Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Δευτέρα 9 Οκτωβρίου 2017
Efficacy of perilesional and intralesional triamcinolone acetonide injections in pemphigus vulgaris lesions of the scalp: an effective therapeutic option
Summary
The scalp is a common location for pemphigus vulgaris (PV), and scalp lesions may be resistant to standard treatment. Perilesional/intralesional triamcinolone acetonide (TA) injections have been used successfully to treat oropharyngeal and ocular involvement in PV. Data on the efficacy of perilesional and intralesional triamcinolone acetonide injections in scalp lesions in PV are lacking. We report two patients with immunopathologically and histopathologically confirmed PV and residual scalp lesions resistant to standard treatment, who were treated with perilesional and intralesional injections of TA 10 mg/mL. Clearance of scalp lesions was achieved after one after, respectively, one and two perilesional and intralesional injections. Perilesional and intralesional TA injections may serve as an effective and safe treatment for recalcitrant scalp lesions in pemphigus.
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First-line treatment in lymphomatoid papulosis: a retrospective multicentre study
Summary
Background
Data regarding response to treatment in lymphomatoid papulosis (LyP) are scarce.
Aim
To assess the daily clinical practice approach to LyP and the response to first-line treatments.
Methods
This was a retrospective study enrolling 252 patients with LyP.
Results
Topical steroids, methotrexate and phototherapy were the most common first-line treatments, prescribed for 35%, 20% and 14% of the patients, respectively. Complete response (CR) was achieved in 48% of treated patients. Eczematous lesions significantly increased relative risk (RR) of not achieving CR (RR = 1.76; 95% CI 1.16–2.11). Overall median time to CR was 10 months (95% CI 6–13 months), and 78% of complete responders showed cutaneous relapse; both results were similar for all treatment groups (P > 0.05). Overall estimated median disease-free survival (DFS) was 11 months (95% CI 9–13 months) but DFS for patients treated with phototherapy was 23 months (95% CI 10–36 months; P < 0.03). Having the Type A LyP variant (RR = 2.04; 95% CI 0.96–4.30) and receiving a first-line treatment other than phototherapy (RR = 5.33; 95% CI 0.84–33.89) were significantly associated with cutaneous early relapse. Of the 252 patients, 31 (13%) had associated mycosis fungoides unrelated to therapeutic approach, type of LyP or T-cell receptor clonality.
Conclusions
Current epidemiological, clinical and pathological data support previous results. Topical steroids, phototherapy and methotrexate are the most frequently prescribed first-line treatments. Although CR and cutaneous relapse rates do not differ between them, phototherapy achieves a longer DFS. Presence of Type A LyP and use of topical steroid or methotrexate were associated with an increased risk of early relapse.
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Self-reported minor infections in patients with hidradenitis suppurativa and healthy controls
Summary
Background
Patients with hidradenitis suppurativa (HS) often report opportunistic infections such as herpes and urinary tract infections.
Aim
To compare opportunistic infections in patients with HS against a group of healthy controls (HCs).
Methods
In total, 99 patients with HS and 109 HCs were recruited at random to this retrospective case–control study. We devised a questionnaire to explore the frequency of minor infections, general practitioner (GP) visits and sick days experienced during the past 6 months. Additionally, participants were asked if they felt unwell more often compared with their peers.
Results
Patients with HS felt unwell more often than did HCs (26.3% vs. 7.3%, P < 0.001). Although there was no difference between the groups in five of the seven diseases studied, patients with HS had a higher frequency of the common cold (P < 0.01) and genital herpes (P < 0.01). Number of pack-years of smoking did not affect risk of infections (Pearson correlation, P = 0.51). Subgroup analysis of nonsmokers found the same differences in frequency of minor infections, common cold and genital herpes between patients with HS and controls.
Conclusions
Patients with HS appear to experience more frequently symptoms compatible with minor infections in general, and the common cold and genital herpes specifically. This results in more GP visits and more sick days. Further research is needed to determine if this is caused by an immunological hyper-reactive state in these patients or a reduced threshold for minor infections.
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Relapsing polychondritis, an underestimated dermatological urgency: case report and literature review
Abstract
Background
Relapsing polychondritis is an autoimmune multisystemic disease with primary chondral involvement. Its high mortality and morbidity make it a real clinical challenge.
Case description
A 32-year-old woman with a history of relapsing polychondritis, refractory to multiple treatments, with multisystem compromise, imminent risk of death due to severe tracheobronchial damage and difficult ventilatory support, and successful treatment with infliximab.
Discussion and evaluation
Several treatments have been described in the literature, such as nonsteroidal anti-inflammatory drugs, corticosteroids, dapsone, azathioprine, cyclosporine, cyclophosphamide, and methotrexate. However, the cases refractory to conventional therapy may lead to chronicity, irreversibility, and death. As a result, a third-line therapy could improve the prognosis of these patients.
Conclusions
Biological therapy is a good option for disease control and quality of life improvement. In addition, the physician should consider these treatments to avoid the chronicity and risk of death of these patients.
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Macrophage subtypes in recurrent nodular basal cell carcinoma after Mohs micrographic surgery
Abstract
Background
The macrophages associated with solid tumors are related to the progression or regression of tumors, depending on the differentiation in M1 or M2. M2 subtype promotes angiogenesis, remodeling, and tissue repair (tumor proliferation). In contrast, M1 produces toxic mediators and presents antigens, destroying microorganisms and tumor cells. The microenvironment of most aggressive forms of basal cell carcinoma (BCC) shows an increase in macrophages due to M2 phenotype compared to noninvasive forms. The treatment of nodular BCC by Mohs micrographic surgery (MMS) provides high cure rates, but relapses can occur.
Aims
To compare the total population of macrophages and their subpopulations M1 and M2 in cases of recurrent and nonrecurrent nodular BCC after excision by MMS.
Materials & Methods
Histological sections obtained from paraffin blocks of nine cases of recurrent nodular BCC after MMS and 18 cases of nonrecurrent nodular BCC operated by MMS were immunostained for iNOS, CD204, CD163, and CD68. The expression of these markers was analyzed by image analysis.
Results
No significant differences were found between the groups in relation to the average percentage of M1 cells, M2 cells, and total cells.
Discussion and Conclusion
A relationship was not seen between tumor-associated macrophages (TAM) and tumor recurrence.
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Acute pancreatitis with eruptive xanthoma
Eruptive xanthomas are benign skin lesions caused by localised deposition of lipids in the dermis. Xanthomas can present as early manifestations of systemic disorders, which are typically caused by elevated levels of serum triglycerides and uncontrolled diabetes. Early recognition and treatment of the underlying condition decreases morbidity and mortality. After treatment of the underlying metabolic disorders, lesions mostly disappear without leaving scars. We present a case with multiple yellowish, erythematous papules on the extremities suggestive of eruptive xanthomas admitted to our hospital with acute pancreatitis.
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Ogilvies syndrome treated with an emergency laparotomy, right hemicolectomy and end ileostomy
Acute colonic pseudo-obstruction (ACPO), or Ogilvie's syndrome, is a rare clinical entity in which there is massive non-toxic colonic dilatation in the absence of a mechanically obstructing lesion. It is an important yet poorly recognised cause of surgical morbidity and mortality occurring typically in elderly patients with multiple comorbidities. ACPO can often be reversed conservatively with colonoscopic or nasogastric decompression. Surgical intervention is seldom necessary. We present a case of Ogilvie's syndrome in which a healthy 76-year-old man developed life-threatening pseudo-obstruction following rib polytrauma after a mechanical fall. Pneumatosis coli was evident radiologically, prompting emergency exploratory laparotomy. Operative findings of serosal tearing and ischaemic colitis necessitated treatment with right hemicolectomy and ileostomy formation. Microbiological and histopathological analyses proved negative for inflammatory, obstructive and infectious colitides. The case emphasises the importance of early recognition and timely intervention in the management of this rare yet potentially fatal cause of megacolon.
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ANCA and IgA glomerulonephritis all in one: prognosis and complications
We present the case of a 75-year-old Hispanic woman with known stage 3 chronic kidney disease, long-standing hypertension and type 2 diabetes mellitus who presented with right-sided abdominal pain and acute kidney injury, nephrotic range proteinuria with positive antimyeloperoxidase antibody. A renal biopsy revealed IgA nephropathy with superimposed pauci-immune antineutrophilic cytoplasmic antibody (ANCA)-associated crescentic glomerulonephritis. The patient was treated with pulse intravenous methylprednisolone, cyclophosphamide and plasmapheresis. One week after her second dose of cyclophosphamide, she was readmitted for infectious complications including influenza A respiratory infection, Rothia bacteraemia associated with diarrhoea and herpes zoster of the trunk. In this report, we review the prevalence, treatment and prognosis of coexistent IgA nephropathy and pauci-immune ANCA-associated crescentic glomerulonephritis. We propose that a reduced-dose treatment regimen should be considered in elderly patients due to their higher risk of infectious complications. Current literature suggests that this treatment approach may reduce infectious complications without compromising therapeutic efficacy.
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Knee upside down
We present a case of a 19-year-old woman with a forced hyperextension trauma of the knee causing a posteromedial fracture, a medial meniscus root tear and rupture of the posterior cruciate ligament. The posteromedial fracture of the tibial plateau was treated operatively with open reduction and internal fixation. Anatomical reconstruction was achieved. Postoperative treatment included unlimited flexion and minimal weight bearing. After 3 months, the patient had minimal pain after weight bearing and returned to preoperative range of motion.
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Positive experiences related to living with tinnitus: A cross-sectional survey
Abstract
Objective
The aim of this study was to gain insights related to positive experiences reported by adults with tinnitus living in the UK.
Design
A cross-sectional survey design was used in a sample of adults with tinnitus who were interested in undertaking an Internet-based intervention for tinnitus.
Setting
The study was UK wide and data collection was online.
Participants
Participants consisted of 240 adults (137 males, 103 females), with an average age of 48.16 years and average tinnitus duration of 11.52 years (SD: 11.88).
Main outcome measures
Tinnitus severity was measured by means of the Tinnitus Functional Index. To evaluate the secondary effects of tinnitus, the Insomnia Severity Index, the Hearing Handicap Inventory for Adults-Screening Version and the Cognitive Failures Questionnaires were administered. Positive experiences related to tinnitus were explored using an open-ended question format.
Results
Around a third of participants (32.5%) reported positive experiences associated with tinnitus. The number of positive responses ranged from one to eight responses per participant, although there were fewer participants with more than one positive response. The predominant themes concerned: (1) coping; (2) personal development; (3) support, and to a lesser extent (4) outlook. Younger participants, those with a lower hearing disability and those with fewer cognitive failures were more likely to report positive experiences associated with having tinnitus.
Conclusions
This study has identified that personal development and a positive outlook is possible despite experiencing tinnitus. Ways to facilitate positive experiences related to tinnitus should be promoted, as these may reduce the negative consequences associated with tinnitus.
