A rare case of right pulmonary segmental artery dissection following pacemaker insertion

Description

This paper describes a case of pulmonary segmental artery dissection following pacemaker insertion. The patient was admitted electively and was clinically well prior to admission. The patient had a history of factor V Leiden disease, trifascicular heart block and ischaemic heart disease. The pacemaker was inserted successfully under general anaesthesia.

At day 0 after the operation, the patient was diagnosed with a left leg deep venous thrombosis. Given the high-risk patient factor of developing pulmonary embolism (PE), a CT pulmonary angiogram (CTPA) was performed. No PE was diagnosed; instead, the CTPA discovered a focal dissection flap that originated from the right lower lobe segmental artery, extending into the subsegmental branches craniocaudally for 3 cm (figure 1, figure 2 and figure 3). The CTPA was reviewed by a consultant radiologist. The patient remained asymptomatic. Subsequent discussions with the cardiothoracic surgical team concluded that...

http://ift.tt/2CiiJm3

Severe hypophosphataemia: a rare cause of postoperative muscle weakness

We report a case of severe generalised muscle weakness in a 66-year-old man who underwent revision of left knee arthroplasty. On postoperative day 1, he developed non-focal muscle weakness and shortness of breath which progressed over a 6-hour period. Serum phosphorus level was severely low at 0.5 mg/dL, along with mild degree of hypokalaemia, hypocalcaemia and hypomagnesaemia. His symptoms completely resolved after emergent phosphorus replacement. The authors believe this case is of educational interest to physicians as generalised muscle weakness is an uncommon presentation of severe hypophosphataemia. In a postoperative setting, hypophosphataemia is often multifactorial, thought to result from combination of perioperative catecholamine surge, administration of saline, diuretics, glucose and antacids, poor oral intake and respiratory alkalosis secondary to pain. We report this case to raise awareness among physicians on severe phosphate imbalance as the primary aetiology for acute generalised muscle weakness and respiratory failure, especially after a surgery.

http://ift.tt/2oxmcUi

Role Of Conservative Management In Emphysematous Gastritis

Emphysematous gastritis (EG) is a rare disease of the stomach that is caused by gas-forming bacteria, and it can be lethal. There have been <70 reported cases in the English literature of this disease which carries a mortality rate up to 60%. Early recognition and treatment through conservative management have been a popular and successful choice in today's medicine. Studies have shown that surgical intervention does not confer a statistical benefit on mortality in this condition. We present another case of EG in a 33-year-old woman who was successfully managed conservatively.

http://ift.tt/2CiiHKX

Portomesenteric vein thrombosis following laparoscopic sleeve gastrectomy: are underlying haematological disorders the culprit?

Description

A 51-year-old woman with a medical history of hypothyroidism and deep vein thrombosis (DVT) during pregnancy presented to the emergency department 5 days after laparoscopic sleeve gastrectomy (LSG) complaining of worsening abdominal pain and low-grade fevers. A CT scan and upper  gastrointestional series were performed with no evidence of leak or abscess, and the patient was admitted for observation.

On hospital day 2, the patient had worsening abdominal pain and an episode of emesis. An ultrasound revealed a new moderate amount of intraperitoneal-free fluid. A CT scan was repeated which revealed a segmental non-occlusive thrombus in the splenic vein (figure 1) as well as an occlusive thrombus in the superior mesenteric vein near the portosplenic confluence (figure 2).

Figure 1

(A, B) Segmental non-occlusive thrombus (blue arrow) in the splenic vein. 

Figure 2

(A, B) Occlusive...

http://ift.tt/2ovcZw2

First case of acute granulomatous interstitial nephritis with immune reconstitution inflammatory syndrome in a patient with HIV coinfected with disseminated Mycobacterium kansasii

Restoration of immune response by highly active antiretroviral therapy (HAART) effectively improved the overall prognosis of HIV infection. However, 25%–31.7% of patients experience paradoxical worsening of pre-existing infections or unmasking of subclinical infections after starting HAART therapy, which is termed as immune reconstitution inflammatory syndrome (IRIS). Acute granulomatous interstitial nephritis as a consequence of IRIS has never been reported with Mycobacteriumkansasiicoinfection. Here, we describe an HIV/AIDS patient coinfected with disseminated M. kansasii infection, who presented with acute kidney injury 4.5 months after initiation of HAART. The diagnostic workup revealed IRIS was the cause of acute kidney injury. Short-term course of prednisone (1 mg/kg/day) along with antimycobacterial and HAART regimen achieved significant improvement.

