regularly checked; and patient-specific masking rules should be systematically applied. It should be ensured that masking is not overmasking. Adult pure-tone audiometry data should be interpreted taking account of clinical data, speech audiometry and impedancemetry. In case of discrepancies between clinical and pure-tone and speech audiometry data, objective auditory tests should be perform. In children aged 2 years or younger, subjective audiometry should be associated to behavioral audiometry adapted to the child's age. In suspected hearing impairment, behavioral audiometry should be systematically supplemented by objective hearing tests to determine and confirm the level and type of hearing impairment.



https://ift.tt/2Ka3Buq

How to perform microscopic/endoscopic resection of large petrous apex lesions

Publication date: Available online 20 June 2018
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): V. Patron, M. Humbert, E. Micault, E. Emery, M. Hitier
The endoscope and microscope can be used conjointly in certain sites, such as middle ear cholesteatoma or for resection of cerebellopontine angle tumours. Petrous apex tumours are classically accessed via a lateral otological approach, or, for the most anterior tumours, via an endonasal endoscopic approach. Surgical access via a lateral incision is limited inferiorly by the superior bulb of the internal jugular vein, medially by the labyrinth, facial nerve and internal auditory canal, superiorly by the dura mater, and laterally by the internal carotid artery. Via an anterior endonasal approach, the corridor formed by the internal carotid artery and the paraclival dura limits access to the posterior part of the petrous apex, restricting this approach to certain cholesterol granulomas or small cholesteatomas. None of these approaches, on its own, is sufficient in the case of an extensive petrous apex lesion. The objective of this technical note is to describe the combined microscopic/endoscopic approach comprising sequential use of the microscope and the endoscope via a lateral approach for the management of large petrous apex lesions.



https://ift.tt/2I9bWJI

The effect of cochlear implants on vestibular-evoked myogenic potential responses and postural stability

Current spread by electrical stimulation via inserted cochlear implant (CI) electrodes and the consequential increase in sound input can affect the equilibrium of patients. The aim of the present study was to clarify the effect of CIs on the equilibrium of patients through cervical vestibular-evoked myogenic potential (cVEMP) testing and static stabilometry performed with the CIs turned on (CI-on) and off (CI-off).

https://ift.tt/2tpKT7N

Splenogonadal fusion - a rare cause of scrotal swelling: a case report

Splenogonadal fusion is a rare and benign condition. Diagnosis is challenging for clinicians. Despite its indolence, diagnosis is often confirmed after orchidectomy. Surgery is mandatory, particularly to rule ...

https://ift.tt/2yt5n5i

Having small‐for‐gestational‐age infants was associated with maternal allergic features in the JECS birth cohort

Allergy, EarlyView.


https://ift.tt/2tnDfLe

Randomized controlled trials define shape of dose response for Pollinex Quattro Birch allergoid immunotherapy

Allergy, EarlyView.


https://ift.tt/2MK55u7

Preventing Atopic Dermatitis and ALLergies in Children—the PreventADALL study

Allergy, EarlyView.


https://ift.tt/2tqFpcK

Anaphylaxis admissions to pediatric intensive care units in France

Allergy, EarlyView.


https://ift.tt/2t9w5uL

Psoriasis: implication to disease and therapeutic strategies, with an emphasis on drug delivery approaches

International Journal of Dermatology, EarlyView.


https://ift.tt/2locliM

Specialist perioperative allergy clinic services in the UK 2018: Results from the Royal College of Anaesthetists Sixth National Audit Project (NAP6) investigation of perioperative anaphylaxis

Clinical &Experimental Allergy, EarlyView.


https://ift.tt/2KaHcgD

Allergy in the elderly: A case note review of referrals to an adult allergy clinic

Clinical &Experimental Allergy, EarlyView.


https://ift.tt/2I68dwP

Case of infective endocarditis caused by implanted artificial hair pyoderma

The Journal of Dermatology, EarlyView.


https://ift.tt/2I6QMvW

Incontinentia pigmenti in a Japanese female infant with a novel frame‐shift mutation in the IKBKG gene

The Journal of Dermatology, EarlyView.


https://ift.tt/2K6D1CE

Two cases of dabrafenib and trametinib therapy‐failed advanced melanoma successfully controlled by nivolumab monotherapy

The Journal of Dermatology, EarlyView.


https://ift.tt/2K5XJiy

Novel mutation c.263A>G in the ACVRL1 gene in a Japanese patient with hereditary hemorrhagic telangiectasia 2

The Journal of Dermatology, EarlyView.


https://ift.tt/2KbzB1y

Vitiligo at a keloid scar: A possible case of Koebner phenomenon

The Journal of Dermatology, EarlyView.


https://ift.tt/2I6QyVC

Association of human beta‐defensin 1 gene polymorphisms with nonsegmental vitiligo

Clinical and Experimental Dermatology, EarlyView.


https://ift.tt/2KaDC6b

Aciclovir for treatment of pityriasis lichenoides?