The most prevalent positive theme was the ability to cope with tinnitus. Positive experiences were also drawn from having clinical and other support networks. This highlights the importance of providing tinnitus interventions that can assist people in coping with tinnitus, particularly to those less likely to relate tinnitus to any positive experiences. Those most likely to be helped include those who are older with greater cognitive difficulties and a greater hearing disability.
This article is protected by copyright. All rights reserved.
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Have we pushed the needle for treatment of Type 1 diabetes?
Nida Naushad | Ana Luisa Perdigoto | Jinxiu Rui | Kevan C Herold
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Pathogenesis of infections in HIV-infected individuals: insights from primary immunodeficiencies
Qian Zhang | Pierre Frange | Stéphane Blanche | Jean-Laurent Casanova
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Landmarks for the preservation of the middle temporal artery during mastoid surgery: Cadaveric dissection study
The middle temporal artery flap is a vascularized periosteal flap that is highly useful for otologic reconstruction including the middle cranial fossa, mastoidectomy defect, and external auditory canal. The course of the artery is close to the external auditory canal and is easily injured during preliminary exposure and elevation of flaps.
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The role of explorative tympanotomy in patients with sudden sensorineural hearing loss with and without perilymphatic fistula
The purpose of this study was to describe the role of explorative tympanotomy in patients with Profound Sudden Sensorineural Hearing Loss (SSNHL) without clinical evidence of perilymphatic or labyrinthine fistula and to compare intraoperative findings with the postoperative hearing outcome.
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Outcome of spray cryotherapy plus functional endoscopic sinus surgery on management of healing in nasal polyposis
Nasal Polyposis is a benign tumor in nasal or paranasal mucosa, which confronts difficulties in management of healing after treatments with surgery. The aim of this study was to evaluate the effects of Spray Cryotherapy (SCT) on management of healing in patients with nasal polyposis who undergone functional endoscopic sinus surgery.
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Endoscopic versus microscopic approach in attic cholesteatoma surgery
Compare the outcomes of primary exclusive endoscopic ear surgery with those of the microscopic ear surgery in a group of patients affected by attic cholesteatoma.
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Payer database and geospatial analysis to evaluate practice patterns in treating allergy in North Carolina
The objective of this study was to characterize the delivery of allergy care in North Carolina using a large payer charge database and visualization techniques.
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Write your first article, but …
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): F. Rubin, H. Maisonneuve, C. Martin, O. Laccourreye
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Atrial myxomas causing severe left and right ventricular dysfunction
Annals of Cardiac Anaesthesia 2017 20(4):450-452
Myxomas are the most common cardiac tumors, accounting for about 50% of benign primary cardiac tumors, with the majority located in the left atrium, and 80% of which originate in the interatrial septum. We report two cases with severe cachexia, neurological sequelae, and severe biventricle dysfunction secondary to atrial myxomas with marked early improvement after tumor excision.
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Think beyond right bundle branch block in atrial septal defect
Annals of Cardiac Anaesthesia 2017 20(4):475-476
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Congenital syndromes affecting heart and airway alike
Annals of Cardiac Anaesthesia 2017 20(4):393-394
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The use of intravenous hydroxocobalamin as a rescue in methylene blue-resistant vasoplegic syndrome in cardiac surgery
Annals of Cardiac Anaesthesia 2017 20(4):462-464
Vasoplegic syndrome is a well-recognized complication during cardiopulmonary bypass (CPB) and is associated with increased morbidity and mortality, especially when refractory to conventional vasoconstrictor therapy. This is the first reported case of vasoplegia on CPB unresponsive to methylene blue whereas responsive to hydroxocobalamin, which indicates that the effect of hydroxocobalamin outside of the nitric oxide system is significant or that the two drugs have a synergistic effect in one or multiple mechanisms.
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Low-dose intravenous ketamine for postcardiac surgery pain: Effect on opioid consumption and the incidence of chronic pain
Annals of Cardiac Anaesthesia 2017 20(4):395-398
Background: Recent meta-analyses have concluded that low-dose intravenous ketamine infusions (LDKIs) during the postoperative period may help to decrease acute and chronic postoperative pain after major surgery. Aims: This study aims to evaluate the level of pain at least 3 months after surgery for patients treated with a postoperative LDKI versus patients who were not treated with a postoperative LDKI. Methods: Administrative and Ethics Board approval were obtained for this study. We performed a retrospective chart review for all patients receiving LDKI, and equal number of age-, sex-, and surgery-matched patients who did not receive LDKI. Low-dose ketamine was prepared using 100 mg of ketamine in 100 ml of normal saline and run between 50 and 200 mcg/kg/h. Results: We reviewed 115 patients with LDKI and 115 without LDKI. The average age was 63.1 years, 73% of the patients were men and sex was evenly distributed between LDKI and non-LDKI. The average duration of the ketamine infusions was 26.8 h with the average dose being 169.9 mg. At an average of 9 months after surgery, 42% of the ketamine group and 38% of the nonketamine group stated that they had had pain on discharge. Of these patients, 30% of the ketamine group and 26% of the nonketamine group still had pain at the time of the phone call. Women in both groups had more acute and chronic pain than men. Conclusion: These results show that LDKI does not promote a decrease in long-term postoperative pain.
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An uncommon intraoperative implantable cardiac device complication and subsequent troubleshooting
Annals of Cardiac Anaesthesia 2017 20(4):483-484
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An innovative technique to improve safety of volatile anesthetics suction from the cardiopulmonary bypass circuit
Annals of Cardiac Anaesthesia 2017 20(4):399-402
Context: Myocardial injury during cardiac surgery on cardiopulmonary bypass (CPB) is a major determinant of morbidity and mortality. Preclinical and clinical evidence of dose- and time-related cardioprotective effects of volatile anesthetic drugs exist and their use during the whole surgery duration could improve perioperative cardiac protection. Even if administering volatile agents during CPB are relatively easy, technical problems, such as waste gas scavenging, may prevent safe and manageable administration of halogenated vapors during CPB. Aims: The aim of this study is to improve the safe administration of volatile anesthesia during CPB. Settings and Design: Tertiary teaching hospital. Subjects and Methods: We describe an original device that collects and disposes of any volatile anesthetic vapors present in the exit stream of the oxygenator, hence preventing its dispersal into the operating theatre environment and adaptively regulates pressure of oxygenator chamber in the CPB circuit. Results: We have so far applied a prototype of this device in more than 1300 adult cardiac surgery patients who received volatile anesthetics during the CPB phase. Conclusions: Widespread implementation of scavenging system like the one we designed may facilitate the perfusionist and the anesthesiologist in delivering these cardioprotective drugs with beneficial impact on patients' outcome without compromising on safety.
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Lutembacher syndrome: Dilemma of doing a tricuspid annuloplasty
Annals of Cardiac Anaesthesia 2017 20(4):456-458
We discuss the case of a 24-year-old woman with Lutembacher syndrome and severe tricuspid regurgitation (TR) who underwent surgical closure of atrial septal defect and mitral valve replacement without tricuspid annuloplasty despite a severe TR and a large tricuspid annulus on preoperative echo. The pathophysiology of Lutembacher syndrome is discussed below. The utility of perioperative echocardiography in assessing the annular diameter, tenting area and coaptation depth and thus providing insights into the functioning of the tricuspid valve will also be emphasized.
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Relationship between perioperative left atrial appendage doppler velocity estimates and new-onset atrial fibrillation in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass
Annals of Cardiac Anaesthesia 2017 20(4):403-407
Background: Literature search reveals that postoperative atrial fibrillation (POAF) occurs in 15%–40% of coronary artery bypass graft (CABG) patients. Although several risk models exist for predicting the development of POAF, few have studied left atrial appendage (LAA) velocity. We hypothesize that an association between LAA velocity and development of POAF exists. Design and Methods: Single institution university hospital prospective observational clinical study performed between May 2016 and November 2016 in 96 adult patients undergoing CABG surgery utilizing cardiopulmonary bypass (CPB). Transesophageal echocardiography was performed perioperatively to measure LAA velocity and left atrial (LA) size after anesthetic induction, post-CPB and during the postoperative period before extubation. Student's t-test was used for inter-group comparisons. Data are expressed as mean ± (standard deviation). The value of P < 0.05 was considered statistically significant. Results: A total of 95 patients (69 males and 26 females) completed the study and were included in the final analysis. Of these, 21 (22%) (15 males and 5 females) developed POAF. The patient group which developed POAF was compared with the group that did not develop POAF. On comparing mean age of patients in each group (59 years in patients with no POAF and 63.71 years in patients with POAF, P = 0.04). LA volume indexed in POAF group (34.13 ml/m2) compared with that in group with no POAF (34.82 ml/m2) resulted in P = 0.04. Mean LAA velocities (pre-CPB, post-CPB, postoperative Intensive Care Unit) in group with no POAF were 41.06, 56.33, and 60.44 cm/s, respectively, whereas in the other group with POAF the values were 39.68, 55.04, and 58.09 cm/s, respectively. No statistical significance was noted (P > 0.05). Comparison of comorbidities also did not yield any significant results (P > 0.05). Conclusions: Decreasing LAA velocity does not appear to independently predict the development of POAF in patients undergoing CABG surgery with the use of CPB. There is, however, a positive correlation of POAF with age and LA volume.
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Perioperative management of a patient with glanzmann's thrombasthenia for mitral valve repair under cardiopulmonary bypass
Annals of Cardiac Anaesthesia 2017 20(4):468-471
A 30-year-old male patient presented with Glanzmann's thrombasthenia and mitral valve prolapse. He was in acute decompensated congestive heart failure due to severe mitral and tricuspid regurgitation. After his cardiac failure had been stabilized, the patient was subjected to mitral and tricuspid valve repair. His transfusion requirements were guided by thrombelastography and his bleeding disorder was managed by infusing single donor plasmapheresed platelet transfusions in the perioperative period. The patient underwent surgery uneventfully.
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Comparison of the renoprotective effect of dexmedetomidine and dopamine in high-risk renal patients undergoing cardiac surgery: A double-blind randomized study
Annals of Cardiac Anaesthesia 2017 20(4):408-415
Objective: The purpose of the current study was to compare the renoprotective effects of continuous infusion of dexmedetomidine and dopamine in high-risk renal patients undergoing cardiac surgery. Design: A double-blind randomized study. Setting: Cardiac Centers. Patients: One hundred and fifty patients with baseline serum creatinine level ≥1.4 mg/dl were scheduled for cardiac surgery with cardiopulmonary bypass. Intervention: The patients were classified into two groups (each = 75): Group Dex – the patients received a continuous infusion of dexmedetomidine 0.4 μg/kg/h without loading dose during the procedure and the first 24 postoperative hours and Group Dopa – the patients received a continuous infusion of dopamine 3 μg/kg/min during the procedure and the first 24 postoperative hours. Measurements: The monitors included serum creatinine, creatinine clearance, blood urea nitrogen, and urine output. Main Results: The creatinine levels and blood urea nitrogen decreased at days 1, 2, 3, 4, and 5 in Dex group and increased in patients of Dopa group (P < 0.05). The creatinine clearance increased at days 1, 2, 3, 4, and 5 in Dex group and decreased in patients of Dopa group (P < 0.05). The amount of urine output was too much higher in the Dex group than the Dopa group (P < 0.05). Conclusions: The continuous infusion of dexmedetomidine during cardiac surgery has a renoprotective effect and decreased the deterioration in the renal function in high-risk renal patients compared to the continuous infusion of dopamine.