http://ift.tt/2onFmwJ

Nail to the heart: no big deal. A rare case of post-traumatic pericarditis

This is a unique case report of a 32-year-old man who presented with pneumatic nail gun injury to his right chest at work. He removed the nail and continued to work through the day. With continued chest pain, he presented to the emergency room and an echocardiogram revealed moderate-size pericardial effusion. He was managed conservatively as he was haemodynamically stable. Serial echocardiograms revealed slow resolution of the effusion over 3 days. At his 3-month follow-up appointment, there was complete resolution of his effusion. This case highlights the importance of obtaining imaging studies in penetrating chest wall injuries and utilisation of medications to prevent expected complications.

http://ift.tt/2osUzfe

Recurrent postinfectious glomerulonephritis: an unusual evolution compatible with C3 glomerulopathy

Acute endocapillary glomerulonephritis, as its name suggests, is a one-time process, which usually resolves within weeks. However, in a small percentage of patients, the disease becomes chronic. In these cases, a deregulation in the alternative complement pathway, which can be caused by mutations or autoantibodies, has been proposed as a pathophysiological mechanism. As a result, the alternative complement pathway remains active after resolution of infection. We report a patient with two episodes of acute renal failure, both times diagnosed by renal biopsy of acute endocapillary glomerulonephritis, with slow recovery after two episodes of low-serum complement C3, haematuria and proteinuria.

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Stimming behaviour in a 4-year-old girl with autism spectrum disorder

Description

A 4-year-old girl with autism spectrum disorder (ASD) developed a new behaviour of biting hard objects over the previous 6 months. The behaviour has not gotten better over time and she would always explore toys made of hard material (video 1) this way. Fortunately, she has not sustained any injury, choked on or swallowed these objects. She likes hot and spicy foods with textures. Her expressive language has only developed poorly.

Video 1

The child instantly bites and puts hard toys she found in the room into her mouth.

'Stimming' or self-stimulatory behaviours, also known as stereotypic behaviours in ASD, usually come in the form of hand-flapping, body-rocking, pacing or repetition of words. However, chewing or biting non-edible objects is also common. There are a number of possibilities to explain this behaviour. First, stimming acts as a self-regulatory mechanism to help relieve anxiety, anger,...

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Postoperative epidural abscess after spinal anaesthesia for a circumcision necessitated by phimosis

A 70-year-old man was admitted to our hospital for a penile circumcision due to phimosis using continuous dose spinal anaesthesia. On postoperative day 10 he came to the emergency department with a superficial abscess localised at the injection site of the spinal catheter. He was treated with intravenous antibiotics for 10 days, and the superficial abscess was incised and drained. Ten days later, the patient was readmitted to the emergency department with complaints of back pain and fever. A repeat MRI scan of his lumbar sacral area was done and showed epidural abscesses without any compression of the medulla or the myelum. The patient did not have any signs of spinal cord or nerve root compression at that time. He was treated with intravenous antibiotics with resolution of symptoms.

http://ift.tt/2HJFwXw

Incidental presentation of a button battery within a pharyngeal pouch: the first reported case

Description

An 88-year-old woman presented acutely to the ear, nose and throat (ENT) department at a District General Hospital with an unusual foreign body discovered on videofluoroscopy. This investigation had been organised by her general practitioner as the patient was experiencing progressive dysphagia with food regurgitation and weight loss. There was no history of chest or abdominal pain, haemoptysis or known foreign body ingestion. She had a background of polymyalgia rheumatica, ischaemic heart disease, pharyngeal pouch and wore bilateral hearing aids for presbycusis. During videofluoroscopy a circular, radiopaque foreign body was noted within the pharyngeal pouch resembling a button battery (figures 1 and 2). Given these unusual findings, the ENT team was urgently contacted by the speech and language practitioner for further assessment.