Clinical and Experimental Dermatology, EarlyView.


https://ift.tt/2K2tysI

Actinic Keratosis Area Severity Index (AKASI): reproducibility study and comparison with total lesion count

British Journal of Dermatology, EarlyView.


https://ift.tt/2K3sMyZ

Herpetiform pemphigus with characteristic transmission electron microscopic findings of various‐sized ballooning vacuoles in keratinocytes without acantholysis

British Journal of Dermatology, EarlyView.


https://ift.tt/2I7ynz4

Clinical and dermoscopic features of Spitz naevus by sex, age and anatomical site: a study of 913 Spitz naevi

British Journal of Dermatology, EarlyView.


https://ift.tt/2K7KUrm

Hyperspectral imaging system in the delineation of Ill‐defined basal cell carcinomas: a pilot study

Journal of the European Academy of Dermatology and Venereology, EarlyView.


https://ift.tt/2I6mGJ6

Biologic switching between interleukin 17A antagonists secukinumab and ixekizumab: a 12‐week, multicenter, retrospective study

Journal of the European Academy of Dermatology and Venereology, EarlyView.


https://ift.tt/2K9DNys

Dermoscopic clues in Pagetoid reticulosis Woringer–Kolopp type

Journal of the European Academy of Dermatology and Venereology, EarlyView.


https://ift.tt/2K3K7V6

Primary and secondary prevention of skin cancer in mountain guides: attitude and motivation for or against participation

Journal of the European Academy of Dermatology and Venereology, EarlyView.


https://ift.tt/2K7KCAM

High-Mobility Group Protein Box 1 is Upregulated in Children with Henoch-Schonlein Purpura

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 66-72, June 2018.


https://ift.tt/2lmaLOc

Food Security, Utilization of Food Assistance Programs, and Caregiver Perceptions of Food-Induced Anaphylaxis Risk in Children with Food Allergies

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 91-96, June 2018.


https://ift.tt/2toa0Ig

Asthma Endotyping and Biomarkers in Childhood Asthma

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 44-55, June 2018.


https://ift.tt/2lo6I48

Chronic Granulomatous Disease: A Study of Two Cases with Fungal Infection in Early Infancy

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 116-118, June 2018.


https://ift.tt/2yySIxY

World Asthma Day 2018: Increasing Awareness for Asthma and Allergies

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 43-43, June 2018.


https://ift.tt/2tvphaj

Clinical Evaluation of Specific Immunoglobulin E in Sputum in Pediatric Patients

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 73-77, June 2018.


https://ift.tt/2lmaGdm

Identification of Methylated Gene Markers in Childhood Atopic Asthma by Integrating Gene Expression and Methylation Profiles Based on Bioinformatic Analysis

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 97-106, June 2018.


https://ift.tt/2tlBH4k

Prepregnancy Extreme Obesity Is Associated with Increased Steroid Dispensing in Early Childhood

Pediatric Allergy, Immunology, and Pulmonology, Volume 31, Issue 2, Page 84-90, June 2018.


https://ift.tt/2lmatH6

Early detection of gastric cancer after Helicobacter pylori eradication due to endoscopic surveillance

Helicobacter, EarlyView.


https://ift.tt/2JTuSlN

The “three‐in‐one” formulation of bismuth quadruple therapy for Helicobacter pylori eradication with or without probiotics supplementation: Efficacy and safety in daily clinical practice

Helicobacter, EarlyView.


https://ift.tt/2M6GY7y

Prophylactic central neck dissection and local recurrence in papillary thyroid microcarcinoma: a meta-analysis

Publication date: Available online 20 June 2018
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Hui Su, Yujie Li
IntroductionFor papillary thyroid microcarcinoma patients, the reported incidence of lymph node metastasis is as high as 40%, and these occur mainly in the central compartment of the neck. Because these metastases are difficult to detect using ultrasonography preoperatively, some authors advocate routine central neck dissection in papillary thyroid microcarcinoma patients at the time of initial thyroidectomy.ObjectiveTo evaluate whether prophylactic central neck dissection can decrease the local recurrence rate of papillary thyroid microcarcinoma after thyroidectomy.MethodsThe publicly available literature published from January 1990 to December 2017 concerning thyroidectomy plus prophylactic central neck dissection versus thyroidectomy for papillary thyroid microcarcinoma was retrieved by searching the national and international online databases. A meta-analysis was performed after the data extraction process.ResultsFour studies were finally included with a total of 727 patients, of whom, 366 cases underwent thyroidectomy plus prophylactic central neck dissection and 361 cases received thyroidectomy only. As shown by the meta-analysis results, the recurrence rates in cases of thyroidectomy plus prophylactic central neck dissection were approximately 1.91% and were significantly lower than those with thyroidectomy only (OR=0.24, 95% CI [0.10, 0.56], p=0.0009).ConclusionFor patients with papillary thyroid microcarcinoma, thyroidectomy plus prophylactic central neck dissection is a safe and efficient procedure and it results in lower recurrence rate. Since the evidences are of low quality (non-randomized studies), further randomized trials are needed.



https://ift.tt/2K2kp3m

Nailing Nail Pathology: Primary Care Case Challenge

Can you 'nail' the diagnosis of these nail disorders?
Medscape Family Medicine

https://ift.tt/2ytw5KZ

Robotic Head and Neck Surgery: History, Technical Evolution and the Future

The first application of robotic technology in surgery was described in 1985 when a robot was used to define the trajectory for a stereotactic brain biopsy. Following its successful application in a variety of surgical operations, the da Vinci® robot, the most widely used surgical robot at present, made its clinical debut in otorhinolaryngology and head and neck surgery in 2005 when the first transoral robotic surgery (TORS) resections of base of tongue neoplasms were reported. Subsequently, the indications for TORS rapidly expanded, and they now include tumours of the oropharynx, hypopharynx, parapharyngeal space, and supraglottic larynx, as well as obstructive sleep apnoea (OSA). The da Vinci® robot has also been successfully used for scarless-in-the-neck thyroidectomy and parathyroidectomy. At present, the main barrier to the wider uptake of robotic surgery is the prohibitive cost of the da Vinci® robotic system. Several novel, flexible surgical robots are currently being developed that are likely to not only enhance patient safety and expand current indications but also drive down costs, thus making this innovation more widely available. Future directions relate to overlay technology through augmented reality/AR that allows real-time image-guidance, miniaturisation (nanorobots), and the development of autonomous robots.
ORL

https://ift.tt/2tjRHor

Regulatory T cells as a biomarker for response to adalimumab in rheumatoid arthritis