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Bifid epiglottis: What perioperative physician should know about it?
Annals of Cardiac Anaesthesia 2017 20(4):479-480
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Does bilevel positive airway pressure improve outcome of acute respiratory failure after open-heart surgery?
Annals of Cardiac Anaesthesia 2017 20(4):416-421
Background: Respiratory failure is of concern in the postoperative period after cardiac surgeries. Invasive ventilation (intermittent positive pressure ventilation [IPPV]) carries the risks and complications of intubation and mechanical ventilation (MV). Aims: Noninvasive positive pressure ventilation (NIPPV) is an alternative method and as effective as IPPV in treating insufficiency of respiration with less complications and minimal effects on respiratory and hemodynamic parameters next to open-heart surgery. Design: This is a prospective, randomized and controlled study. Materials and Methods: Forty-four patients scheduled for cardiac surgery were divided into two equal groups: Group I (IPPV) and Group II (NIPPV). Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), oxygen saturation (SpO2), arterial blood gas, weaning time, reintubation, tracheotomy rate, MV time, postoperative hospital stay, and ventilator-associated pneumonia during the period of hospital stay were recorded. Results: There was statistically significant difference in HR between groups with higher in Group I at 30 and 60 min and at 12 and 24 h. According to MAP, it started to increase significantly at hypoxemia, 15 min, 30 min, 4 h, 12 h, and at 24 h which was higher in Group I also. RR, PaO2, and PaCO2showed significant higher in Group II at 15, 30, and 60 min and 4 h. According to pH, there was a significant difference between groups at 15, 30, and 60 min and at 4, 12, and 24 h postoperatively. SpO2showed higher significant values in Group I at 15 and 30 min and at 12 h postoperatively. Duration of postoperative supportive ventilation was higher in Group I than that of Group II with statistically significant difference. Complications were statistically insignificant between Group I and Group II. Conclusion: Our study showed superiority of invasive over noninvasive mode of ventilator support. However, NIPPV (bilevel positive airway pressure) was proved to be a safe method.
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Atmospheric pollution in cardiac operating rooms
Annals of Cardiac Anaesthesia 2017 20(4):391-392
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Comparison of dexmedetomidine and ketamine versus propofol and ketamine for procedural sedation in children undergoing minor cardiac procedures in cardiac catheterization laboratory
Annals of Cardiac Anaesthesia 2017 20(4):422-426
Background: The ideal anaesthetic technique for management of paediatric patients scheduled to undergo cardiac catheterisation is still not standardised. Aim: To compare the effects of ketamine-propofol and ketamine-dexmedetomidine combinations on hemodynamic parameters and recovery time in paediatric patients undergoing minor procedures and cardiac catheterisation under sedation for various congenital heart diseases. Material and Methods: 60 children of either sex undergoing cardiac catheterisation were randomly assigned into two groups Dexmedetomidine-ketamine group (DK) and Propofol-ketamine (PK) of 30 patients each. All patients were premedicated with glycopyrrolate and midazolam (0.05mg/kg) intravenously 5-10 min before anaesthetic induction. Group 'DK'received dexmedetomidineiv infusion 1 μg/kg over 10 min + ketamine1mg/kg bolus, followed by iv infusion of dexmedetomidine 0.5μg/kg/hr and of ketamine1 mg/kg/hr. Group 'PK' received propofol 1mg/kg and ketamine 1mg/kg/hr for induction followed by iv infusion of propofol 100 μg/kg/hr and ketamine 1 mg/kg/hr for maintenance. Haemodynamic parameters and recovery time was recorded postoperatively. Statistical Analysis: Independent sample t test was used to compare the statistical significance of continuous variables of both the groups.Chi square test was used for numerical data like gender.Fischer exact test was applied for non parametric data like ketamine consumption. Results: We observed that heart rate in dexmedetomidine (DK) group was significantly lower during the initial 25 mins after induction compared to the propofol (PK) group. Recovery was prolonged in the DK group compared to the PK group (40.88 vs. 22.28 min). Even ketamine boluses consumption was higher in DK group. Conclusion: Use of dexmedetomidine-ketamine combination is a safe alternative, without any hemodynamic orrespiratory effects during the cardiac catheterization procedure but with some delayed recovery.
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Rhabdomyolysis and compartment syndrome in a bodybuilder undergoing minimally invasive cardiac surgery
Annals of Cardiac Anaesthesia 2017 20(4):453-455
Rhabdomyolysis is the result of skeletal muscle tissue injury and is characterized by elevated creatine kinase levels, muscle pain, and myoglobinuria. It is caused by crush injuries, hyperthermia, drugs, toxins, and abnormal metabolic states. This is often difficult to diagnose perioperatively and can result in renal failure and compartment syndrome if not promptly treated. We report a rare case of inadvertent rhabdomyolysis and compartment syndrome in a bodybuilder undergoing minimally invasive cardiac surgery. The presentation, differential diagnoses, and management are discussed. Hyperkalemia may be the first presenting sign. Early recognition and management are essential to prevent life-threatening complications.
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Evaluation of the effect of metformin and insulin in hyperglycemia treatment after coronary artery bypass surgery in nondiabetic patients
Annals of Cardiac Anaesthesia 2017 20(4):427-431
Introduction: Insulin therapy is the most commonly used treatment for controlling hyperglycemia after coronary artery bypass surgery in both diabetic and nondiabetic patients. Metformin has been indicated for critically ill patients as an alternate for the treatment of hyperglycemia. This study evaluated the effect of metformin and insulin in hyperglycemia treatment after coronary artery bypass surgery in nondiabetic patients. Settings and Design: This study was a clinical trial comprising nondiabetic patients who had undergone coronary artery bypass surgery. Patients were randomly divided into the insulin group and the metformin group. Methods: Patients in the insulin group received continuous infusion of insulin while those in the metformin group received 500 mg metformin tablets twice daily. All the patients were followed up for 3 days after stabilization of blood glucose levels. Statistical Analysis: Data were analyzed using Chi-square test and Mann–Whitney U-test. Results: This study included a total of 56 patients. During the study period, the mean blood glucose levels decreased from 225.24 to 112.36 mg/dl (↓112.88 mg/dl) in the insulin group and from 221.80 to 121.92 mg/dl in the metformin group (↓99.88 mg/dl). There was no significant difference in the blood glucose levels of the patients between the two groups at any measurement times (P > 0.05). Conclusion: Using 500 mg metformin twice daily is similar to using insulin in nondiabetic patients undergoing coronary artery bypass graft. Therefore, the use of metformin can be considered as a treatment strategy for controlling hyperglycemia in this group of patients.
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Two episodes of cardiac tamponade in the same patient from removing pacing wires and a pericardial drain: A case report
Annals of Cardiac Anaesthesia 2017 20(4):459-461
A patient presented for an elective transcatheter aortic valve replacement with temporary transvenous pacing (TVP) wires placement per protocol. On postoperative day 1, the patient remained stable, so the wires were subsequently removed, after which the patient acutely decompensated, with transthoracic echocardiography revealing pericardial effusion. Emergent pericardiocentesis was performed, and a pericardial drain was placed. Three days later, the drain was removed; again, the patient acutely decompensated, requiring another emergent pericardiocentesis. Despite the relatively benign nature of TVP wires and pericardial drains, the possibility of cardiac tamponade should be kept in mind as a potential complication when they are being removed.
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Ischemic mitral regurgitation
Annals of Cardiac Anaesthesia 2017 20(4):432-439
Ischemic mitral regurgitation (IMR) is a frequent complication of left ventricular (LV) global or regional pathological remodeling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces and reduced closing forces. IMR is defined as mitral regurgitation caused by chronic changes of LV structure and function due to ischemic heart disease and it worsens the prognosis. In this review, we discuss on etiology, pathophysiology, and mechanisms of IMR, its classification, evaluation, and therapeutic corrective methods of IMR.
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A case report of combined radical pericardiectomy and beating heart coronary artery bypass grafting in a patient with tubercular chronic constrictive pericarditis with coronary artery disease
Annals of Cardiac Anaesthesia 2017 20(4):465-467
We here report a successful midterm outcome following combined off-pump radical pericardiectomy and coronary artery bypass surgery (CABG) in a 65-year-old male patient who was suffering from chronic constrictive calcified tubercular pericarditis with coronary artery disease. Simultaneous off-pump CABG and radical pericardiectomy for nonsurgical constrictive pericarditis is reported very rarely in English literature.
http://ift.tt/2kBt0BN
Clinical and dermoscopic characterization of pediatric and childhood melanomas. Multicenter study of 52 cases
Knowledge regarding the morphologic spectrum of pediatric melanoma (PM) is sparse and this may in part contribute to delay in detection and thicker tumors.
http://ift.tt/2g6uvGv
87th Annual Meeting of the American Thyroid Association October 18–22, 2017, Victoria, British Columbia, Canada
Angela M. Leung and Mingzhao Xing
2017 ATA Annual Meeting Co-Chairs.
2017 ATA Annual Meeting Co-Chairs.
We are excited that the 87th annual meeting of the American Thyroid Association (ATA) is almost upon us! On behalf of the Program Committee, we look forward to welcoming attendees and their guests to the annual meeting that will be held October 18–22, 2017, at the Fairmont Empress and Victoria Conference Centre in Victoria, British Columbia, Canada. Over this past year, the committee, comprised of experts from all thyroid disciplines, has thoughtfully worked to put together a program featuring the latest advances in basic, translational, and clinical thyroidology. Read More….
The post 87th Annual Meeting of the American Thyroid Association October 18–22, 2017, Victoria, British Columbia, Canada appeared first on American Thyroid Association.
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Calcium channel blockers for lung function improvement in asthma
For decades, calcium channel blockers (CCBs) have been believed to play a role in asthma treatment. However, the clinical efficacy of CCBs for lung function improvement in patients with asthma has not been qualitatively evaluated.
http://ift.tt/2wJYW8K
Serum and sputum calprotectin, a reflection of neutrophilic airway inflammation in asthmatics after high altitude exposure
Abstract
Until recently, asthma has been characterized as a T(h)2-disorder with eosinophilic airway inflammation. However, several studies showed the existence of patients with asthma characterized by neutrophilic airway inflammation.[1] Seys et al. showed an increased proportion of sputum neutrophils in asthmatic patients after exposure to environmental conditions at high altitude (HA) and in elite athletes after intensive exercise (swimming).[2,3] As patients with neutrophilic asthma poorly respond to classic therapies such as inhaled corticosteroids, it is crucial to identify these patients to predict their medication response and to provide them with an appropriate therapy.[4]
This article is protected by copyright. All rights reserved.
