Therapeutic reduction of cell-mediated immunosuppression in mycosis fungoides and Sézary syndrome

Abstract

Tumor progression is associated with progressive immunosuppression mediated in part by T regulatory cell(s) (Treg) and/or myeloid-derived suppressor cell(s) (MDSC). Development of strategies to reduce populations of immune cells with suppressive function in cancer patients may enable the induction or recovery of immunity against tumor cells, which may limit or reverse disease progression. With a goal of developing Treg and MDSC neutralizing strategies to treat mycosis fungoides (MF) and Sézary syndrome (SzS), we determined the association between disease stage and suppressor cell populations in patients with MF/SzS, including those responding to therapy. We found elevations in Treg populations, across Treg subtypes, in patients with SzS, and these Treg markedly suppressed proliferation of autologous CD4⁺CD25⁻ responder T cells. Interestingly, while MDSC numbers were not increased in MF/SzS patients, MDSC from patients with stage IB and above produced significantly more reactive oxygen species than those from stage IA MF patients and control cohorts. Therapy with the CD25-targeting agent denileukin diftitox or IFN-α2b was associated with a reduction in Treg numbers or MDSC function, respectively. These studies identify potential mechanisms of action for these therapies and support the development of coordinated strategies targeting both Treg and MDSC activities in patients with MF/SzS.

http://ift.tt/2jHWv16

Unusual presentation of prune belly syndrome: a case report

Prune belly syndrome is a rare congenital malformation of unknown etiology, with the following triad of findings: abdominal muscle wall weakness, undescended testes, and urinary tract abnormalities. In most ca...

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Treatment of severe recalcitrant pyoderma gangrenosum with ustekinumab

Abstract

An increased expression of interleukin-23 has been observed in patients with pyoderma gangrenosum, leading to the use of ustekinumab as a therapeutic option. We report the successful use of ustekinumab in three patients with treatment-resistant pyoderma gangrenosum of varying clinical presentations.

http://ift.tt/2iIyMBp

Successful treatment of facial milia in an infant with orofaciodigital syndrome type 1

Abstract

We report the successful treatment of multiple facial milia with manual extraction and tretinoin in a child with orofaciodigital syndrome type 1. Treatment with topical medications may be insufficient in individuals with orofaciodigital syndrome type 1, and pitted scarring is often a sequala. This case demonstrates that manual extraction is well tolerated and effective in the treatment of multiple milia. In addition, clinicians need to be aware of this rare genetic condition, which commonly presents de novo and can lead to significant morbidity if untreated.

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Magnitude of benefit for topical crisaborole in the treatment of atopic dermatitis in children and adults does not look promising: a critical appraisal

Summary

Aim

To assess the efficacy and safety of crisaborole ointment, a phosphodiesterase 4 inhibitor, for the treatment of mild or moderate atopic dermatitis (AD) in two phase III studies (AD-301 and AD-302).

Design and setting

Two identically designed multicentre, double-blind randomized controlled trials were conducted in the U.S.A. Participants were randomized 2 : 1 to receive crisaborole or vehicle treatment. In total 47 and 42 investigational centres were identified for AD-301 and AD-302, respectively.

Study participants

Inclusion criteria were identified as age ≥ 2 years, clinical diagnosis of AD (as per the Hanifin and Rajka criteria), ≥ 5% body surface area involvement, and baseline Investigator's Static Global Assessment (ISGA) mild or moderate. Exclusion criteria included previous use of biologics or systemic corticosteroids (within the last 28 days) or a topical calcineurin inhibitor/corticosteroid (within the last 14 days), and active skin infection.

Exposures

Participants were instructed to apply the study drug twice daily to all lesions identified at baseline, and all new lesions identified after day 1 (with weekly review of application instructions). Bland emollients were permitted to be used on skin not treated with the study drug.

Primary outcome

The primary outcome was defined as ISGA clear or almost clear at day 29, with a 2-grade or more improvement from baseline.