Figure 1

Videofluoroscopy image (lateral view) showing a foreign body resembling a button battery within a pharyngeal pouch.

http://ift.tt/2GGSQul

Attenuated form of type II mucopolysaccharidoses (Hunter syndrome): pitfalls and potential clues in diagnosis

Description

A 7-year-old boy, born of a non-consanguineous union, presented with pain over both hips and progressive difficulty in walking for preceding 2 years. He had normal developmental milestones with satisfactory scholastic performances and his family and perinatal histories were unremarkable. Clinical examination revealed short stature (height SD score (SDS): –2.3; midparental height (MPH) SDS: –1.7) with upper segment (US):lower segment (LS) ratio of 0.97, umbilical hernia, apical pansystolic murmur of mitral regurgitation and waddling gait without corneal opacity or organomegaly (figure 1). Complete blood count, baseline biochemistry and thyroid function tests were normal except presence of azurophilic granules within white blood cells seen in peripheral blood smear (figure 2). Transthoracic echocardiography confirmed moderate mitral regurgitation secondary to prolapsed posterior mitral leaflet leading to coaptation failure. Though the difference between his height centile and MPH centile was not striking, his body proportion was suggestive of short trunk dwarfism (US:LS is normally...

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Cutaneous tuberculosis in China: A multicenter retrospective study of cases diagnosed between 1957 and 2013

Abstract

Background

China has one of the largest populations with tuberculosis worldwide. Cutaneous tuberculosis (CTB) is a rare manifestation of mycobacterial infection. Although CTB is well described, it is important to periodically revisit the prevailing clinical and epidemiological features in most populated countries such as China, India, and Indonesia, where tuberculosis is still a major health problem.

Objective

This retrospective study aimed to reevaluate the CTB cases in China in the past 50 years to btain a comprehensive insight into this multiplex entity.

Methods

Cases of diagnosed CTB with confirmed histology from four large medical centers in central China between 1957 and 2013 were collected and analyzed, including demographic data, clinical manifestations and pathological findings.

Results

Of the 1194 cases enrolled, there were 666 (55.78%) and 528 cases (44.22%) of true CTB and tuberculids, respectively. Erythema induratum of Bazin (EIB) was the most common CTB (35.8%), followed by lupus vulgaris (LV, 32.7%), tuberculosis verrucosa cutis (18.9%), papulonecrotic tuberculid (8.0%), scrofuloderma (2.8%), tuberculosis cutis ulcerosa (1.3%), penile tuberculids (0.4%), and lichen scrofulosorum (0.1%). EIB was the predominant tuberculid (80.87%), while LV the predominant true CTB (58.7%). The number of diagnosed CTB showed a decreasing trend in the 1960s and 1970s, then increased again, and peaked in the 1990s.

Conclusions

CTB is still a common problem in China. Chronologic changes of CTB cases reported in China over the past 50 years may reflect the prevalence transition of overall tuberculosis. CTB has diverse clinical presentations, and each subtype is characterized by specific gender predilection, duration, age, clinic, and pathological findings.

This article is protected by copyright. All rights reserved.

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Otolaryngology-Related Disorders in Underserved Populations, Otolaryngology Training and Workforce Considerations in North America

In North America, underserved and vulnerable populations experience poorer health outcomes despite greater per capita health care expenditures. Biologic, behavioral, and socioeconomic factors lead to more advanced disease presentation that may necessitate disparate treatment. Additionally, vulnerable populations are more likely to obtain care from low-volume providers, and are more likely to receive inappropriate care. Disparities in care are exacerbated by the distribution of the physician workforce and limited participation by physicians in the care of vulnerable populations. Multipronged strategies are needed to ameliorate observed disparities in care.

http://ift.tt/2BLFP3q

Workforce Considerations, Training, and Diseases of the Asia-Pacific Region

The Asia-Pacific region has 60% of the world's population. There is a huge variability in ethnic groups, geography, diseases, and income. The otolaryngology workforce depends on the number of medical graduates, training programs, scope of practice, and available employment. Training has been influenced by the British, Russian, and US training systems, and by local influences and experience. Otolaryngologic diseases are similar to those seen in the United States but with ethnic and regional differences. There are opportunities for humanitarian service but the most sustainable projects will include repetitive visits with transfer of knowledge.

http://ift.tt/2ENeh09

Xolair®-induced recurrent anaphylaxis through sensitization to the excipient polysorbate