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Tooth damage in captive orcas (Orcinus orca)
Source:Archives of Oral Biology, Volume 84
Author(s): John Jett, Ingrid N. Visser, Jeffrey Ventre, Jordan Waltz, Carolina Loch
ObjectivesTooth damage as a result of oral stereotypies is evident in captive orca, yet little research on the topic exists. This study examines the associations between dental pathology, sex, facility, duration of captivity and other factors in captive orca.DesignWe evaluated mandibular and maxillary teeth from dental images of 29 captive orca owned by a US-based theme park. Each tooth was scored for coronal wear, wear at or below gum line and bore holes. Fractured and missing teeth were also noted. Summary statistics described the distribution and severity of pathologies; inferential statistics examined how pathologies differed between sexes, between wild-captured and captive-born orcas and between captive orca at four facilities. We also evaluated how dental pathology and duration of captivity were related.ResultsApproximately 24% of whales exhibited "major" to "extreme" mandibular coronal tooth wear, with coronal wear and wear at or below gum line highly correlated. More than 60% of mandibular teeth 2 and 3 exhibited fractures. Bore holes were observed primarily among anterior mandibular teeth, with more than 61% of teeth 2 and 3 bearing evidence of having been drilled. Four of five orca with the highest age-adjusted tooth pathology indices were captive-born.ConclusionsVarious dental pathologies were observed across all whales, with pathologies beginning at a young age. Oral stereotypies exhibited by captive orca contributed to the observed dental damage. By making dental and health records of captive whales publicly available, the theme park industry is uniquely positioned to provide further insight into dental pathology and resultant health consequences in captive orca.
http://ift.tt/2g6yoLR
Association between the IRF6 rs2235371 polymorphism and the risk of nonsyndromic cleft lip with or without cleft palate in Chinese Han populations: A meta-analysis
Source:Archives of Oral Biology, Volume 84
Author(s): Yinlan Xia, Bo Hu, Jin Chen, Leilei Zheng, Jinlin Song
ObjectiveTo investigate the association between the risk of nonsyndromic cleft lip with or without cleft palate (NSCL/P) and the IRF6 rs2235371 (C>T) polymorphism in Chinese Han populations.DesignPubMed, Web of Science and EMBASE were searched through May 31, 2016, to select eligible studies. Pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) were applied to estimate the risk of NSCL/P associated with the IRF6 rs2235371 polymorphism. Subgroup analyses were conducted according to NSCL/P types (CLO, CPO and CLP) and the geographical location (Northern China and Southern China). Publication bias and sensitivity analyses were performed to assess the reliability of the results.ResultsA total of 1275 NSCL/P cases and 1294 controls from seven eligible case-control studies were included. In the overall analysis, a significant association between the IRF6 rs2235371 polymorphism and the risk of NSCL/P was identified under all genetic models, with the exception of the recessive model (T vs. C: OR=0.68, 95%CI=0.60-0.76, P<0.00001). A subgroup analysis by NSCL/P types indicated that the variant T allele significantly decreased the risk of CLO and CLP but not CPO. A subgroup analysis of the geographical location further showed significantly decreased susceptibility in Northern China under all genetic models, but in Southern China, only the heterozygote and dominant models showed a significantly decreased risk of NSCL/P. Funnel plot analysis and the Egger linear regression method detected no publication bias.ConclusionsThe IRF6 rs2235371 T allele decreased the risk of NSCL/P in Chinese Han populations. However, further studies with large sample sizes should be conducted to confirm this association.
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Professional Autonomy Slipping Away
Physicians are frustrated with the countless ways their professional autonomy is slowly being stripped from clinical practice.
Medscape Family Medicine
http://ift.tt/2yuYX50
Présentation atypique d’un lymphome du manteau
Source:Annales de Dermatologie et de Vénéréologie
Author(s): L. Orgeolet, F. Staroz, M. Acquitter, P. Plantin, C. Fleuret
http://ift.tt/2za6bs4
Cosmétiques et médicaments topiques dans l’acné : où est la frontière ?
Source:Annales de Dermatologie et de Vénéréologie
Author(s): F. Poli, J.-P. Claudel, N. Auffret, M.-T. Leccia, B. Dréno
L'acné est une maladie chronique pouvant induire des séquelles telles que des cicatrices atrophiques ou hypertrophiques, ou de l'hyperpigmentation postinflammatoire. Les médicaments topiques ou systémiques ayant une activité pharmacologique et une autorisation de mise sur le marché sont les acteurs clés du traitement de l'acné. Ces traitements topiques ou systémiques induisent souvent des effets secondaires en lien avec l'altération de la barrière cutanée. Ils doivent donc être associés à des cosmétiques qui viseront à protéger la barrière cutanée. Avec l'arrivée sur le marché de produits cosmétiques contenant des ingrédients actifs évalués en laboratoire sur des cultures cellulaires ou des échantillons de tissus, et testés cliniquement sur un nombre souvent très limité de sujets, le monde des cosmétiques a changé. En utilisant le terme « dermo-cosmétique » et avec l'introduction d'ingrédients actifs dans les formulations, les cosmétiques se présentant aujourd'hui comme adaptés à une pathologie cutanée ne se limitent plus à l'entretien et l'hygiène de la peau, mais visent à apporter aux personnes souffrant de cette pathologie cutanée un produit complémentaire, voire une alternative aux médicaments. Le but de cet article est de mieux comprendre et clarifier le rôle respectif des médicaments topiques et des cosmétiques dans la prise en charge de l'acné.Acne is a chronic disease that may cause sequels such as atrophic or hypertrophic scars or post-inflammatory hyperpigmentation. Topical and systemic medications with proven pharmacologic activity and which have received marketing authorization are the key actors in the treatment of acne. However, these topical or systemic treatments frequently cause adverse effects related to impairment of the skin barrier, and cosmetics must therefore be used in combination to help protect the skin barrier. Nowadays, new cosmetic products containing active ingredients tested in vitro or in a small number of subjects have changed the world of cosmetics. In being described as "dermo-cosmetic" and in integrating active ingredients in their formulations, these cosmetics are now being presented as being specifically adapted for a given disease, and no longer limited to skin care and hygiene but suitable as an adjunctive or even an alternative to current medications. The aim of this article is to provide a better understanding of the respective roles of medications and cosmetics in the management of acne.
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Les syndromes d’Ehlers-Danlos
Source:Annales de Dermatologie et de Vénéréologie
Author(s): D.-P. Germain
Les syndromes d'Ehlers-Danlos (SED) sont un groupe de maladies génétiques du tissu conjonctif caractérisées par une hyperélasticité cutanée, une hyperlaxité articulaire et une fragilité des tissus. Au-delà de ces caractéristiques communes, ils se distinguent les uns des autres par la présence ou l'absence de cicatrices cutanées, la variabilité des atteintes organiques et des variants génétiques différents. Il s'agit de maladies génétiques complexes, souvent invalidantes. La classification de Villefranche, établie en 1997, a défini 6 sous-types de SED mais de nombreuses autres formes rares ont été décrites depuis. À côté des classiques altérations de la synthèse du collagène sont à présent décrites des anomalies de la synthèse des glycosaminoglycanes ou de l'organisation de la matrice extracellulaire dues à des déficits enzymatiques et de nombreux SED rares ou apparentés sont de facto des maladies métaboliques. Il n'existe pas de traitement curatif des SED mais il importe de porter un diagnostic précoce pour une prise en charge symptomatique optimale des patients et une prévention des complications évitables. Une approche multidisciplinaire, dans un centre de référence, un centre de compétence, un service de dermatologie ou un service de génétique médicale, est souhaitable. Nous présentons un état actuel des connaissances sur ces pathologies que la génétique a permis de démembrer au fil des années.Ehlers-Danlos syndromes (EDS) are a heterogeneous group of inheritable connective tissue disorders characterized by skin hyperextensibility, joint hypermobility and cutaneous fragility with delayed wound healing. Over and above these common features, they differ in the presence or absence of various organ and tissue abnormalities, and differences in genetic causal mechanisms and degree of severity. They are complex and multisystem diseases, with the majority being highly disabling because of major joint problems and neurosensory deficiencies, and in some cases, they may be life-threatening due to associated complications, especially vascular disorders. In 1997, the Villefranche classification defined 6 subtypes of EDS. However, many other new variants have been described over the last years. The "historical" EDS were characterized by abnormalities in fibrillar collagen protein synthesis. More recently, disorders of synthesis and organization of the extracellular matrix have been shown to be responsible for other types of EDS. Thus, many EDS are in fact metabolic diseases related to enzymatic defects. While there is no curative treatment for any type of EDS, early diagnosis is of utmost importance in order to optimize the symptomatic management of patients and to prevent avoidable complications. Patients must be treated and monitored by multidisciplinary teams in highly specialized reference centers. In this article, we present the current state of knowledge on these diseases that continue to be elucidated thanks to new molecular genetic techniques.
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Reconstruction design before tumour resection: A new concept of through-and-through cheek defect reconstruction
Source:Oral Oncology, Volume 74
Author(s): Zhao-Jiang Gong, Zhen-Hu Ren, Kai Wang, Hong-Yu Tan, Sheng Zhang, Han-Jiang Wu
ObjectiveTo explore a new method of reconstruction of through-and-through cheek defects and to evaluate this method's efficacy and patient prognosis.Materials and methodsThis retrospective study included 70 patients who underwent reconstruction of through-and-through cheek defects. The surgical approach, design of facial skin incisions, selection and design of flaps, postoperative quality of life and prognosis of patients were recorded and reported.ResultsPostoperative quality of life gradually increased over time, and the mean scores of University of Washington Quality of Life (UW-QOL) Questionnaire was more than 80 at 1-year postoperatively. The appearance, oral competence, chewing, swallowing, speech and other oral functions were well recovered in about 90% of patients at 1-year postoperatively.ConclusionThis new idea of reconstruction before tumour resection, brings the effect of plastic and reconstructive surgery to a new height.