Outcomes

Secondary outcomes included the proportion of patients with an ISGA score of clear or almost clear at day 29, and time to success in ISGA score. Additional outcomes included pruritus severity and signs of AD (erythema, exudation, excoriation, induration/papulation and lichenification), and were measured on a 4-point scale (none, mild, moderate, severe). Adverse events were also recorded.

Results

More participants in the crisaborole-treated group achieved ISGA scores of clear or almost clear with ≥ 2-grade improvement than in the vehicle-treated group (AD-301, 32·8% vs. 25·4%, P = 0·38; AD-302, 31·4% vs. 18·0%, P < 0·001). Greater percentages of clear and almost clear scores were observed in the treatment groups (51·7% vs. 40·6%, P = 0·005; 48·5% vs. 29·7%; P < 0·001), as well as earlier success in ISGA score and improvement in pruritus (P ≤ 0·001). No serious treatment-related adverse events were identified.

Conclusions

Based on the study results, the authors suggest that crisaborole is a safe treatment that improves disease severity, pruritus and clinical signs associated with AD.

http://ift.tt/2A0RXhn

Issue Information

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Issue Information

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Volume Contents

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Hydrochlorothiazide use and risk of non-melanoma skin cancer: A nationwide case-control study from Denmark

Hydrochlorothiazide, one of the most frequently used diuretic and antihypertensive drugs in the United States and Western Europe, is photosensitizing and has previously been linked to lip cancer.

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Changing Default Ventilator Settings on Anesthesia Machines Improves Adherence to Lung-Protective Ventilation Measures

Perioperative lung-protective ventilation (LPV) can reduce perioperative pulmonary morbidity. We hypothesized that modifying default anesthesia machine ventilator settings would increase the use of intraoperative LPV. Default tidal volume settings on our anesthesia machines were decreased from 600 to 400 mL, and default positive end-expiratory pressure was increased from 0 to 5 cm H2O. This modification increased mean positive end-expiratory pressure from 3.1 to 5.0 cm H2O and decreased mean tidal volume from 8.2 to 6.7 mL/kg predicted body weight. Notably, increased adherence to LPV from 1.6% to 23.0% occurred quickly with the rate of increase more than doubling from 1.8% to 3.9% per year. Accepted for publication September 12, 2017. Funding: This work was supported by Institutional and Departmental Sources. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Katherine T. Forkin, MD, Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908. Address e-mail to ket2a@hscmail.mcc.virginia.edu. © 2017 International Anesthesia Research Society

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Respiratory Gas Analysis—Technical Aspects

A technology-focused review of respiratory gas analysis, with an emphasis on carbon dioxide analysis, is presented. The measurement technologies deployed commercially are highlighted, and the basic principles and technical concerns of infrared spectroscopy and mainstream versus sidestream gas sampling are discussed. The specifications of particular interest to the clinician, accuracy and response time, and the related standard, with typical values for a capnometer, are presented. Representative time and volumetric capnograms are shown with the clinically relevant parameters described. Aspects of the terminology in present-day use and the need for clarity in defining what is a breath and an end-tidal value are reviewed. The applications of capnography of particular interest to the anesthesiologist are noted, and key references are provided. Ongoing developments with respect to respiratory gas analysis, and those that will impact it, are noted. Accepted for publication June 28, 2017. Funding: None. The author declares no conflicts of interest. Reprints will not be available from the author. Address correspondence to Michael B. Jaffe, PhD, Cardiorespiratory Consulting, LLC, 410 Mountain Rd, Cheshire, CT 06410. Address e-mail to mbjengineering@cox.net. © 2017 International Anesthesia Research Society

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Is Compliance With Surgical Care Improvement Project Cardiac (SCIP-Card-2) Measures for Perioperative β-Blockers Associated With Reduced Incidence of Mortality and Cardiovascular-Related Critical Quality Indicators After Noncardiac Surgery?