Publication date: Available online 20 June 2018
Source:Journal of Allergy and Clinical Immunology
Author(s): Dao X. Nguyen, Alice Cotton, Laura Attipoe, Coziana Ciurtin, Caroline J. Doré, Michael R. Ehrenstein




https://ift.tt/2yuwVqU

IL-33 induces functional CCR7 expression in human mast cells

Publication date: Available online 19 June 2018
Source:Journal of Allergy and Clinical Immunology
Author(s): Maiko Emi-Sugie, Sumika Toyama, Akio Matsuda, Hirohisa Saito, Kenji Matsumoto

Teaser

Functional CCR7 expression—which enables Erk 1/2 phosphorylation, chemotaxis and enhancement of cytokine production upon exposure to CCR7 ligands—was induced in human mast cells, strongly by IL-33 and weakly by anti-IgE Ab stimulation.


https://ift.tt/2lnBiLi

Distinguishing Mild, Moderate, and Severe Hidradenitis Suppurativa

In Reply We are grateful for the very constructive and positive feedback from Kokolakis and Sabat regarding our newly proposed Severity Assessment of Hidradenitis Suppurativa (SAHS) score.

https://ift.tt/2tnqqQY

A Twitter Analysis of the #DontFryDay Campaign

This study assessed the reach of the "Don't Fry Day" campaign on Twitter, using the hashtag #DontFryDay, and identified what types of individuals and/or tweeters are engaging in the campaign.

https://ift.tt/2lp0YHg

Persistent Malar Erythema With Atrophy in a Young Woman

A young woman had asymptomatic, facial redness that flared in sunlight, previously treated with doxycycline and topical sulfacetamide with no effect; on her cheeks and nasal bridge there were multiple erythematous, annular plaques with focal areas of atrophy. What is your diagnosis?

https://ift.tt/2tpzq86

Distinguishing Mild, Moderate, and Severe Hidradenitis Suppurativa

To the Editor We read with great interest the article by Hessam and colleagues published in a recent issue of JAMA Dermatology describing the evaluation of a novel comprehensive score for hidradenitis suppurativa (HS) severity assessment. A highly inflammatory destructive disease, HS mainly affects axillary, inguinal, and perianal body areas. Patients with HS show signs of systemic inflammation and additionally often have metabolic syndrome, spondyloarthritis, or inflammatory bowel disease. Furthermore, HS has a tremendous negative effect on life quality and leads to reduced life expectancy.

https://ift.tt/2lk32QE

Assessment of a Predictive Scoring Model for Dermoscopy of Subungual Melanoma In Situ

This cohort study identifies the dermoscopic features of subungual melanoma in situ in a Korean population and assesses a predictive scoring model that distinguishes the diagnosis of subungual melanoma in situ from longitudinal melanonychia in patients with pigmented nails.

https://ift.tt/2ypUXDF

Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis

This systematic review presents evidence-based dietary recommendations for adults with psoriasis or psoriatic arthritis from the Medical Board of the National Psoriasis Foundation.

https://ift.tt/2ljU7yN

Muscle-Tendon Mechanics During Locomotor Tasks, Efficacy of Collagen Supplementation for Older Adults

Condition:   Tendon Stiffness With Age
Interventions:   Dietary Supplement: Collagen supplement group;   Dietary Supplement: Placebo supplement group
Sponsor:   Liverpool John Moores University
Not yet recruiting

https://ift.tt/2tmLmYk

Hyperacusis in children: The Edinburgh experience

Publication date: September 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 112
Author(s): Ida Amir, Dawn Lamerton, Mary-Louise Montague
ObjectivesThis study aimed to determine the factors associated with hyperacusis in children referred to an audiology-led paediatric hyperacusis clinic in a Paediatric tertiary centre. It also aimed to identify current management strategies in paediatric hyperacusis and their outcomes.MethodsRetrospective cohort study conducted by case note and AuditBase^® review over a 5-year period (March 2010 to March 2015) in a tertiary Paediatric ENT and Audiology service.Results412 children were referred with hyperacusis during the 5-year period. All children were assessed and managed within a dedicated Paediatric hyperacusis clinic. Median age at referral was 7 years. 76% were boys (n = 313). On average, children were sensitive to 6 identifiable sound stimuli at presentation (range 1–20). 82% complained of sensitivity to noise from household appliances and hand dryers. 60% had a background history of autistic spectrum disorder (ASD), followed by attention deficit hyperactivity disorder (ADHD) and other neurodevelopmental problems. In 91% management comprised behavioural therapy and provision of a 'sound-ball' (Wellcare^® Naturcare Relaxation Therapy Ball) to take home. Of these, 25% did not attend their first review appointment. A further 25% were considered to have sufficient symptom improvement to permit discharge after a single clinic review. Only 2% of children required more than 3 review sessions before achieving resolution of symptoms.ConclusionsIn our paediatric cohort, hyperacusis is more common in boys and in those children with ASD. A combined treatment approach with behavioural therapy and the provision of a sound-ball has a very high success rate in our experience.