Omalizumab is an anti-IgE humanized IgG1 monoclonal antibody, indicated for the treatment of moderate-to-severe allergic and uncontrolled asthma. Anaphylaxis was found to occur in 0.1 to 0.2% of patients taking Xolair®, the commercialized form of omalizumab1, with no known underlying mechanism. Although it has been very difficult to develop a reliable assay to detect clinically significant anti-omalizumab IgE, a recent report suggested that Xolair®-induced anaphylaxis is not mediated by IgE sensitization to the monoclonal antibody (mAb) omalizumab itself2.

http://ift.tt/2sQKFJL

Cow's milk-associated chronic food protein-induced enterocolitis syndrome (FPIES) exacerbated by extensively hydrolyzed formula

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy predominantly seen in infancy or early childhood. While its incidence has been steadily increasing over the past two decades, it is still often misdiagnosed due to lack of awareness.1 It presents in two forms: acute and chronic.

http://ift.tt/2Cj8xcQ

Concurrent IgE-mediated NMBA-allergy in systemic mastocytosis

Mastocytosis is a rare clinical condition characterized by an abnormal increase in tissue mast cells, which can be limited to the skin (cutaneous mastocytosis) or infiltrate the bone marrow and other organs with or without skin involvement (systemic mastocytosis). Systemic mastocytosis (SM) is reported primarily in adulthood, where indolent SM is the most common form. We report an unusual case consistent with IgE-mediated neuromuscular blocking agent (NMBA) allergy evidenced in a patient with previously unsuspected mastocytosis.

http://ift.tt/2sR42T6

Evaporative coolers are not associated with dust mite or mold sensitization in large pediatric cohort

The primary species of house dust mites (HDM), Dermatophagoides farinae and Dermatophagoides pteronyssinus, are associated with asthma, atopic dermatitis, and allergic rhinitis1. Mold exposure is also implicated in allergic disease, most prominently with asthma2. HDM survival is dependent on a relative humidity of greater than 55-75%3, and most species of fungi grow at a relative humidity greater than 60% 4. Evaporative (or swamp) coolers (ECs) are used as a low-cost air conditioning alternative in arid and semi-arid climates.

http://ift.tt/2CgFUwS

Relationship between traffic related air pollution particle exposure and asthma exacerbations: association or causation?

Clinicians are often asked about articles in the media proclaiming new and unexpected causes of disease. Often, these headlines are based not on randomized clinical trials but rather on associations discovered in observational studies. Most clinicians realize that a p-value less than 0.05 does not prove causation but do not necessarily know how to critically judge whether a reported association should be considered to be a true cause of the disease. In 1965, Austin Bradford Hill published "The Environment and Disease: Association or Causation?" 1.

http://ift.tt/2sOLC5g

A case of neuropathic pain in monoclonal mast cell activation syndrome

Neuropathic pain is an uncommon symptom associated with mast cell disorders but can significantly impact quality of life. Mast cells are known to be gatekeepers of nociception and play an important role in the development of neuropathic pain in the central and peripheral nervous system1. Although musculoskeletal pain has been associated with mast cell disorders2, neuropathic pain associated with mast cell disorders and its management has not been well described in the literature. We present a patient with neuropathic pain associated with monoclonal mast cell activation syndrome (MMAS) and review the agents used in his treatment.

http://ift.tt/2F39VkQ

Relying on allergy skin test results

We appreciate the comments related to our recent publication, "Reliability of allergy skin testing". The author writes, "Reliability (precision, repeatability) and validity (accuracy) are two completely different methodological issues". We agree that other titles such as, "Accuracy of allergy skin testing" may have fit more pedantic epidemiological definitions. However, this would not have emphasized the clinical concerns any greater. We had chosen to use the lay term for reliability as it appears in the Oxford English dictionary where it is defined as, "the degree to which the result of a measurement, calculation, or specification can be depended on to be accurate1."

http://ift.tt/2sLLGmA

Soluble Expression in Escherichia coli of a Single-Domain Antibody–Tumor Necrosis Factor α Fusion Protein Specific for Epidermal Growth Factor Receptor

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy Feb 2018, Vol. 37, No. 1: 20-25.


http://ift.tt/2EMTTfz

Synergistic Cytotoxic Effect on Gastric Cancer Cells of an Immunotoxin Cocktail in Which Antibodies Recognize Different Epitopes on CDH17

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy Feb 2018, Vol. 37, No. 1: 1-11.