BACKGROUND: While continuation of β-blockers (BBs) perioperatively has become a national quality improvement measure, the relationship between BB withdrawal and mortality and cardiovascular-related critical quality indicators has not been studied in a contemporary cohort of patients undergoing noncardiac surgery. METHODS: For this retrospective study, the quality assurance database of a large community-based anesthesiology group practice was used to identify 410,288 surgical cases, 18 years of age or older, who underwent elective or emergent noncardiac surgical procedures between January 1, 2009, and December 31, 2014. Each surgical case that was withdrawn from BBs perioperatively was propensity matched by clinical and surgical characteristics to 4 cases that continued BBs perioperatively. Subsequently, multivariable conditional logistic regression analyses were performed in the matched cohort to determine the extent to which withdrawal of perioperative BBs was independently associated with mortality as the primary outcome and cardiovascular-related critical quality indicators as the secondary outcome (need for vasopressor, electrocardiographic changes requiring treatment, unplanned admission to intensive care unit, postanesthesia care unit stay >2 hours, and a combination of cardiac arrest and myocardial infarction) within 48 hours postoperatively. RESULTS: Of the 66,755 (16%) cases in the cohort admitted on BB therapy, BBs were withdrawn in 3829 (6%) and continued in 62,926 (94%). Propensity score matching resulted in an analysis cohort of 19,145 cases. Withdrawal of perioperative BBs in the multivariable conditional logistic regression analysis was significantly associated with an increased risk for mortality (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.75–7.35; P = .0003), but a significantly decreased risk for need of blood pressure support requiring vasopressor initiation (OR, 0.84; 95% CI, 0.76–0.92; P = .0003) and extended postanesthesia care unit stay (OR, 0.69; 95% CI, 0.54–0.88; P = .004) within 48 hours after noncardiac surgery. CONCLUSIONS: Perioperative withdrawal of BBs was associated with increased risk for mortality within 48 hours after noncardiac surgery and with decreased risk for need of vasopressor during the early postoperative period and a shorter stay in the postanesthesia care unit. Accepted for publication September 12, 2017. M. D. Kertai is currently affiliated with the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Miklos D. Kertai, MD, PhD, Department of Anesthesiology, Vanderbilt University Medical Center, 1215 21st Ave S, Suite 5160, Nashville, TN 37232. Address e-mail to miklos.kertai@vanderbilt.edu. © 2017 International Anesthesia Research Society

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In Response

No abstract available

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Informed Consent and Cognitive Dysfunction After Noncardiac Surgery in the Elderly

Cognitive dysfunction 3 months after noncardiac surgery in the elderly satisfies informed consent thresholds of foreseeability in 10%–15% of patients, and materiality with new deficits observed in memory and executive function in patients with normal test performance beforehand. At present, the only safety step to avoid cognitive dysfunction after surgery is to forego surgery, thereby precluding the benefits of surgery with removal of pain and inflammation, and resumption of normal nutrition, physical activity, and sleep. To assure that consent for surgery is properly informed, risks of both cognitive dysfunction and alternative management strategies must be discussed with patients by the surgery team before a procedure is scheduled. Accepted for publication October 23, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Kirk J. Hogan, MD, JD, Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, B6/319 Clinical Science Center, 600 Highland Ave, Madison, WI 53792. Address e-mail to khogan@wisc.edu. © 2017 International Anesthesia Research Society

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Cardiac Arrest in the Operating Room: Part 2—Special Situations in the Perioperative Period