https://ift.tt/2JPPrzr

Curvature of the left main bronchus caused by postural change from supine to left lateral position

Abstract

This study was designed to examine deviation of the bronchus by postural change from supine to lateral position during spontaneous respiration. Fifteen healthy volunteers [13 men and 2 women, mean age: 34 years (range 26–42)] participated. Chest radiograms (anterior–posterior) were acquired in the order of supine, left lateral, and right lateral position. The bilateral bronchus angles and secondary carina angles were measured in the acquired images, and the angles were compared between the supine and lateral positions to evaluate deviation of the bronchus in the lateral position. The left secondary carina angle in the supine position was 61.3° ± 4.0° and it significantly increased to 65.5° ± 6.0° in the left lateral position (P = 0.001), but no significant difference was noted in the left bronchus angle between the supine and left lateral positions (P = 0.158). The curvature of left main bronchus, which we defined more than 5° increase in secondary carina angle, was observed in a half of the male participants during left lateral position. We should be aware of these anatomical changes due to the surgical posture as a possible cause for ventilation failure during one-lung ventilation.

https://ift.tt/2yxGlCi

Emergency department visits and unplanned hospitalizations in the treatment period for head and neck cancer patients treated with curative intent: A population-based analysis

Publication date: August 2018
Source:Oral Oncology, Volume 83
Author(s): A. Eskander, M.K. Krzyzanowska, H.D. Fischer, N. Liu, P.C. Austin, J.C. Irish, D.J. Enepekides, J. Lee, E. Gutierrez, E. Lockhart, M. Raphael, S. Singh
BackgroundMucosal head and neck squamous cell cancers are often managed with multimodality treatment which can be associated with significant toxicity. The objective of this study was to assess emergency department visits and unplanned hospitalizations for these patients during and immediately after their treatment.MethodsA cohort of patients treated for head and neck squamous cell carcinoma was developed using administrative data. Emergency department visits and hospitalizations in the 90-day post-treatment period was determined. If a second treatment was initiated prior to the completion of 90 days, the attributable risk period was changed to the second treatment.ResultsCohort of 3898 patients (1312 larynx/hypopharynx; 2586 oral cavity/oropharynx) from 2008 to 2012. The number of unplanned hospitalizations or ED visits (per 100 patient days) were 0.69 for surgery, 0.78 for surgery followed by concurrent chemoradiotherapy (CCRT), 0.55 for surgery followed by radiotherapy, 0.86 for CCRT, and 0.50 for radiation. Patients receiving CCRT had a statistically higher likelihood of treatment period events. The larynx/hypopharynx cancer subsite, higher comorbidity and more advanced stage of disease were all independent predictors of events.ConclusionsPatients undergoing treatment for head and neck cancer have significant unplanned hospitalizations and visits to the emergency department in the treatment period. Rates are higher in patients receiving CCRT. Quality improvement interventions should be used to improve these rates.



https://ift.tt/2JTBNuW

Delayed Presentation of Tetralogy of Fallot with Isolated Cyanosis

A pediatric patient with hypoxia or cyanosis can frighten even the most seasoned emergency providers. Patients with these symptoms require immediate evaluation and intervention to stabilize their condition. While the differential can be broad, specific attention must be paid to cardiopulmonary etiologies. Tetralogy of Fallot is the most common cyanotic congenital heart abnormality, and routine screening surprisingly misses a significant amount of these cases. This case serves as an example of a missed diagnosis by screening efforts and reaffirms the resuscitation algorithm of a hypoxic pediatric patient that all emergency providers should be familiar with.

https://ift.tt/2t6UvFd

Cryptogenic Organizing Pneumonia with Sarcoidosis Overlap: An Atypical Case Study

Case Summary. We present a case of a young female with subacute symptoms of cough and progressive dyspnoea. On evaluation, the patient was diagnosed as cryptogenic organizing pneumonia based on her histopathological reports. However, her significant elevation of serum angiotensin-converting enzyme (SACE) levels which drop after treatment with oral steroids, relapse, and clinical presentation pointed towards sarcoidosis as clinical diagnosis. Discussion. Here, in this patient, transbronchial biopsy was suggestive of cryptogenic organizing pneumonia along with chest X-ray, and the HRCT finding was also favouring the same. But in this case, we have also seen elevated levels of serum ACE which dropped significantly to the normal level along with a complete clearance of lesions with systemic steroids, and this favours sarcoidosis. Also, the recurrence was in different areas of the lung, and lesions once again responded both clinically and radiologically to steroids with a consistent drop in serum angiotensin-converting enzyme (SACE) levels, which again is a feature common in sarcoidosis. In COP, often complete clearance of the lesions is seldom seen, even though they do respond to steroids but not as dramatically as in our case. Also, recurrence of the lesion with BOOP at different sites is uncommon as it generally progresses in the same site. Conclusion. This case report suggests that sarcoidosis as a possible cause of cryptogenic organizing pneumonia is worth considering with the mixed spectrum of presentation as in our case. And to our knowledge, this type of presentation of cryptogenic organizing pneumonia with sarcoidosis as an overlap disease is very rare, and this possibility needs to be explored by more series of such cases.

https://ift.tt/2M6rpNf

The EBV-DNA Can be Used as a Diagnostic and Follow-up Parameter of the Rhinopharyngeal Tumors in the Non-Endemic Population of the Western Sicily