http://ift.tt/2BKvDYO

Detecting Receptor Tyrosine Kinase ROR1 Using a Developed Anti-ROR1 Polyclonal Antibody

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy Feb 2018, Vol. 37, No. 1: 38-44.


http://ift.tt/2EMSaai

Anti-Semaphorin3Fc Monoclonal Antibody

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy Feb 2018, Vol. 37, No. 1: 67-67.


http://ift.tt/2BMwXug

Generating a Battery of Monoclonal Antibodies Against Firefly Luciferase for Dot Blot Analysis, Western Blot Analysis, and Immunostaining of Cells in Culture and Paraffin Sections

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy Feb 2018, Vol. 37, No. 1: 45-51.


http://ift.tt/2EQzM0g

First-Line Biologics for Moderate-to-Severe Psoriasis

Multiple therapeutic options exist for moderate-to-severe psoriasis, each with unique benefits and limitations. This review offers guidance on choosing the optimal therapy for your patients.
American Journal of Clinical Dermatology

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How to get rid of a hard pimple

This article discusses how to get rid of hard pimples. It also looks at different kinds of pimples, their causes, and how to prevent them.

http://ift.tt/2EYo4jo

Erratum to “Guidelines of the French Society of Otorhinolaryngology (SFORL), short version. Extension assessment and principles of resection in cutaneous head and neck tumors” [Eur. Ann. Otorhinolaryngol. Head Neck Dis. 131 (6) (2014) 375–383]

Publication date: Available online 23 February 2018
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): M. Durbec, V. Couloigner, S. Tronche, S. Albert, J. Kanitakis, A. Ltaief Boudrigua, O. Malard, E. Maubec, E. Mourrain Langlois, B. Navailles, L. Peuvrel, B. Phulpin, J.-C. Thimonier, F. Disant, G. Dolivet




http://ift.tt/2ojkcjy

Flu Experts at Johns Hopkins

Johns Hopkins has a range of experts available for interviews and comments about seasonal flu, infection control, flu transmission in children and flu treatment.

http://ift.tt/2omMBoV

Lessons from the sky: an aviation-based framework for maximizing the delivery of quality anesthetic care

Abstract

Though aviation is practiced in airplanes and anesthesiology in operating rooms, the two professions have substantial parallels. Both require readiness to manage a crisis situation, where lives are at stake, at a moment's notice and with incomplete information. The determinants of quality performance in both professions extend far beyond knowledge base and formal training. The science of human factors, a prominent cornerstone of the aviation industry, has not yet found the same place in medicine, but it could change the understanding and execution of medical decision-making in profound ways. This article reviews specific components of crisis management and root cause analysis in aviation that can serve as models for improving those same aspects within anesthesiology.

http://ift.tt/2oshYxp

A case of anosmia and hypogeusia as a complication of propofol

Abstract

Anesthetics represent an uncommon cause of taste and smell disorders. We describe a case of anosmia and hypogeusia for 6 weeks after recovery from a uterine curettage operation in a 32-year-old woman. The case is unusual because propofol was the only anesthetic used during surgery and anesthesia. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed no abnormality. This case may highly suggest that propofol could induce smell and taste disorders.

http://ift.tt/2olMGZL

Distinction between rhinovirus-induced acute asthma and asthma-augmented influenza infection

Abstract

Background

Rhinovirus (RV) is an established trigger of asthma attacks, whereas such a link is less consistent for influenza virus (IFV).

Objective

In the context of precision medicine, we hypothesized that IFV infection may cause a condition essentially different from RV, and we investigated this by evaluating clinical characteristics of RV/IFV-positive and -negative children with respiratory symptoms and/or fever.

Methods

1207 children, 6-months to 13-years old, hospitalized for flu-like illness were recruited in this cross-sectional study. Collected information included demographics, medical history, symptoms/physical findings/diagnosis at presentation, and treatment. Nasal secretions were PCR-tested for IFV/RV. Associations were evaluated with adjusted logistic regression models.

Results

RV positivity was associated with an asthma-like presentation, including increased wheeze/effort of breathing/diagnosis of acute asthma, and decreased fever/vomiting. Conversely, IFV⁺ children presented with less wheeze/effort of breathing/diagnosis of acute asthma, while they were more frequently febrile. In those with previous asthma history, both viruses induced wheeze, however, IFV was uniquely associated with a more generalised and severe presentation including fever, rales, intercostal muscle retractions and lymphadenopathy. These symptoms were not seen in RV⁺ asthmatics, who had fewer systemic signs and more cough.