As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes. Accepted for publication September 8, 2017. Funding: This review was developed from previous iterations on behalf of the American Society of Anesthesiologists and the Society of Critical Care Anesthesiologists. Portions of those documents appear verbatim and are used with the permission of the ASA. Conflicts of Interest: See Disclosures at the end of the article. Implication statement: The spectrum of causes of periprocedural cardiac arrest warrants specific adaptations of the advanced circulatory life support algorithms. A number of rare, life-threatening etiologies of profound hemodynamic and respiratory disturbance leading to cardiac arrest are reviewed. Good patient outcomes in these special situations can be achieved by vigilance, timely formulation of a differential diagnosis for the crisis, and adherence to best practices. Reprints will not be available from the authors. Address correspondence to Matthew D. McEvoy, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Dr, TVC 4648, Nashville, TN 37232. Address e-mail to matthew.d.mcevoy@vanderbilt.edu. © 2017 International Anesthesia Research Society

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Reduced Left Ventricular Global Longitudinal Strain Predicts Prolonged Hospitalization: A Cohort Analysis of Patients Having Aortic Valve Replacement Surgery

BACKGROUND: Left ventricular ejection fraction (LVEF) is often preserved in patients with aortic stenosis and thus cannot distinguish between normal myocardial contractile function and subclinical dysfunction. Global longitudinal strain and strain rate (SR), which measure myocardial deformation, are robust indicators of myocardial function and can detect subtle myocardial dysfunction that is not apparent with conventional echocardiographic measures. Strain and SR may better predict postoperative outcomes than LVEF. The primary aim of our investigation was to assess the association between global longitudinal strain and serious postoperative outcomes in patients with aortic stenosis having aortic valve replacement. Secondarily, we also assessed the associations between global longitudinal SR and LVEF and the outcomes. METHODS: In this post hoc analysis of data from a randomized clinical trial (NCT01187329), we examined the association between measures of myocardial function and the following outcomes: (1) need for postoperative inotropic/vasopressor support; (2) prolonged hospitalization (>7 days); and (3) postoperative atrial fibrillation. Standardized transesophageal echocardiographic examinations were performed after anesthetic induction. Myocardial deformation was measured using speckle-tracking echocardiography. Multivariable logistic regression was used to assess associations between measures of myocardial function and outcomes, adjusted for potential confounding factors. The predictive ability of global longitudinal strain, SR, and LVEF was assessed as area under receiver operating characteristics curves (AUCs). RESULTS: Of 100 patients enrolled in the clinical trial, 86 patients with aortic stenosis had acceptable images for global longitudinal strain analysis. Primarily, worse intraoperative global longitudinal strain was associated with prolonged hospitalization (odds ratio [98.3% confidence interval], 1.22 [1.01–1.47] per 1% decrease [absolute value] in strain; P = .012), but not with other outcomes. Secondarily, worse global longitudinal SR was associated with prolonged hospitalization (odds ratio [99.7% confidence interval], 1.68 [1.01–2.79] per 0.1 second−1 decrease [absolute value] in SR; P = .003), but not other outcomes. LVEF was not associated with any outcomes. Global longitudinal SR was the best predictor for prolonged hospitalization (AUC, 0.72), followed by global longitudinal strain (AUC, 0.67) and LVEF (AUC, 0.62). CONCLUSIONS: Global longitudinal strain and SR are useful predictors of prolonged hospitalization in patients with aortic stenosis having an aortic valve replacement. Accepted for publication October 10, 2017. Funding: This investigation was supported by National Institutes of Health K23 HL093065 (A.E.D.) and the Departments of Cardiothoracic Anesthesia and Outcomes Research at the Cleveland Clinic. None of the investigators has a personal financial interest in this research. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Abraham Sonny, MD, is currently affiliated with the Harvard Medical School, Boston, Massachusetts; and Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Clinical Trial Registry: Clinical Trials.gov #NCT01187329. Reprints will not be available from the authors. Address correspondence to Andra E. Duncan, MD, MS, FASE, Departments of Cardiothoracic Anesthesia and Outcomes Research, Cleveland Clinic, 9500 Euclid Ave/J4, Cleveland, OH 44195. Address e-mail to duncana@ccf.org. © 2017 International Anesthesia Research Society

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Randomized Clinical Trial of Preoperative High-Dose Methylprednisolone on Postoperative Pain at Rest After Laparoscopic Appendectomy