Abstract

To evaluate whether EBV-DNA can be used as a diagnostic and follow-up parameter for nasopharyngeal tumors in a non-endemic population. The study was carried out in a university hospital. A retrospective study was conducted on 40 paraffin samples of histological preparations. EB-DNA was detected by real-time PCR technique. A prospective study was also conducted on a group of 30 patients who underwent nasopharyngeal biopsy for suspected nasopharyngeal carcinoma (NPC) by comparing EBV-DNA concentrations between the histological specimen and the serum. Quantification of genomic copies of EBV-DNA in serum and detection of anti-EBV antibodies was performed. In both groups the presence of high viral load of EBV-DNA was found in nonkeratinizing squamous cell carcinomas, in three cases of lymphepitomyoma and in 4 out of 6 cases of non-differentiated non-carcinoma lymph node metastases. squamous keratinizing cells. In all cases of NPC, an antibody pattern typical of reactivations (IgGVCA+, IgG-EA+, IgG-EBNA+) and IgA-EA-D, frequently positive in cases of NPC, has been highlighted. A good correlation between the high EBV-DNA charges and the histological diagnosis was highlighted. Our study also found that the assessment of viral EBV load can also be considered in the prognostic evaluation and in the follow-up of patients with NPC.

https://ift.tt/2tbtznQ

Skull Base Mucormycosis in an Immunocompetent Patient: A Case Report and Literature Review

Abstract

To demonstrate the affection of skull base by mucormycosis in an immunocompetent individual. Mucormycosis is an opportunistic infection principally seen in immunocompromised individuals, but recently being increasingly recognized in otherwise healthy individuals. Skull base involvement secondary to otogenic nidus, mimicking otitis media was rarely reported. A 34 year-old male, an otherwise healthy patient presented with facial nerve palsy followed by trismus, neck swelling and neck stiffness. Radical mastoidectomy with tympanoplasty and Facial nerve decompression along with Endoscopic guided debridement of sinuses and pterygopalatine fossa followed by medical treatment for 14 weeks. Facial nerve functioning, dry ear canal and relief from other symptoms. Surgical debridement and post op Anti fungal treatment improved the facial nerve function to House brackmann grade-II and also provided relief from trismus and stiffness and improved the overall general condition of the patient. Mucor is a saprophytic organism, which can cause extensive progression, regardless of the immune status. To the best of our knowledge, this is one of the very few rare cases that have been reported in the context of skull base mucormycosis in immunocompetent individuals. Surgical debridement followed by anti fungal therapy continues to remain the mainstay of treatment.

https://ift.tt/2I50nTX

Pectoralis Major Myocutaneous Flap Reconstruction for the Mandibular Defects in Advanced Oral Cavity Malignancies: A Retrospective Study of 30 Cases

Abstract

To evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for the reconstruction of the mandible in advanced oral cavity malignancies in the Indian population. It was a retrospective study contained 30 patients with advanced oral cancer from July 2012 to August 2016. The PMMC reconstruction was done in all the patients to repair the bony defects in segmental/hemi mandibulectomy. The patients were followed up for a mean period of 6 months in the postoperative period and the utility of the PMMC flaps were evaluated. The mean age of the patients was 45 years (range 30–63 years). The average Karnofsky performance status score was 70 and majority of the patients had history of chronic medical illness. Of the 30 PMMC flaps, partial necrosis of the skin was noticed 2 (06.66%) patients. Orocutaneous fistula was detected in 2 (06.66%) patient and 3 (10%) patients presented with wound dehiscent in the immediate postoperative period. 3 (10%) patients had recurrence of the disease. PMMC flap can be a reliable option for advanced oral malignancies, especially in patients with poor status with the coexisting chronic illness. Due to the presence of a definite vascular pedicle, ease of harvesting the flap, quick surgical procedure, and the minimal postoperative morbidities, it can be considered as a valid alternative to the free flap to repair the bony defect, especially in patients with low socioeconomic corridor like India.

https://ift.tt/2t9O8AP

Ultrasound-Guided Infraclavicular Brachial Plexus Block: Prospective Randomized Comparison of the Lateral Sagittal and Costoclavicular Approach

Background and Objectives It has recently been proposed that an infraclavicular brachial plexus block (BPB) at the costoclavicular (CC) space may overcome some of the limitations of the lateral sagittal (LS) approach. In this study, we hypothesized that the CC approach will produce faster onset of sensory blockade of the 4 major terminal nerves of the brachial plexus than the LS approach. Methods Forty patients undergoing elective upper extremity surgery under a BPB were randomized to receive either the LS (Gp-LS, n = 20) or CC approach (Gp-CC, n = 20) for infraclavicular BPB. Twenty-five milliliters of 0.5% ropivacaine was used for the BPB in both study groups. Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at regular intervals for 45 minutes after the block. Sensory block was assessed using a verbal rating scale (0–100) and motor block using a 3-point qualitative scale (0–2). Onset of sensory (primary outcome variable) and motor blockade was defined as the time it took to achieve a sensory verbal rating scale of 30 or less and motor grade of 1 or less, respectively. Time to readiness for surgery was defined as the time it took to achieve a sensory score of 30 or less and motor grade of 1 or less in all the 4 nerves tested. Results The overall sensory onset time (median [interquartile range]) was significantly faster (P = 0.004) in Gp-CC (10 [10–26.25] minutes) than in Gp-LS (20 [15–30] minutes). The overall sensory score was significantly lower in Gp-CC than in Gp-LS at 5 (P

https://ift.tt/2yqcR91

Lack of Association Between Levels and Length of Intraoperative Controlled Hypotension and Acute Kidney Injury in Total Hip Arthroplasty Patients Receiving Neuraxial Anesthesia