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The effect of home-based program and outpatient physical therapy in patients with head and neck cancer: A randomized, controlled trial
Publication date: November 2017
Source:Oral Oncology, Volume 74
Author(s): Tsui-Ling Su, An-Ni Chen, Chau-Peng Leong, Yu-Chi Huang, Chia-Wei Chiang, I-Hsuan Chen, Yan-Yuh Lee
ObjectivesPhysical therapy improves outcomes for patients with head and neck cancer (HNC) but home-based program (HBP) has not yet been investigated thoroughly. This study compared a HBP with outpatient physical therapy (OPT).MethodsThis trial categorized patients with primary HNC into OPT and HBP groups. The patients in the HBP group received home-based therapy once a day for 5 days per week. By contrast, the OPT group received various physical therapies, including aerobic, anaerobic, and stretching therapies, twice per week, plus a thrice-weekly home-based therapy that similarly consisted of aerobic, anaerobic, and stretching exercises. The major outcome was the Functional Assessment of Cancer Therapy—Head and Neck (FACT H&N), and secondary outcomes were the visual analog scale (VAS) of shoulder pain, 6-min walking test (6MWT), and shoulder range of motion (ROM), all of which were evaluated before, during, and after interventions.ResultsSignificant improvements were found after 12 weeks of the HBP or OPT. The HBP was not inferior to OPT regarding FACT H&N (p=.074), VAS of shoulder pain (p=.677), 6MWT (p = .677), and shoulder ROM (p=.145 for flexion; p=.383 for abduction).ConclusionsBoth the HBP and OPT can improve shoulder abduction, shoulder flexion and functional capacity.
http://ift.tt/2i1GkPa
Ixekizumab treatment for psoriasis: Integrated efficacy analysis of three double-blinded, controlled studies (UNCOVER-1, UNCOVER-2, UNCOVER-3)
Abstract
Background
Ixekizumab, a high-affinity monoclonal antibody that selectively targets interleukin (IL)-17A, is approved for the treatment of moderate-to-severe psoriasis.
Objectives
This analysis represents an overview of the efficacy outcomes from three Phase 3 psoriasis studies.
Methods
Data were integrated from the 12-week induction period of three studies in which patients received ixekizumab 80 mg every 2 (IXE Q2W; N=1169) or 4 weeks (IXE Q4W; N=1165) after an initial 160-mg dose for both, etanercept (ETN) (50 mg biweekly; N=740; two studies), or placebo (PBO) (N=792). The co-primary endpoints were the percentages of patients with response of sPGA (0,1) and a 75% improvement in baseline psoriasis area severity index (PASI 75) at Week 12. Response rates were compared between treatments using the Cochran-Mantel-Haenszel test stratified by study. Treatment comparisons with placebo included data from three studies, whereas etanercept comparisons were based on two studies.
Results
Ixekizumab treatment was superior to placebo (p<0.001) and etanercept (p<0.001) on sPGA (0,1) and PASI 75, with significant differences in PASI improvement at Week 1. With IXE Q2W, at Week 12, the frequency of patients achieving PASI 75/90/100 was nearly 90%/70%/40%, respectively. Ixekizumab-treated patients showed significantly greater improvement versus placebo and etanercept in percent body surface area involvement and fingernail psoriasis. IXE Q2W was superior to IXE Q4W on all treatment outcomes.
Conclusions
Ixekizumab therapy at both dosing regimens demonstrated rapid onset and superior efficacy compared with placebo and etanercept, with IXE Q2W providing better outcomes than IXE Q4W during the first 12 weeks of treatment.
This article is protected by copyright. All rights reserved.
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No Elevated Risk for Depression, Anxiety, or Suicidality with Secukinumab in a Pooled Analysis of Data from 10 Clinical Studies in Moderate-to-Severe Plaque Psoriasis
Abstract
Concerns have emerged over the potential for brodalumab, a monoclonal antibody that binds to the human interleukin (IL)-17 receptor A and blocks the activity of multiple IL-17 isoforms, to increase risk of suicidal ideation and behaviour. Although the validity of this association has been questioned,1,2 brodalumab has a boxed warning regarding suicidality in its US label and is only available through a Risk Evaluation and Mitigation Strategy. Regardless of the true association between suicidality and brodalumab, the demonstrated adverse impact of psoriasis on mental health necessitates careful assessment for possible psychiatric adverse effects of psoriasis therapies, including those that inhibit the IL-17 pathway.
This article is protected by copyright. All rights reserved.
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The prevalence of psychological co-morbidity in people with vitiligo: a systematic review and meta-analysis
Abstract
Background
Vitiligo is a chronic disorder causing skin depigmentation with global prevalence varying from 0.2 to 1.8%. UK guidelines recommend assessment of psychological state during clinical evaluation of vitiligo. However, the prevalence of psychological co-morbidity in people with vitiligo has not been described.
Objectives
We aimed to establish the prevalence of psychological symptoms or disorders in people with vitiligo and describe the outcome measures used.
Methods
We performed a comprehensive search of MEDLINE, Embase, CINAHL and PsychInfo to identify observational studies assessing the prevalence of psychological symptoms or disorders (December 2016). DerSimonian and Lard random-effects models were utilized to estimate the overall pooled prevalence.
Results
We identified 29 studies with 2530 people with vitiligo. Most studies included a measure of either depression (n=25) or anxiety (n=13).The commonest tools were the Hospital Anxiety and Depression Scale and the Centre for Epidemiology Studies Depression Scale. Ten studies provided information on thirteen other psychological outcomes. Pooled prevalence using depression-specific and anxiety-specific questionnaires was 0.29 (95%CI 0.21, 0.38) and 0.33 (95%CI 0.18, 0.49) respectively. Prevalence was lower for clinically diagnosed depression (0.21; 95%CI 0.15, 0.28) and anxiety (0.15; 95%CI 0.06, 0.24). When non-specific tools were used the prevalence remained similar for depression (0.27; 95%CI 0.08, 0.46) but increased for anxiety (0.46; 95% CI 0.39, 0.52). High heterogeneity was observed.
Conclusions
A range of psychological outcomes are common in people with vitiligo. The prevalence of anxiety was influenced by type of screening tool, suggesting validation of psychological outcome screening tools in the field of dermatology.
This article is protected by copyright. All rights reserved.
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Low dose naltrexone: a novel treatment for Hailey-Hailey disease
Summary
Hailey-Hailey disease (chronic benign familial pemphigus) is a rare inherited dermatosis typically characterised by erosions at intertriginous sites preceded by minor trauma or stress. We report a case of treatment resistant Hailey-Hailey disease, having failed topical and oral steroids, prophylactic acyclovir and doxycycline, and systemic therapies including dapsone, acitretin and ciclosporin. Low dose naltrexone (LDN) 4.5mg one daily was commenced following an incidental benefit in this patient's similarly affected sister. The clinical and psychological response to date has been considerable.
This article is protected by copyright. All rights reserved.
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A Case of Peripheral Ulcerative Keratitis Associated with Autoimmune Hepatitis
Purpose. To describe a case of peripheral ulcerative keratitis in the setting of autoimmune hepatitis and possible overlap syndrome with primary sclerosing cholangitis. Case Report. A 48-year-old African American female with autoimmune hepatitis with possible overlap syndrome with primary sclerosing cholangitis presented with tearing, irritation, and injection of the left eye that was determined to be peripheral ulcerative keratitis. The patient was treated with topical and systemic steroids, immunosuppressant drugs (azathioprine and mycophenolate mofetil), a biologic (rituximab), and surgery (conjunctival resection), and the peripheral ulcerative keratitis epithelialized but ultimately led to corneal perforation. Conclusion. In this unique case, a patient with peripheral ulcerative keratitis who underwent treatment ultimately had a corneal perforation. This case may suggest a possible relationship between autoimmune hepatitis and peripheral ulcerative keratitis.
http://ift.tt/2kxjaki
Isolation and Establishment of Gustatory Cell Lines in Patients Operated on for Cancer of the Mobile Tongue - ImmortTasteCELL
Condition: Cancer of the Tongue
Intervention: Procedure: Sample of cancerous epithelium from the tongue
Sponsor: Centre Hospitalier Universitaire Dijon
Recruiting
http://ift.tt/2yBgB7e
Intervention: Procedure: Sample of cancerous epithelium from the tongue
Sponsor: Centre Hospitalier Universitaire Dijon
Recruiting
http://ift.tt/2yBgB7e
A rare case of extra-adrenal bilateral perirenal and periureteric myelolipoma
A 30-year-old immunocompetent female presented with right flank pain since 3 years. MRI revealed a large well-defined T1 and T2 hypointense mildly enhancing lesion in the right anterior pararenal space displacing the right kidney and encasing the right ureter with T2 hyperintense wall thickening of the left renal pelvis and ureter. A provisional diagnosis of solitary fibrous tumour was kept. Bilateral double J stenting was done for hydronephrosis. Surgical debulking of the lesion was done with biopsy from the left periureteral wall thickening and was found to be myelolipoma on histopathological examination. This case is a novel variety of myelolipoma which is lipid poor, extra-adrenal and in bilateral perirenal and periureteric location.
http://ift.tt/2fWBu1j
Spontaneous bilateral carpopedal spasm in a bulimic patient
Description
A 36-year-old woman presented to the emergency department after she woke up with painful spasm of bilateral hands. She had been vomiting 10–15 times daily for the past few days. She denied any laxative or diuretic abuse. She had 18-year history of bulimia nervosa, primarily involving self-induced vomiting and excessive exercising. Her body mass index was 20.7 kg/m2. Vital signs and physical examination were unremarkable except for dry oral mucosa, poor oral dentition and classic bilateral carpopedal spasm (figure 1). Labs revealed hypocalcaemia (ionised calcium 0.88 mmol/L), hypokalaemia (potassium 2.8 mEq/L), hypomagnesaemia (magnesium 1.6 mEq/L), metabolic alkalosis (serum bicarbonate 34.5 mEq/L), hypochloraemia (chloride 78 mEq/L), hypophosphataemia (phosphorus 1.6 mg/dL), acute kidney injury (serum creatinine 2.49 mg/dL, baseline of 0.9), leucocytosis (white blood cells 15 700 x109/L mm3) and normal serum albumin 4 g/dL. ECG showed normal sinus rhythm with prolonged QTc of 550 ms (figure 2). Urine drug screen was positive...