BACKGROUND: Methylprednisolone administered intravenously preoperatively has been shown to reduce pain, nausea, and fatigue after elective surgery. We aimed to show that 125 mg of methylprednisolone given intravenously 30 minutes before laparoscopic surgery for suspected appendicitis would reduce pain at rest during the first 3 postoperative days. METHODS: A multicenter, parallel-group, double-blind, placebo-controlled study was conducted including patients 18 years of age and older with an American Society of Anesthesiologist class of I–III undergoing laparoscopic surgery for suspected appendicitis. The primary outcome was pain at rest measured on the 11-point numerical rating scale 5 times during the first 3 days after surgery. The effect of 125 mg of methylprednisolone on postoperative pain at rest during the first 3 days was assessed using a mixed-effects model with time and intervention as main effects. RESULTS: From April 2016 to August 2016, 78 patients were included, and all were eligible for analysis of the primary outcome. The estimated effect of 125 mg of methylprednisolone on pain at rest during the first 3 days after surgery was a nonsignificant increase of 0.2 (95% confidence interval, −0.5 to 0.9; P = .571) on the 11-point numerical rating scale. There was no difference between the 2 groups regarding the need for opioid agonists during hospital stay on the first postoperative day (P = .381). CONCLUSIONS: A 125-mg dose of methylprednisolone given intravenously 30 minutes before laparoscopic surgery for appendicitis seemed no better than placebo at providing a clinical meaningful reduction in postoperative pain at rest. Accepted for publication October 24, 2017. Funding: This work was supported by the A.P. Møller Foundation for the Advancement of Medical Science, Grosserer L.F. Foghts Fond, and the Augustinus Foundation. The primary author received a research grant from Nordsjællands Hospital and financial support from the Department of Surgery, Nordsjællands Hospital, Copenhagen University Hospital. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Trial Registration: Registered at http://ift.tt/PmpYKN (NCT02711449) and EudraCT (2015-004800-46). All authors agree to be accountable for all aspects of the work presented. Reprints will not be available from the authors. Address correspondence to Jakob Kleif, MD, Department of Surgery, Nordsjællands Hospital, Copenhagen University Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark. Address e-mail to kleifen@dadlnet.dk. © 2017 International Anesthesia Research Society

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Distracted Doctoring: Returning to Patient-Centered Care in the Digital Age. Do We Have Time for This?

No abstract available

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Visualization Improves Supraclavicular Access to the Subclavian Vein in a Mixed Reality Simulator

BACKGROUND: We investigated whether visual augmentation (3D, real-time, color visualization) of a procedural simulator improved performance during training in the supraclavicular approach to the subclavian vein, not as widely known or used as its infraclavicular counterpart. METHODS: To train anesthesiology residents to access a central vein, a mixed reality simulator with emulated ultrasound imaging was created using an anatomically authentic, 3D-printed, physical mannequin based on a computed tomographic scan of an actual human. The simulator has a corresponding 3D virtual model of the neck and upper chest anatomy. Hand-held instruments such as a needle, an ultrasound probe, and a virtual camera controller are directly manipulated by the trainee and tracked and recorded with submillimeter resolution via miniature, 6 degrees of freedom magnetic sensors. After Institutional Review Board approval, 69 anesthesiology residents and faculty were enrolled and received scripted instructions on how to perform subclavian venous access using the supraclavicular approach based on anatomic landmarks. The volunteers were randomized into 2 cohorts. The first used real-time 3D visualization concurrently with trial 1, but not during trial 2. The second did not use real-time 3D visualization concurrently with trial 1 or 2. However, after trial 2, they observed a 3D visualization playback of trial 2 before performing trial 3 without visualization. An automated scoring system based on time, success, and errors/complications generated objective performance scores. Nonparametric statistical methods were used to compare the scores between subsequent trials, differences between groups (real-time visualization versus no visualization versus delayed visualization), and improvement in scores between trials within groups. RESULTS: Although the real-time visualization group demonstrated significantly better performance than the delayed visualization group on trial 1 (P = .01), there was no difference in gain scores, between performance on the first trial and performance on the final trial, that were dependent on group (P = .13). In the delayed visualization group, the difference in performance between trial 1 and trial 2 was not significant (P = .09); reviewing performance on trial 2 before trial 3 resulted in improved performance when compared to trial 1 (P