Background and Objectives Previous research suggests that increased duration and lower levels of intraoperative hypotension (IOH) are associated with postoperative acute kidney injury (AKI). However, this association has not been evaluated in the context of intraoperative controlled hypotension (IOCH), a practice that has been linked in the past to improved outcomes with respect to blood loss and transfusion needs. This study aimed to investigate whether IOCH is associated with postoperative AKI among total hip arthroplasty patients at an institution where this technique is commonly practiced. Methods We performed a retrospective cohort study of 2431 unilateral total hip arthroplasty patients who received IOCH under neuraxial anesthesia as well as invasive arterial monitoring between March 2016 and January 2017. Multiple logistic regression was used to compute the adjusted odds ratios of postoperative AKI, adjusting for covariates including duration of intraoperative mean arterial pressure of less than 60 mm Hg. Sensitivity analyses also considered the effects of IOH defined at mean arterial pressure of less than 55 and less than 65 mm Hg. Results Acute kidney injury occurred in 45 (1.85%) of the 2431 patients in this cohort. Longer duration of hypotension was not associated with increased odds of postoperative AKI. Preexisting differences, such as compromised renal function, best predicted increased odds of AKI. Conclusions In this study, AKI was rare. We found a lack of association between IOH and postoperative AKI in a setting where neuraxial anesthesia–facilitated IOCH is routinely practiced. Therefore, it seems prudent for future research and clinical guidelines to consider the distinction between inadvertent and controlled hypotension. Accepted for publication February 11, 2018. Address correspondence to: Stavros G. Memtsoudis, MD, PhD, FCCP, Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 (e-mail: memtsoudiss@hss.edu). This study was internally funded by the Department of Anesthesiology, Hospital for Special Surgery, New York, NY. J.T.Y. is coinvestigator on a project about intravenous acetaminophen for postoperative analgesia funded by Mallinckrodt and performs editorial board activity for Anesthesia & Analgesia and Regional Anesthesia and Pain Medicine. S.G.M. is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine and the Society of Anesthesia and Sleep Medicine. He is a one-time consultant for Sandoz Inc. and the holder of US Patent US-2017-0361063, Multicatheter Infusion System. He is the owner of SGM Consulting, LLC and co-owner of FC Monmouth, LLC. None of the above relations influenced the conduct of the present study. S.M.W. declares no conflict of interest. Author Contributions: S.M.W. helped design the study, analyze the data, and write the manuscript. J.T.Y. helped design the study, analyze the data, and write the manuscript. S.G.M. helped design the study, analyze the data, and write the manuscript. 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 Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

https://ift.tt/2lk2LgI

A Cadaver Study Investigating Structures Encountered by the Needle During a Retroclavicular Approach to Infraclavicular Brachial Plexus Block

Background and Objectives Retroclavicular block is designed to overcome the negative aspects of the commonly utilized ultrasound-guided parasagittal approach to the infraclavicular block. However, this approach necessitates the needle traversing an area posterior to the clavicle inaccessible to ultrasound wave conduction. This study sought to document the structures vulnerable to needle injury during a retroclavicular block. Methods A Tuohy needle was inserted using a retroclavicular approach to the infraclavicular block in 3 lightly embalmed cadavers followed by a catheter insertion 4 cm beyond the needle tip. The process was repeated on the contralateral side. With the needle and catheter in position, the cadavers were dissected and photographed. Results In 4 of the 6 dissections, the needle was directly touching the suprascapular nerve deep to the clavicle. In the remaining 2 dissections, the suprascapular nerve was within 2 cm of the needle. In 1 dissection, the suprascapular vein was indented, behind the clavicle. The trapezius was the only muscle layer traversed by the needle in all dissections. In 3 of the 6 dissections, the catheter penetrated the posterior cord. In the remaining 3, the catheter threaded along the neurovascular bundle. Conclusions The suprascapular nerve is consistently in the path of the block needle posterior to the clavicle. This raises the possibility of risk of injury to the suprascapular nerve when using this approach to the brachial plexus. Vascular injury is also possible deep to the clavicle, and because of the noncompressible location, caution is advised in patients with disordered coagulation. Accepted for publication March 10, 2018. S.F.S. is now with the Department of Anesthesiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Address correspondence to: Vishal Uppal, DA, EDRA, FRCA, Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and IWK Health Centre, Halifax, Nova Scotia, Canada B3H 2Y9 (e-mail: v.uppal@dal.ca). No external funds were obtained for the study. Internal departmental funds were used. V.U. has been a principal investigator for a Recro Pharma (Devault, PA)–funded clinical trial involving intravenous meloxicam in Halifax, Nova Scotia, Canada. This conflict does not directly or indirectly affect the conduct or reporting of this study. The authors declare no conflict of interest. Author contributions: Study design/planning: all authors; study conduct: S.F.S., V.U., R.S.; writing of the paper: S.F.S., V.U; revision of the manuscript: all authors. 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 Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