Conclusions and Clinical relevance

In children with respiratory symptoms and/or fever, RV but not IFV is associated with wheeze and an asthma-like presentation. In those with an asthma history, IFV causes more generalised and severe disease that may be better described as 'asthma-augmented influenza' rather than an 'asthma attack'. Differences in the acute conditions caused by these viruses should be considered in the design of epidemiological studies.

This article is protected by copyright. All rights reserved.

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Alternaria alternata challenge at the nasal mucosa results in eosinophilic inflammation and increased susceptibility to influenza virus infection

Abstract

Background

Eosinophils in the nasal mucosa are an elemental feature of allergic rhinitis.

Objective

Our objective was to explore eosinophilic inflammation and its impact on respiratory virus infection at the nasal mucosa.

Methods

Inflammation in the nasal mucosae of mice was evaluated in response to repetitive stimulation with strict intranasal volumes of a filtrate of Alternaria alternata. Mice were then challenged with influenza virus.

Results

Repetitive stimulation with A. alternata resulted in eosinophil recruitment to the nasal passages in association with elevated levels of IL-5, IL-13, and eotaxin-1; eosinophil recruitment was diminished in eotaxin-1^-/- mice, and abolished in Rag1^-/- mice. A. alternata also resulted in elevated levels of nasal-wash IgA in both wild-type and eosinophil-deficient ∆dblGATA mice. Interestingly, A. alternata-treated mice responded to an influenza virus infection with profound weight loss and mortality compared to mice that received diluent alone (0% vs. 100% survival, ***p < 0.001); the lethal response was blunted when A. alternata was heat-inactivated. Minimal differences in virus titer were detected, and eosinophils present in the nasal passages at the time of virus inoculation provided no protection against the lethal sequelae. Interestingly, nasal-wash fluids from mice treated with A. alternata included more neutrophils and higher levels of proinflammatory mediators in response to virus challenge, among these, IL-6, a biomarker for disease severity in human influenza.

Conclusions and Clinical Relevance

Repetitive administration of A. alternata resulted in inflammation of the nasal mucosae and unanticipated morbidity and mortality in response to subsequent challenge with influenza virus. Interestingly, and in contrast to findings in the lower airways, eosinophils recruited to the nasal passages provided no protection against lethal infection. As increased susceptibility to influenza virus among individuals with rhinitis has been the subject of several clinical reports, this model may be used for further exploration of these observations.

This article is protected by copyright. All rights reserved.

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Needs Assessment Tool Integrated in Clinical Practice of Head and Neck Cancer Rehabilitation

Condition:   Head and Neck Neoplasms
Intervention:   Other: Needs assesment tool integrated in nursing consultation.
Sponsors:   Rigshospitalet, Denmark;   Novo Nordisk A/S;   Danish Nurses Organisation
Not yet recruiting

http://ift.tt/2sO1Rjd

A Study of E7130 in Participants With Solid Tumors

Condition:   Solid Tumors
Intervention:   Drug: E7130
Sponsor:   Eisai Co., Ltd.
Recruiting

http://ift.tt/2sO1Pb5

Asymptomatic thyroiditis presenting as pyrexia of unknown origin: a case report

Pyrexia of unknown origin is a difficult and challenging problem for the physician. Endocrine disorders, such as subacute thyroiditis, rarely present with pyrexia of unknown origin. Subacute thyroiditis can ha...

http://ift.tt/2GE9rPo

The use of Latin terminology in medical case reports: quantitative, structural, and thematic analysis

This paper focuses on the prevalence of Latin terms and terminological collocations in the issues of Journal of Medical Case Reports (February 2007–August 2017) and discusses the role of Latin terminology in the ...

http://ift.tt/2HDDmbE

Flu Experts at the Johns Hopkins Medical Institutions

Johns Hopkins has a range of experts available for interviews and comments about seasonal flu, infection control, flu transmission in children and flu treatment.

http://ift.tt/2omMBoV

Systematic review of wound healing biomarkers in peri-implant crevicular fluid during osseointegration