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Perioperative Management of the Patient With a Left Ventricular Assist Device for Noncardiac Surgery

The pandemic of heart failure and the limited options for treatment of end-stage disease have resulted in an increase in the utilization of left ventricular assist devices (LVADs). Improvements in device technology and patient survival have led to an expanding population of patients requiring noncardiac surgery while on LVAD therapy, thus leading to a growing need for familiarity with the physiology of these patients. This review describes the functional mechanics of the most prevalent continuous-flow LVAD, the HeartMate II, and focuses on perioperative anesthetic concerns. Accepted for publication October 16, 2017. Funding: None. The author declares no conflicts of interest. Reprints will not be available from the author. Address correspondence to Mabel Chung, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to mchung8@mgh.harvard.edu. © 2017 International Anesthesia Research Society

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Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III Local Instillation Analgesia—A Systematic Review and Meta-Analysis

BACKGROUND: Local infiltration analgesia offers effective postoperative analgesia after knee arthroplasty, but the role of its counterpart, local instillation analgesia (LIA), in anterior cruciate ligament reconstruction (ACLR) is unclear. This systematic review and meta-analysis evaluates the analgesic benefits of LIA for outpatient ACLR. METHODS: We sought randomized controlled trials investigating the analgesic effects of LIA versus control in adults having outpatient ACLR and receiving multimodal analgesia (excluding nerve blocks, which are examined in parts I and II of this project). Cumulative postoperative analgesic consumption at 24 hours was designated as a primary outcome. Analgesic consumption during postanesthesia care unit stay, proportion of patients requiring analgesic supplementation, time-to-first analgesic request, rest pain scores during the first 48 hours, hospital length of stay, and incidence of opioid-related side effects were analyzed as secondary outcomes and pooled using random effects modeling. RESULTS: Eleven randomized controlled trials (515 patients) were included. Analgesic consumption was selected as the primary outcome in 4 trials (36%). Compared to control, LIA reduced the 24-hour morphine consumption by a weighted mean difference (95% confidence interval) of −18.0 mg (−33.4 to −2.6) (P = .02). LIA reduced postanesthesia care unit morphine consumption by −55.9 mg (−88.4 to −23.4) (P

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Tailored Holder for Continuous Echocardiographic Monitoring

Hemodynamic monitoring is essential for prompt and effective interventions in intensive care unit patients. We developed a custom-made transthoracic echocardiography transducer holder consisting of transducer holder and skin patch attachment. This holder allowed continuous transthoracic echocardiography monitoring in 5 adult patients with circulatory failure due to shock, and 6 pediatric patients after successful percutaneous closure of a ventricular septal defect. One case of an unexpected hemopericardium was promptly diagnosed and pericardiocentesis was performed, and 1 patient required extracorporeal membrane oxygenation support. Accepted for publication October 16, 2017. Funding: This study was supported by research grants from the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (Zy2016101) and Taipei Cheng Hsin General Hospital (CHGH105-1). The authors declare no conflicts of interest. H. Song and S. K. Tsai contributed equally to this work. Reprints will not be available from the authors. Address correspondence to Jin Liu, MD, PhD, Department of Anesthesiology, West China Hospital, Sichuan University, Wainan Guoxuexiang St #37, Chengdu, Sichuan 610041, China. Address e-mail to scujinliu@foxmail.com. © 2017 International Anesthesia Research Society

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Decreased Parasympathetic Activity of Heart Rate Variability During Anticipation of Night Duty in Anesthesiology Residents