https://ift.tt/2ytkxHM

Ketamine for Refractory Headache: A Retrospective Analysis

Background and Objectives The burden of chronic headache disorders in the United States is substantial. Some patients are treatment refractory. Ketamine, an N-methyl-D-aspartate antagonist, provides potent analgesia in subanesthetic doses in chronic pain, and limited data suggest it may alleviate headache in some patients. Methods We performed a retrospective study of 61 patients admitted over 3 years for 5 days of intravenous therapy that included continuous ketamine to determine responder rate and patient and ketamine infusion characteristics. Pain ratings at 2 follow-up visits were recorded. An immediate responder was a patient with decrease of 2 points or greater in the numerical rating scale (0–10) from start to final pain in the hospital. Sustained response at office visits 1 and 2 was determined based on maintaining the 2-point improvement at those visits. Patients were assessed daily for pain and adverse events (AEs). Results Forty-eight (77%) of the 61 patients were immediate responders. There were no differences regarding demographics, opioid use, or fibromyalgia between immediate responders and nonresponders. Maximum improvement occurred 4.56 days (mean) into treatment. Sustained response occurred in 40% of patients at visit 1 (mean, 38.1 days) and 39% of patients at visit 2 (mean, 101.3 days). The mean maximum ketamine rate was 65.2 ± 2.8 mg/h (0.76 mg/kg per hour). Ketamine rates did not differ between groups. Adverse events occurred equally in responders and nonresponders and were mild. Conclusions Ketamine was associated with short-term analgesia in many refractory headache patients with tolerable adverse events. A prospective study is warranted to confirm this and elucidate responder characteristics. Accepted for publication March 25, 2018. Address correspondence to: Eric S. Schwenk, MD, Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Suite 8130, Gibbon Bldg, 111 South 11th St, Philadelphia, PA 19107 (e-mail: Eric.Schwenk@jefferson.edu). E.S.S. has received consulting fees from Avenue Therapeutics. C.G.L. has received honoraria from Cefaly Technology. S.D.S. receives, or has received, honoraria from Alder Biopharmaceuticals; Allergan, Inc; Amgen; Avanir Pharmaceuticals, Inc; Curelator, Inc; Dr Reddy's Laboratories; eNeura Inc; electroCore Medical, LLC; Lilly USA, LLC; Medscape, LLC; NINDS; Supernus Pharmaceuticals, Inc; Teva Pharmaceuticals; Theranica; and Trigemina, Inc. W.Y. has received consulting fees from Allergan; he is on the advisory board for Amgen, Avanir, Cipla, Alder, Eli Lilly, and Supernus. He has received research support from Allergan, Amgen, Autonomic Technologies, Colucis, Cumberland, Dr Reddy's Laboratories, Eli Lilly, Novartis, PCORI, Scion, Teva, and Zosano. Eugene Viscusi has served as a consultant for AcelRx, Medicines Company, Mallinkrodt, Trevena, Cara Pharmaceuticals, Salix, AstraZeneca, and Merck. His institution has received research grants in the past from AcelRx, Adolor, Progenics, and Pacira. He has been a paid lecturer for AcelRx, Merck, Salix, and Mallinkrodt. None of these companies were involved in any aspect of the development of this manuscript. A.C.D., A.R., M.C.T., and M.G.H. declare no conflict of interest. Institutional affiliation of manuscript: Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA. Source of funding: Departmental funding. 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 Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

https://ift.tt/2li2RFA

Hypertonic Sodium Chloride Preinjectate Increases In Vivo Radiofrequency Ablation Size: Histological and Magnetic Resonance Imaging Findings

Background and Objectives Emphasis has been placed on methods to enlarge monopolar radiofrequency (RF) lesion size for pain management. Ex vivo research has suggested that fluid modulation may be an effective method to enlarge lesion zone. To date, these findings have not been confirmed in vivo. The purpose of this study was to determine the effect of hypertonic saline on in vivo lesion size through both histological and magnetic resonance imaging (MRI) analysis. A secondary purpose was to validate in vivo characterization of RF lesions using contrast-enhanced MRI. Methods Monopolar RF was performed in an in vivo porcine model in 3 groups: (1) without fluid preinjection, (2) with preinjection of 1% lidocaine, or (3) with preinjection of 1% lidocaine and 8% sodium chloride. Following lesioning, MRI processing with gadolinium-enhanced, T1-weighted imaging and histological analysis was performed. Results The addition of 8% sodium chloride significantly increased the size of RF lesion in comparison to the addition of 1% lidocaine alone and to the absence of fluid injection, as assessed by histological and MRI analysis. Three distinct histological lesion zones were identified. In comparison to the no-fluid group, the addition of hypertonic saline significantly altered the shape and histological composition of the lesion. There was a significant correlation of lesion volume as assessed by MRI and by histology measurements. Peak power and total energy delivery also correlated with lesion size. Conclusions This study validates the ability of hypertonic saline to increase in vivo RF lesion size. With further refinement, MRI may be a viable method to assess RF lesion size. Accepted for publication March 28, 2018. Address correspondence to: David A. Provenzano, MD, Pain Diagnostics and Interventional Care, 301 Ohio River Blvd, Suite 203, Edgeworth Medical Commons, Sewickley, PA 15143 (e-mail: davidprovenzano@hotmail.com). This study was supported by Medtronic. This study was conducted at the Medtronic Physiological Research Laboratory. Medtronic PLC provided funding for animal acquisition and supplies. No monetary compensation was provided to any of the investigators for their participation in this nonclinical research. This work was presented in part at the American Academy of Pain Medicine 33th Annual Meeting, Orlando, FL, April 2017; and the American Society of Regional Anesthesia and Pain Medicine 15th Annual Meeting, San Diego, CA, November 2016. D.A.P. is a consultant for Bioness, Boston Scientific, Halyard, Medtronic, Nevro, Sollis, and Abbott. He receives research support from Medtronic and Abbott. D.A.P. received no funding or reimbursement for his work on this project. J.T.W. is an employee of Medtronic. E.R.C. is an employee of Boston Scientific. Cosman Medical is a wholly owned subsidiary of Boston Scientific. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

https://ift.tt/2ytkkEu

Is a Retrolaminar Approach to the Thoracic Paravertebral Space Possible?: A Human Cadaveric Study