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Delayed spinal cord infarction following anterior cervical surgical decompression
Anterior cervical discectomy and fusion (ACDF) for cord compression is a safe and effective procedure with good outcomes. However, worsening of myelopathy is the most feared adverse event of the surgery. We report the case of a 36-year-old male patient who presented with an acute non-traumatic C5–6 cervical disc herniation causing incomplete quadriparesis. He underwent an uncomplicated ACDF at C5–6, and after an initial period of improvement, he developed a delayed onset of an anterior cord syndrome on day 3, without any discerning cause. We have reviewed similar cases reported in the literature and believe that our patient's postsurgical course is consistent with a delayed ischaemic/reperfusion injury to the cord following surgical decompression and restoration of blood flow through the anterior spinal artery and we make suggestions for management of such clinical events.
http://ift.tt/2fVzTbX
Videoscopic-assisted removal of a left ventricular mass in an octogenarian
Description
An 85-year-old female with history of hypertension, diabetes, coronary artery disease and emphysema presented with episodes of confusion. MRI demonstrated bilateral acute infarcts. She had non-ST elevation myocardial infarction and underwent percutaneous intervention with drug-elating stent for left anterior descending artery stenosis. Transthoracic echocardiography (TTE) (see online ) and transoesophageal echocardiography (TEE) demonstrated calcified left ventricular mass (LVM) (see online ), severe mitral annular calcification and moderate mitral stenosis (figure 1). Forced expiratory volume in one second 0.89 (85% of predicted), forced vital capacity 1.01 (69% of predicted) and frail body habitus. Multidisciplinary discussions (MDD) with family and they agreed to video-assisted LVM removal.1 2 Double lung ventilation was initiated, peripheral cardiopulmonary bypass (CPB) instituted through femoral vessels, ventilation stopped and resumed at the end of CPB. A 4 cm right intercostal incision performed and 10 mm videoscope inserted through separate 12 mm port. After cross-clamp, induction antegrade cardioplegia administrated...
http://ift.tt/2hXIkYk
Aspirin safety in glucose-6-phosphate dehydrogenase deficiency patients with acute coronary syndrome undergoing percutaneous coronary intervention
The use of aspirin, as part of a dual antiplatelet therapy regimen, is an established standard following coronary stenting in patients suffering from acute coronary syndrome (ACS). However, in glucose-6-phosphate dehydrogenase (G6PD) deficient patients, precaution is always taken with aspirin use, due to the risk of haemolysis. We reviewed all previous cases of G6PD deficient patients with ACS, in addition to a review of the available literature, to better understand the safety of aspirin use in this population. To date, there are no reported cases of haemolysis following aspirin use in this patient group and no guideline is established to date.
http://ift.tt/2z8tItx
Hoarseness as a presentation of mycosis fungoides infiltrating the larynx
Laryngeal involvement is a rare manifestation of mycosis fungoides (MF), with only nine reported cases of cutaneous T cell lymphoma with laryngeal or vocal cord involvement. Herein, we report the case of a patient with a 7-year history of MF who presented to the emergency department with hoarseness, throat tightness and cough, as well as erythroderma and skin tumours. Laryngoscopy and CT imaging were concerning for lymphomatous involvement of the left false vocal cord. A biopsy was taken of the false vocal cord lesion, which revealed an aberrant immunophenotype consistent with MF. The patient was started on doxorubicin with initial rapid improvement in symptoms. Within 2 months, her respiratory status and skin involvement worsened. Subsequent studies showed bone marrow involvement. The patient expired 4 months after original presentation. This report describes the patient's presentation and clinical course, and reviews the literature on vocal cord and laryngeal involvement of MF.
http://ift.tt/2y2XXEq
Nodular fasciitis of soft tissue over the mandible
Nodular fasciitis (NF) is an unusual, benign condition which can mimic more sinister, sarcomatous lesions both clinically and histologically. This case report presents a 35-year-old male, with a rapidly growing mass on the border of his left mandible, referred to a specialist head and neck unit. The initial presentation, radiology and cytology were initially inconclusive and the possibility of a malignant process was considered. Final histology was that of NF, the treatment of which is complete surgical excision. Therefore, NF is an important differential to consider when assessing similar clinical presentations, as highlighted in this case report.
http://ift.tt/2z9RrJN
Rare postoperative complication: Clostridium perfringens septic shock following elective abdominal surgery
Postoperative infections are one of the most common complications in general surgery, and while rates have reduced with the routine administration of perioperative antibiotics, around 5% of patients undergoing a surgical procedure will develop an infective complication.1 The Gram-positive, obligate anaerobe, Clostridium perfringens, is a well-known pathogen that forms part of both the environmental and gastrointestinal flora.2 While more commonly associated with food poisoning, anaerobic cellulitis and traumatic gas gangrene, rare cases of spontaneous non-traumatic gas gangrene of abdominal viscera have also been recorded.3 Although potentially treatable with appropriate antibiotic cover, cases of C. perfringens can rapidly progress into fulminant and fatal sepsis.4 Moreover, the timing of symptom onset postoperatively can vary significantly, reports ranging from hours to days.5 6 We report a case of C. perfringens-induced septic shock following elective bowel resection.
http://ift.tt/2y2XVMO
Haematuria in ADPKD: not always benign. Be aware!
Haematuria in patients with autosomal dominant polycystic kidney disease (ADPKD) is a very common manifestation. The cause of haematuria is often benign with the most common cause being haemorrhage within the renal cyst. But haematuria may also be caused by a coincident malignancy, the diagnosis of which may be missed if not investigated thoroughly. Herein, we present a case of ADPKD who presented to us with haematuria and was later found to have bladder cancer.
http://ift.tt/2za07Qs
Isolated adductor myocysticercosis in a 6-year-old girl
Description
A 6-year-old girl presented with asymptomatic right thigh swelling over medial aspect for 6 weeks. Examination revealed a 5 cmx4 cm, non-tender, mobile swelling, not fixed to the skin or underlying structures. The rest of the examination was within normal limits. There was no history of seizures, headache or ophthalmic complaints. Ultrasonography of the right thigh revealed a well-defined cystic lesion measuring 11.5 cmx4.3 cm seen in the adductor muscle of the thigh with eccentric echogenic focus within (figure 1). No perilesional oedema was seen. Stool examination was negative for Taenia solium eggs. Serological testing could not be done due to affordability issues. A diagnosis of vesicular stage of isolated adductor myocysticercosis was made. Neuroimaging and ophthalmic assessment were unremarkable. Patient was treated with oral albendazole as an outpatient basis and had uneventful recovery at 1 month of follow-up with thigh swelling got completely resolved. However, we could not repeat an ultrasonography a few months...
http://ift.tt/2y4EwLo
Delays in diagnosis and treatment of extrapulmonary tuberculosis in Guatemala
A 23-year-old indigenous Guatemalan man presented in 2016 to our clinic in Sololá, Guatemala, with 10 months of recurrent neck swelling, fevers, night sweats and weight loss. Previously, he had sought care in three different medical settings, including a private physician-run clinic, a tertiary private cancer treatment centre and, finally, a rural government health post. With assistance from our institution's accompaniment staff, the patient was admitted to a public tertiary care hospital for work-up. Rifampin-susceptible tuberculosis was diagnosed, and appropriate treatment was begun. The case illustrates how low tuberculosis recognition among community health workers and health system segmentation creates obstacles to appropriate care, especially for patients with limited means. As a result, significant diagnostic and treatment delays can occur, increasing the public health burden of tuberculosis.
http://ift.tt/2z9YodF
Interrupted aortic arch complicated with takotsubo cardiomyopathy mimicking aortic dissection
A 50-year-old man presented to the emergency department with interscapular pain, diaphoresis and restlessness. Initial examination raised the possibility of aortic dissection; however, the CT scan did not concur with the diagnosis. An ECG showed ST segment elevation in leads V1–V6 and echocardiography showed severe left ventricular systolic dysfunction. Coronary angiography through the right femoral artery was attempted but the diagnostic catheter could not be advanced to the ascending aorta. Radiocontrast injection showed complete obstruction of the descending aorta. Coronary angiography through right radial approach showed mild left anterior descending disease. The aortogram showed complete interruption of the ascending aorta with extensive collateral network. Left ventricle gram was consistent with stress-induced cardiomyopathy. We noticed intermittent confusion and agitation. MRI of the brain showed areas of deep white matter ischaemia as well as microhaemorrhages, suggesting posterior reversible leucoencephalopathy syndrome. He unfortunately went into cardiac arrest and could not be revived.
http://ift.tt/2y4Ukhq
Lipoedematous scalp: is there an association with fatty infiltration of the parotid?
Lipoedematous scalp (LS) is an extremely rare condition characterised by a soft and boggy consistency in the scalp due to an increased layer of subcutaneous tissue.
In this report, we present a case of LS in a 64-year-old Indian woman. Clinical examination revealed only vague boggy lumpiness involving the whole of occipital scalp extending to parietal scalp. MRI scalp showed diffuse fatty infiltration of the scalp, particularly at the posterior parietal and occipital convexity extending to both lateral aspects of the cranium, with homogeneous signal in keeping with fat. Incidentally MRI also found diffuse fatty infiltration of the parotids.
The aethiopathogenesis of LS is still unknown, however it is believed that the hormone leptin could be the key hormone in the dysregulation of fat deposition and distribution. This case report highlights the subtle features with which these cases can present and explores the literature on reported cases of LS.
http://ift.tt/2za033a
Pertussis manifesting as recurrent cough and wheezing in an incompletely vaccinated 8-month-old infant
Pertussis is an acute respiratory illness caused by Bordetella pertussis, showing a re-emergence in developed countries. However, it is probably under-recognised and, as a consequence, its burden is underestimated. Here, we report the clinical case of an infant diagnosed with pertussis, despite a regular schedule of vaccination, thanks to a careful clinical evaluation, including personal and family history. In addition to pointing the attention on a precocious diagnosis of atypical cases of pertussis, this case report further raised the issue of modifying and/or implementing the immunisation strategy, considering the ongoing changes of social (eg, immigration) and sanitary (eg, vaccine coverage) background in Italy and all over the Europe.
http://ift.tt/2y2XSk6
Endoscopic shaving of hair in a gastric bypass patient with a large bezoar
Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history of diabetes, certain psychiatric disorders, prior gastric surgery and poor mastication ability are at an increased risk of developing bezoars. We are presenting a case of patient who suffered from a large, recurrent trichobezoar, who had a history of gastric bypass surgery as well as trichotillophagia. The endoscopic method used to remove the large bezoar will also be discussed. We have reviewed the cases published, in which patients developed bezoars after undergoing gastric bypass surgery. The purpose of this study is to raise awareness among clinicians that patients with certain psychiatric issues who had prior gastric surgeries, are at eminent risk of bezoar formation. A multidisciplinary approach including cognitive behavioural therapy, dietary education and pharmacotherapy should be taken to prevent complications.
http://ift.tt/2z9xEdi
Unusual case of urethral steinstrasse following laser cystolitholapaxy
Urethral steinstrasse is a rare finding. This case describes a 35-year-old man presenting with urethral steinstrasse 4 weeks following laser cystolitholapaxy of a large bladder stone.
http://ift.tt/2y2XQbY
Bilateral fungal keratitis with ring infiltrates: a rare scenario
A 12-year-old boy presented to the emergency department with chief complaints of pain, redness, discharge and diminution of vision in both eyes over the previous 20 days. There was no history of preceding trauma, contact lens use, any eye drop usage or ocular surgery. Systemic history was not significant. Presenting uncorrected visual acuity in his right eye was counting fingers at 1 m and 20/200 in the left eye, with accurate projection of rays in both eyes. Slit lamp biomicroscopy showed the presence of bilateral diffuse conjunctival congestion, corneal ring infiltrates and epithelial defect with corneal oedema. Potassium hydroxide wet mount showed the presence of septate fungal hyphae. The patient was treated with topical 5% natamycin and 1% voriconazole over a period of 6 weeks. Best-corrected visual acuity was 20/600 in the right eye and 20/20 in the left eye at 6-month follow-up.