BACKGROUND: In residency programs, it is well known that autonomic regulation is influenced by night duty due to workload stress and sleep deprivation. A less investigated question is the impact on the autonomic nervous system of residents before or when anticipating a night duty shift. In this study, heart rate variability (HRV) was evaluated as a measure of autonomic nervous system regulation. METHODS: Eight residents in the Department of Anesthesiology were recruited, and 5 minutes of electrocardiography were recorded under 3 different conditions: (1) the morning of a regular work day (baseline); (2) the morning before a night duty shift (anticipating the night duty); and (3) the morning after a night duty shift. HRV parameters in the time and frequency domains were calculated. Repeated measures analysis of variance was performed to compare the HRV parameters among the 3 conditions. RESULTS: There was a significant decrease of parasympathetic-related HRV measurements (high-frequency power and root mean square of the standard deviation of R–R intervals) in the morning before night duty compared with the regular work day. The mean difference of high-frequency power between the 2 groups was 80.2 ms2 (95% confidence interval, 14.5–146) and that of root mean square of the standard deviation of R–R intervals was 26 milliseconds (95% confidence interval, 7.2–44.8), with P = .016 and .007, respectively. These results suggest that the decrease of parasympathetic activity is associated with stress related to the condition of anticipating the night duty work. On the other hand, the HRV parameters in the morning after duty were not different from the regular workday. CONCLUSIONS: The stress of anticipating the night duty work may affect regulation of the autonomic nervous system, mainly manifested as a decrease in parasympathetic activity. The effect of this change on the health of medical personnel deserves our concern. Accepted for publication July 25, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Hui-Hsun Huang, MD, PhD, Department of Anesthesiology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd, Taipei 10051, Taiwan. Address e-mail to hhhuangq@gmail.com. © 2017 International Anesthesia Research Society

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Survival of Staphylococcus epidermidis in Propofol and Intralipid in the Dead Space of Intravenous Injection Ports

We tested whether propofol or Intralipid inoculated with Staphylococcus epidermidis would promote bacterial growth within an intravenous (IV) injection hub, a site prone to bacterial contamination. In tubes incubated under optimal conditions, S epidermidis exhibited growth in Intralipid, but not in propofol. In contrast, within the IV hub incubated with either propofol or intralipid at room temperature, S epidermidis bacterial numbers declined with time, and virtually no contamination remained after 12 hours. These data suggest that certain IV lines are inhospitable for S epidermidis. Accepted for publication October 9, 2017. The authors Noble, Salim, Gragasin, and Bourque contributed equally to this study. Funding: This study was supported by funds from the Canadian Institutes of Health Research (MOP142396 to S.L.B. and MOP142446 to F.S.G.), and the Department of Anesthesiology & Pain Medicine at the University of Alberta. The authors declare no conflicts of interest. S. L. Bourque and F. S. Gragasin contributed equally to this work. Reprints will not be available from the authors. Address correspondence to Stephane L. Bourque, PhD, Department of Anesthesiology & Pain Medicine, 3-020H Katz Group Centre for Pharmacy and Health Research, University of Alberta, Edmonton, AB T6G 2E1, Canada. Address e-mail to sbourque@ualberta.ca. © 2017 International Anesthesia Research Society

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A World of Need

No abstract available

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Some Cautionary Tales About Ideal Body Weight Dosing of Anesthetic Medications: It Is Not All that Ideal!