Background and Objectives The retrolaminar block (RB) is used for truncal analgesia, but its mechanism of neural blockade remains obscure. We sought to learn the pattern of local anesthetic spread after thoracic RB using cadaveric models. Methods In 8 fresh cadavers, an ultrasound-guided T4 RB was performed with 20 mL of methylene blue 1% and bupivacaine 0.5%. For comparison, an RB at T9 in 1 cadaver and a T4 thoracic paravertebral block in another cadaver were performed. Subsequently, posterior and anterior thoracic dissections were performed to examination where the dye spread. Results After T4 RB, dye was noted to spread in the ipsilateral retrolaminar plane (all 8 cadavers, median cephalad spread 3.5 cm, caudad spread 10.7 cm, lateral spread 2.5 cm), the contralateral retrolaminar plane (6 cadavers), the paravertebral space (5 cadavers, median of 3 segments, T3–T5), the intercostal space (5 cadavers, median of 3.5 cm laterally), the T4 epidural space (6 cadavers), and the intervertebral foramina (4 cadavers, median of 2 segments, T4–T5). After T9 retrolaminar injection, dye was noted in the ipsilateral retrolaminar plane (5.5 cm cephalad, 13.5 cm caudad, and 2.5 cm lateral), the contralateral retrolaminar plane, and the epidural space. Dye after T4 traditional paravertebral block spread to T1–T6 paravertebral space with 15-cm lateral spread. Conclusions Injectate spread to the paravertebral space, epidural space, intercostal space, and intervertebral foramina is possible in the RB but is quite variable. In comparison to the thoracic paravertebral block, injectate spread within the paravertebral space is more limited. Accepted for publication April 23, 2018. Address correspondence to: A. Sassan Sabouri, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, GRJ 446, Boston, MA 02114 (e-mail: asabouri@mgh.harvard.edu). This work is attributed to the Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA. This study was supported by DACCPM Clinical Pilot Grant (no. 1200-218309). Primary results of this study were presented at the 41st American Society of Regional Anesthesia Annual Regional Anesthesia and Acute Pain Medicine Meeting, New Orleans, LA, as a poster presentation on April 2, 2016, and final results were presented as a poster at the Department of Anesthesia, Critical Care and Pain Medicine Research Day, Massachusetts General Hospital, Boston, MA, on October 18, 2017. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

https://ift.tt/2lk2J8A

Lipid Emulsion Pretreatment Decreased the Maximum Total and Free Plasma Concentration of Levobupivacaine for Femoral and Sciatic Nerve Block in Below-Knee Fracture Surgery

Background and Objectives Although intravenous lipid emulsion has been proved a powerful antidote for local anesthetic toxicity, there are few pharmacokinetic data on using lipid infusion as a pretreatment for other clinical applications. We assessed the influence of lipid pretreatment on the pharmacodynamics and pharmacokinetics of levobupivacaine. Methods Altogether, 12 patients undergoing below-knee surgery for a fracture were randomly assigned to 2 groups (6 patients per group): pretreatment with 1.5 mL/kg lipid infusion (lipid group) or saline infusion (control subjects) followed by complete femoral and sciatic nerve block with 0.375% levobupivacaine (2.5 mg/kg). Total and free (non–protein bound) plasma levobupivacaine concentrations and triglycerides in the lipid group were determined. Results Results were given as means ± SD. Total and free maximum plasma levobupivacaine concentrations were lower in the lipid group than in control subjects (865 ± 98 vs 1145 ± 177 μg/L and 56.8 ± 7.5 vs 78.2 ± 13.7 μg/L, respectively; P

https://ift.tt/2tozSn6

Interleukin-1 in monocyte activation phenotypes in systemic juvenile idiopathic arthritis: Observations from a clinical trial of rilonacept, an interleukin-1 inhibitor

Publication date: Available online 19 June 2018
Source:Clinical Immunology
Author(s): Yujuan Zhang, Saloni Gupta, Alexandra Ilstad-Minnihan, Sashi Ayyangar, Arielle D. Hay, Virginia Pascual, Norman T. Ilowite, Claudia Macaubas, Elizabeth D. Mellins
Systemic juvenile idiopathic arthritis (sJIA) is a childhood rheumatic disease of unknown origin. Dysregulated innate immunity is implicated in disease pathology. We investigated if IL-1 inhibition affects circulating cytokines and monocyte gene expression. CD14+ monocytes from patients in the RAPPORT trial were analyzed by RT-PCR for expression of IL1B and transcription factors associated with monocyte activation. Serum IL-1ra decreased with treatment, and IL-18BP transiently increased. Serum levels of IL-1β, IL-6, IL-10 and IL-18 were unchanged. IRF5 and STAT6 were decreased, and PPARG was increased, independent of clinical response, and may represent a skew toward a PPARG-driven M2-like phenotype. IL1B expression was decreased in early clinical responders. A transient increase in STAT1, and a decrease in SOCS1 preceded the reduction in IL1B in early clinical responders. Changes in IL1B/STAT1/SOCS1 could be associated with crosstalk between IL-1 and IFN pathways in sJIA. These transcriptional changes might be useful as drug response biomarkers.



https://ift.tt/2yqxTER