http://ift.tt/2z9ZZQY
Durable complete remission with combination chemotherapy and bortezomib in HIV-associated plasmablastic lymphoma
Plasmablastic lymphoma (PBL) is an aggressive form of non-Hodgkin's lymphoma (NHL) classically seen in patients infected with the human immunodeficiency virus, but can also be seen in other immunocompromised states such as transplant recipients, autoimmune diseases and the elderly. PBL is generally associated with a poor prognosis despite chemotherapy. There is evidence supporting the use of bortezomib in combination with standard chemotherapy to achieve durable responses in patients with PBL. We describe a patient with acquired immunodeficiency syndrome who presented with rectal pain and bright red blood per rectum. He was diagnosed with stage IVA PBL with anorectal, nodal, calvarial and hepatic involvement. Along with highly active antiretroviral therapy, he was treated with six cycles of dose adjusted etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA-EPOCH) plus bortezomib resulting in durable complete remission 30 months after diagnosis.
http://ift.tt/2y2XOAS
Life-threatening parapharyngeal and retropharyngeal abscess in an infant
Severe extensive deep neck abscess in an infant is uncommon. We share the case of a previously well 4-month old infant who was referred for a 4-day history of fever, lethargy and left lateral neck swelling. Contrast-enhanced CT scan revealed a large 5.3x8 cm collection involving the left parapharyngeal and retropharyngeal space, causing significant airway narrowing. 40 mL of frank pus was drained via intraoral incision and drainage with the aid of endoscope, and undesirable complications from an external approach were averted. The infant was extubated 48 hours postsurgery and was discharged home well after completion of 1 week of intravenous antibiotics. The child was discharged well from our follow-up at 1 month review. We discuss the pathophysiology of deep neck space abscesses, its incidence in the paediatric population and the various management options.
http://ift.tt/2z9ZVAI
Mitral valve prosthesis implanted in the atrial position in a patient with extensive calcification extending from epicardium to mitral annulus
Description
A 72-year-old woman with progressive dyspnoea underwent transoesophageal echocardiography demonstrating mixed mitral stenosis and regurgitation, extensive mitral annular calcification (MAC), left atrial appendage clot and mass on aortic valve. Laboratory work-up revealed normal serum calcium. Left heart catheterisation did not reveal any significant coronary artery disease. Right heart catheterisation demonstrated severe pulmonary artery hypertension. Chest CT scan showed extensive calcification extending from left ventricular epicardium to mitral annulus (see online ).1 Median sternotomy revealed epicardial calcification but none on pericardial (figure 1). Aortic right coronary cusp mass was identified and excised through aortotomy. Left atrial appendage clot was evacuated and AtriClip (AtriCure, Cincinnati, Ohio, USA) 45 mm was applied. Mitral valve was exposed through the left atriotomy. Extensive MAC extending to the atrial wall was observed (figure 2). Anterior mitral leaflet was excised and the posterior leaflet was debrided. A 2 cm wide patch (CorMatrix Cardiovascular, Roswell, Georgia, USA) was sutured to the atrial wall next to the posterior mitral...
http://ift.tt/2y53k5S
Revision repair of type IV laryngotracheoesophageal cleft using multiple long tapered engaging grafts
Publication date: Available online 9 October 2017
Source:International Journal of Pediatric Otorhinolaryngology
Author(s): Evan J. Propst
An 8 year-old female with esophageal atresia and a type IV laryngotracheoesophageal cleft underwent tracheostomy, gastric pull-up and fundoplication with G-tube insertion at birth. She remained nil per os due to aspiration. The trachealis was separated from the esophagus that was reapproximated and clavicular periosteum was placed. A long posterior costal cartilage graft that engaged behind the cricoid plate and tapered inferiorly was inserted. A second thin cartilage graft was sutured to it distally to extend the length of the repair. This allowed for removal of the tracheostomy and oral feeding while providing a four-layer closure to prevent aspiration.
http://ift.tt/2g51jzG
Identification of Nasal Irrigation Bottle Contamination in Post Sinonasal Surgery
Abstract
Nasal irrigation is an effective and cheap method in managing post sinonasal surgery patients. It works by improving ciliary clearance and performing mechanical debridement of the thick crust, decreasing mucosal edema and reducing the inflammatory mediators. Presence of nasal irrigation bottle contamination and its effect on patients have been studied. The aim of this study is to prospectively identify the risk of contamination in the nasal irrigation bottle, fluid from the bottle and to correlate with endoscopic findings from the patients who had underwent sinonasal surgery. Swabs will be taken from the nasal irrigation bottle and patient's middle meatus before the surgery and at each post surgery visits (2 and 4 weeks). Patients will be advised to irrigate their nose three times per day post sinonasal surgery. During endoscopic examination of the patient's nasal cavity at 2 and 4 weeks, any evidence of infection will be noted and documented. Additionally, a swab of fluid irrigated from the nasal cavity collected during the clinic follow-ups will also be taken. The specimens will be sent to the Microbiology laboratory for standard culture and sensitivity test. A total of 27 patients completed the study and were divided into case (n = 15) and control (n = 12) groups. The CFU (colony-forming unit) value of the bacteria cultured from the nasal cavity and the nasal irrigation bottle was statistically significantly (P = 0.00) increased from the baseline to the second week follow-up in both groups but not from the second week to the fourth week follow-up. The majority of the swabs from the nasal cavity of the patients and the nasal irrigation bottles were positively cultured for Pseudomonas sp. group. Other groups of bacteria that were cultured were Enterobacter sp., Coagulase Negative Staphylococcus (CONS) and Klebsiella sp. Endoscopically, there was no clinical evidence of infection found in the nasal cavity of the patients. The nasal irrigation bottle that was used in the post sinonasal surgery treatment and for alleviation of symptoms of sinonasal diseases was found to have bacterial contamination from the swabs taken from the bottle. However, despite this finding there was not clinical evidence of infection noted from the nasal endoscopic examination. A simple and effective method of cleaning the bottle would be helpful to reduce the bacterial contamination for this useful treatment method.
http://ift.tt/2g6Vl1j
10-Year-Old Female with Acute Abdominal Pain with Pancreatic Mass
A previously healthy 10-year-old female presented to a local emergency department following three days of nausea and vomiting diagnosed with a solid pseudopapillary tumor. Solid pseudopapillary neoplasms are a rare form of pancreatic cystic neoplasm that typically presents in young females in their 20–30s and are very rare in children. These neoplasms often present as an asymptomatic tumor found on incidental imaging. When symptomatic they most commonly present with abdominal pain and can also cause a palpable abdominal mass, weight loss, gastrointestinal obstruction, and nausea and vomiting. Timely diagnosis of this rare neoplasm is very important because complete resection of the tumor is the definitive treatment and leads to an excellent long-term survival.
http://ift.tt/2kA3aOH
Identification of Nasal Irrigation Bottle Contamination in Post Sinonasal Surgery
Abstract
Nasal irrigation is an effective and cheap method in managing post sinonasal surgery patients. It works by improving ciliary clearance and performing mechanical debridement of the thick crust, decreasing mucosal edema and reducing the inflammatory mediators. Presence of nasal irrigation bottle contamination and its effect on patients have been studied. The aim of this study is to prospectively identify the risk of contamination in the nasal irrigation bottle, fluid from the bottle and to correlate with endoscopic findings from the patients who had underwent sinonasal surgery. Swabs will be taken from the nasal irrigation bottle and patient's middle meatus before the surgery and at each post surgery visits (2 and 4 weeks). Patients will be advised to irrigate their nose three times per day post sinonasal surgery. During endoscopic examination of the patient's nasal cavity at 2 and 4 weeks, any evidence of infection will be noted and documented. Additionally, a swab of fluid irrigated from the nasal cavity collected during the clinic follow-ups will also be taken. The specimens will be sent to the Microbiology laboratory for standard culture and sensitivity test. A total of 27 patients completed the study and were divided into case (n = 15) and control (n = 12) groups. The CFU (colony-forming unit) value of the bacteria cultured from the nasal cavity and the nasal irrigation bottle was statistically significantly (P = 0.00) increased from the baseline to the second week follow-up in both groups but not from the second week to the fourth week follow-up. The majority of the swabs from the nasal cavity of the patients and the nasal irrigation bottles were positively cultured for Pseudomonas sp. group. Other groups of bacteria that were cultured were Enterobacter sp., Coagulase Negative Staphylococcus (CONS) and Klebsiella sp. Endoscopically, there was no clinical evidence of infection found in the nasal cavity of the patients. The nasal irrigation bottle that was used in the post sinonasal surgery treatment and for alleviation of symptoms of sinonasal diseases was found to have bacterial contamination from the swabs taken from the bottle. However, despite this finding there was not clinical evidence of infection noted from the nasal endoscopic examination. A simple and effective method of cleaning the bottle would be helpful to reduce the bacterial contamination for this useful treatment method.
http://ift.tt/2g6Vl1j
Dizziness in a Tertiary Care Centre in Sikkim: Our Experience and Limitations
Abstract
Dizziness is a common symptom and though most of the causes are benign yet some may be potentially life threatening. Diagnosis can be a challenge sometimes due to lack of dedicated vestibular lab and injudicious use of vestibular suppressant medications. A 2 year retrospective study of the hospital records from September 2014 to August 2016 was done to study the causes of dizziness and the limitations and challenges in the diagnosis. 75 complete records of patients presenting with dizziness were accessed and analysed. 54.7% of the patients were males and most patients were young adults. Most of the cases were benign and Benign paroxysmal positional vertigo was the commonest diagnosed case (20%). Potentially life threatening cases diagnosed were cerebellar infarct and posterior fossa space occupying lesion (5.3%). Complete evaluation of a dizzy patient must be done to arrive at a causal diagnosis. Injudicious use of vestibular sedatives should be discouraged. Proper training and education to the primary care physician should be imparted so that they can adopt a practical approach for evaluation and management of a dizzy person.
http://ift.tt/2kAmon0
Managing acne in the Middle East: consensus recommendations
Abstract
Acne has been estimated to affect the majority of people at some point in their life and is common in Middle Eastern countries. While acne is frequently perceived to be a self-limited disease of adolescence, there is an increasing population of adults with acne. Information about the management of acne in the Middle East is somewhat sparse; however, several studies have recently been conducted and will be discussed in this supplement.
http://ift.tt/2xtoKW3
Impact of medialization laryngoplasty on dynamic nanomechanical vocal fold structure properties
Objectives/Hypothesis
Although the primary goal of medialization laryngoplasty is to improve glottic closure, implant placement is also likely to alter the biomechanical properties of the vocal fold (VF). We sought to employ novel, nanoscale technology to quantify these properties following medialization based on the hypothesis that different medialization materials will likely yield differential biomechanical effects.