No abstract available

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Consensus Statement on Perioperative Use of Neuromuscular Monitoring

A panel of clinician scientists with expertise in neuromuscular blockade (NMB) monitoring was convened with a charge to prepare a consensus statement on indications for and proper use of such monitors. The aims of this article are to: (a) provide the rationale and scientific basis for the use of quantitative NMB monitoring; (b) offer a set of recommendations for quantitative NMB monitoring standards; (c) specify educational goals; and (d) propose training recommendations to ensure proper neuromuscular monitoring and management. The panel believes that whenever a neuromuscular blocker is administered, neuromuscular function must be monitored by observing the evoked muscular response to peripheral nerve stimulation. Ideally, this should be done at the hand muscles (not the facial muscles) with a quantitative (objective) monitor. Objective monitoring (documentation of train-of-four ratio ≥0.90) is the only method of assuring that satisfactory recovery of neuromuscular function has taken place. The panel also recommends that subjective evaluation of the responses to train-of-four stimulation (when using a peripheral nerve stimulator) or clinical tests of recovery from NMB (such as the 5-second head lift) should be abandoned in favor of objective monitoring. During an interim period for establishing these recommendations, if only a peripheral nerve stimulator is available, its use should be mandatory in any patient receiving a neuromuscular blocking drug. The panel acknowledges that publishing this statement per se will not result in its spontaneous acceptance, adherence to its recommendations, or change in routine practice. Implementation of objective monitoring will likely require professional societies and anesthesia department leadership to champion its use to change anesthesia practitioner behavior. Accepted for publication October 10, 2017. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Mohamed Naguib, MB BCh, MSc, FCARCSI, MD, Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, NB3-78, Cleveland, OH 44195. Address e-mail to naguibm@ccf.org. © 2017 International Anesthesia Research Society

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Sugammadex and Oral Contraceptives: Is It Time for a Revision of the Anesthesia Informed Consent?

No abstract available

http://ift.tt/2AnBqCY

Occipital spur: understanding a normal yet symptomatic variant from orthodontic diagnostic lateral cephalogram

Eby Varghese<br />May 22, 2017; 2017:bcr-2017-220506-bcr-2017-220506<br />other

http://ift.tt/2iDMPs1

Budesonide-related adrenal insufficiency

Alexander Arntzenius<br />Oct 1, 2015; 2015:bcr2015212216-bcr2015212216<br />case-report

http://ift.tt/2jJGl7c

Pituitary apoplexy initially mistaken for bacterial meningitis

Sui Hsien Wong<br />Sep 5, 2013; 2013:bcr2013009223-bcr2013009223<br />case-report

http://ift.tt/2iaTLc7

Comet-tail artefacts and abdominal pain: radiological mistake or an underestimated event?

Paola Marchetti<br />Jun 12, 2013; 2013:bcr2013009896-bcr2013009896<br />case-report

http://ift.tt/2jHMtwT

Haemophilus influenzae type f meningitis in a previously healthy boy

Andreas Ronit<br />May 2, 2013; 2013:bcr2013008854-bcr2013008854<br />case-report

http://ift.tt/2ie0zpw

Treatment of a colonic Dieulafoy lesion with endoscopic hemoclipping

Yosho Fukita<br />Apr 22, 2013; 2013:bcr2013009734-bcr2013009734<br />case-report

http://ift.tt/2jHMMb1

Acute respiratory failure following traumatic tooth aspiration

Karan Madan<br />Feb 7, 2013; 2013:bcr2012008393-bcr2012008393<br />case-report

http://ift.tt/2ie0vGi

Paediatric talus fracture

Ann-Maria Byrne<br />May 8, 2012; 2012:bcr1020115028-bcr1020115028<br />case-report

http://ift.tt/2jH2rHv

Infiltrating Cardiac Synovial Sarcoma Presenting as Acute Cerebrovascular Accident

Primary cardiac sarcoma is a rare malignant myocardial neoplasm that does not exhibit gender predominance or age predilection. The classification of these tumors includes several subtypes, of which synovial sarcoma is a rare manifestation. When present, these tumors portend a poor prognosis with high morbidity and mortality that is attributable to their inherent infiltrative capacity, especially in the absence of treatment. The general consensus for treatment is surgical excision and neoadjuvant chemotherapy and radiotherapy. In this report, a case of synovial sarcoma involving the left ventricular outflow tract and aortic valve is presented.

http://ift.tt/2iHyb2N