Study Design
Ex vivo.
Methods
Nine pig larynges were divided into three groups: control, Silastic (Dow Corning, Midland, Michigan, U.S.A.) block medialization, or Gore-Tex (W.L. Gore & Associates, Newark, Delaware) medialization. Laryngoplasty was performed on excised, intact larynges. The larynges were then bisected in the sagittal plane and each subjected to dynamic nanomechanical analysis (nano-DMA) at nine locations using a 250-μm flat-tip punch and frequency sweep-load profile across the free edge of the VF and inferiorly along the conus elasticus.
Results
Silastic block and Gore-Tex implant introduced increased storage and loss moduli. Overall, storage moduli mean (maximum) increased from 38 kilopascals (kPa) (119) to 72 kPa (422) and 129 kPa (978) in control, Gore-Tex, and Silastic implants, respectively. Similarly, loss moduli increased from 13 kPa (43) to 22 kPa (201) and 31 kPa (165), respectively. Moduli values varied widely by location in the Silastic block and Gore-Tex groups. At the free VF edge, mean (maximum) storage moduli were lowest in the Gore-Tex group, 20 kPa (44); compared to control, 34.5 kPa (86); and Silastic, 157.9 kPa (978), with similar loss and complex moduli trends.
Conclusion
Medialization laryngoplasty altered VF structure biomechanical properties; Silastic and Gore-Tex implants differentially impact these properties.
Level of Evidence
NA. Laryngoscope, 2017
http://ift.tt/2ySuPMQ
Application of the Eighth Edition American Joint Committee on Cancer Staging System for HPV-Related Oropharyngeal Cancer Treated With Transoral Robotic Surgery
Objective
Analyze patients treated with transoral robotic surgery (TORS) in the context of the eighth edition of the American Joint Committee on Cancer (AJCC) staging system.
Methods
Retrospective cohort study including 110 human papillomavirus-related oropharyngeal cancer (HPV+OPC) patients with a minimum 1-year follow-up treated with TORS between 2007 to 2016. Kaplan-Meier methods were used to estimate 3-year disease-free survival and assess differences in recurrence.
Results
One hundred and ten patients with a median follow-up of 54 months were analyzed. Of those, 85% of patients were male, with a median age of 60. Twenty-two percent of patients received no adjuvant therapy; 43% received adjuvant radiation; and 35% underwent adjuvant chemoradiation. Extracapsular spread was identified in 24% of patients. Overall survival was 100%, with estimated 3-year disease-free survival (DFS) (95% confidence interval) of 87% (77, 93). Under the seventh edition of the AJCC, 5% of patients were stage I; 11% were stage II; 26% were stage III; and 57% were stage IVa. Twenty-seven patients (25%) were upstaged on final pathology, whereas 15 patients (14%) were downstaged. Under the eighth edition of the AJCC, 94% of patients were stage I for both clinical and pathologic staging systems. Six patients (6%) were upstaged on final pathology, whereas six patients (6%) were downstaged. No factors demonstrated statistical significance for DFS. Within pathologic stage I, Kaplan-Meier estimates for DFS did not reach statistical significance.
Conclusion
The majority of patients undergoing TORS for HPV + OPC are stage I under the eighth edition of the AJCC staging system, with limited pathologic re-staging compared with the prior system. Oncologic outcomes are favorable for this group. No clinicopathologic features are significant for DFS within pathologic stage I.
Level of Evidence
2b. Laryngoscope, 2017
http://ift.tt/2kys2GA
National trends in otolaryngology intern curricula following Accreditation Council for Graduate Medical Education changes
Objectives/Hypothesis
In 2016, Accreditation Council for Graduate Medical Education (ACGME) requirements for curriculum and resident experiences were modified to require entering postgraduate year (PGY)-1 residents to spend 6 months of structured education on otolaryngology–head and neck surgery (ORL-HNS) rotations. We aimed to determine how ORL-HNS training programs have adapted curricula in response to 2016 ACGME curriculum requirement changes.
Study Design
Survey study.
Methods
A national survey of ACGME-accredited ORL-HNS programs was distributed via the Otolaryngology Program Directors Organization.
Results
Thirty-seven program directors responded (34.9%). Most common ORL-HNS rotations included general otolaryngology (80.6% of programs, up to 6 months) and head and neck oncology (67.7%, up to 4 months), though more months are also spent on other subspecialty rotations (laryngology, otology, rhinology, and pediatrics) than previously. All programs continue at least 1 month of anesthesiology, intensive care unit, and general surgery. Programs have preferentially eliminated rotations in emergency medicine (77% decrease) and additional months on general surgery (48% decrease). Curricula have incorporated supplemental teaching modalities including didactic lectures (96.3% of programs), simulation (66.7%), dissection courses (63.0%), and observed patient encounters (55.5%), to a greater degree following ACGME changes. More interns are involved in shared call responsibilities than in previous years (70.4% vs. 51.8%). A stable minority of interns take the Otolaryngology Training Examination (approximately 20%).
Conclusions
New ACGME requirements have challenged ORL-HNS training programs to develop effective 6-month rotation schedules for PGY-1 residents. Significant variation exists between programs, and evaluation of first-year curricula and readiness for PGY-2 year is warranted.
Level of Evidence
NA Laryngoscope, 2017
http://ift.tt/2yRzuie
Clinical characteristics and outcomes of major salivary gland malignancies in children
Objectives/Hypothesis
Determine demographics, clinical characteristics, and survival rates for children with primary salivary gland malignancies.
Study Design
Retrospective, population-based cohort study.
Methods
All cases of primary salivary gland malignancies diagnosed between the years of 2002 and 2013 in patients ages 0 to 19 years were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Additional variables collected included age, gender, ethnicity, tumor histological subtype, tumor size, treatment modality, vitality status, and follow-up time. Kaplan-Meier survival curves were generated.
Results
Two hundred forty-five primary salivary gland malignancies were identified (220 parotid, 25 submandibular). Median age at diagnosis was 15 years. Most patients were female (59%), white (74%), and non–Spanish/Hispanic/Latino (81%). Among parotid tumors, mean tumor size was 2.3 cm, and there were 109 (50%) mucoepidermoid carcinomas and 86 (39%) acinic cell carcinomas. Most patients underwent surgery (n = 212, 96%) and 64 (29%) received adjuvant radiation. At a mean follow-up of 62.4 months, 10 patients (5%) were deceased. Kaplan-Meier survival curves illustrated that black children exhibited higher mortality rates than white children (15.8% vs. 4.6%, log-rank = 0.0260) as did those who underwent adjuvant radiation (15.73% vs. 3.2%, log-rank = 0.0209). Among submandibular tumors, mean tumor size was 3.1 cm, and there were 11 (44%) mucoepidermoid carcinomas. All patients underwent surgery and most received adjuvant radiation (n = 15, 60%). At a mean follow-up of 51.25 months, one patient was deceased.
Conclusions
Salivary gland malignancies in children and adolescents are rare. Overall survival for both parotid and submandibular tumors in children is good.
Level of Evidence
4 Laryngoscope, 2017
http://ift.tt/2kwF8Us
The futility of intraoperative frozen section in the evaluation of follicular thyroid lesions
Objective
Investigate the utility of intraoperative frozen section (iFS) in patients with follicular thyroid lesions following publication of the 2015 American Thyroid Association (ATA) guidelines.
Study Design
Retrospective chart review.
Methods
Patient demographics, preoperative cytology, frozen pathology, and final pathology were reviewed on patients undergoing thyroid surgery at a tertiary care hospital in which iFS was utilized over a 5-year period. The test performance of iFS and the frequency of indicated completion/total thyroidectomies pre- and postpublication of the 2015 ATA guidelines were calculated.
Results
One hundred and one patients met inclusion criteria: 54 patients with follicular lesions of undetermined significance (FLUS) and 47 patients with a cytologic diagnosis of suspicious for follicular neoplasm/follicular neoplasm. The malignancy rate was 36%, but only 14% of malignancies were identified on iFS. A definitive benign or malignant diagnosis was given on iFS in only 21% of cases, and operative management was altered in two cases as a result of iFS. There was a statistically significant reduction in the frequency of indicated total/completion thyroidectomies based on high-risk features as a result of the 2015 ATA guidelines compared to prior recommendations (20.8% vs. 5.0%, P = < 0.001). None of these patients had findings on iFS that would have altered management intraoperatively.
Conclusion
Intraoperative frozen section offers minimal diagnostic utility in the evaluation of follicular thyroid lesions. Updates in the 2015 ATA guidelines further diminish its potential to impact management intraoperatively. Significant improvements in its ability to identify malignancies would be needed to justify its use.
Level of Evidence
4. Laryngoscope, 2017
http://ift.tt/2yShnIZ
Hormone receptors analysis in idiopathic progressive subglottic stenosis
Objective
Idiopathic subglottic stenosis predominantly affects fertile and perimenopausal women. Estrogens and/or progesterone have been proposed as mediators of its pathogenesis by stimulating collagen deposition within the upper airway. We evaluated the presence and expression of estrogen-alpha (ER-α), estrogen-beta (ER-β), and progesterone receptors (PR) in idiopathic stenotic patients.
Study Design
A retrospective analysis on 42 surgical specimens from idiopathic stenosis female patients (mean age, 52.4; age range, 31–79) and 28 gender- and age-matched controls.
Methods
Immunoreactivity of ER-α, ER-β, and PR was calculated as the product of intensity (1 = weak, 2 = moderate, 3 = strong) and positive cell percentage (1–4, for < 10/10–50/50–80/ > 80%). This score was calculated on the stenotic and peristenotic tissues. Influence of menopausal status on hormonal expression and stenotic grade was tested.
Results
Stenosis showed ER-α overexpression versus peristenotic tissue and controls (score 6.6 ± 4.4, 0.3 ± 0.5, and 2.2 ± 1.5, respectively; P < 0.001). Overexpression was even more marked for progesterone receptors (score 8.3 ± 3.6, 0.8 ± 0.6, and 1.0 ± 0.7, respectively; P < 0.001). There was no expression of ER-β in stenosis (score 0), whereas it was normally expressed in peristenotic tissue and controls (score 0.7 ± 0.5 and 0.5 ± 0.5; P < 0.001 vs. stenosis). Expression of ER-α was higher in postmenopausal stenotic patients (P < 0.01). This subgroup included a higher proportion of Cotton-Myer grade III stenosis than in premenopausal subjects (P < 0.001).
Conclusion
An imbalance between ER-α, ER-β, and PR is present in idiopathic stenosis patients. The hormonal background may be involved in inappropriate inflammation and increased stenosis susceptibility. Menopausal changes seem to play a role in both stenosis grade and receptor patterns.
Level of Evidence
NA. Laryngoscope, 2017
http://ift.tt/2kxK7Eq
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