Publication date: Available online 22 February 2018
Source:Archives of Oral Biology
Author(s): Amália Machado Bielemann, Raissa Micaella Marcello-Machado, Altair Antoninha Del Bel Cury, Fernanda Faot
ObjectiveTo quantify and characterize the role of biomarkers in peri-implant crevicular fluid (PICF) at each stage of healing during osseointegration.DesignThis systematic review was performed in accordance with PRISMA guidelines using several databases: MedLine (PubMed), Embase, ISI Web of Science, Scopus, and Cochrane Library. Medical subject headings and their indexers were used with no other limitations until December 2017. The dataset was extended with relevant papers from the reference lists of selected papers and from the gray literature. Data was summarized for study objectives, patient demographics, methods used to analyze PICF, biomarker concentrations, results and main findings. Methodologic quality of each included study was assessed using the checklist created by Downs and Black.ResultsElectronic search resulted in 1698 articles. After the duplicates excluded, reading titles, abstracts and reference list reviews yielded, 30 prospective studies with longitudinal follow-up were selected. 52 different biomarkers were identified. The most studied cytokines were interleukin (IL)-1, IL-1β, tumor necrosis factor alpha (TNF-α), and nitric oxide (NO). The earliest PICF specimens were collected immediately after implantation, and the latest at 16 weeks prior to occlusal loading. 36 biomarkers were quantified during week 1, 49 between day 10 and week 6, and 49 between weeks 8 and 12. Only 5 articles received good quality ratings.ConclusionThe mechanism by which inflammatory and bone biomarkers are released during osseointegration has not yet been identified. However, some hypotheses based on immune-modulated reactions are being explored to investigate early and asymptomatic implant failures. Given the available clinical studies, it was not possible to further explore the performance of all biomarkers already analyzed and to extrapolate their results to propose a consultable data system based on release volume or concentration because of clinical study and data heterogeneity.

Graphical abstract

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Systematic Review of Radiofrequency Ablation and Pulsed Radiofrequency for Management of Cervicogenic Headaches

Abstract

Purpose of Review

Cervicogenic headache (CHA) is a secondary headache which has a source in the upper cervical spine. Many traditional analgesic choices lack good efficacy in managing the associated pain. As a result, in management of CHA, radiofrequency ablation (RFA) or pulse radiofrequency (PRF) has been tried with success. Our study investigated the use of RFA and PRF for the management of CHA.

Recent Findings

In the present investigation, a review of the literature was conducted using PubMed (1966 to February 2017). The quality assessment was determined using The Cochrane Risk of Bias. After initial search and consultation with experts, 34 articles were identified for initial review and 10 articles met inclusion for review. Criteria for inclusion were primarily based on identification of articles discussing cervicogenic headaches which were previously treatment resistant and occurred without any other pathology of the craniofacial region or inciting event such as trauma.

Summary

This systematic review demonstrated that RFA and PRFA provide very limited benefit in the management of CHA. At present, there is no high-quality RCT and/or strong non-RCTs to support the use of these techniques, despite numerous case reports which have demonstrated benefit. This review is one of the first to provide a comprehensive overview of the use of RFA and PRF in the management of CHA.

http://ift.tt/2ENuRx8

Headache Diagnosis in Children and Adolescents

Abstract

Purpose of Review

Headache phenotypes can differ between adults and children. While most headaches are due to primary headache disorders, in a small population, they can be an indication of a potentially life-threatening neurologic condition. The challenge lies in identifying warning signs that warrant further workup. This article reviews different types of pediatric headaches and headache evaluation in children and teens, and focuses on the approach for diagnosis of secondary headaches.

Recent Findings

Common thought is that increased frequency and severity of headache may reflect secondary pathology; however, headache phenotype may not be fully developed and can evolve in adolescence or adulthood. Headache location, particularly occipital headache alone, does not necessarily signify secondary intracranial pathology. Certain warning signs warrant neuroimaging, but others only warrant imaging in certain clinical contexts. Brain MRI is the neuroimaging modality of choice, though there is a high rate of incidental findings and often does not change headache management.

Summary

A stepwise approach is essential to avoid missing secondary headaches. There are several differences between adults and children in clinical manifestations of headache. Evaluation and diagnosis of pediatric headache starts with a thorough headache and medical history, family and social history, and identification of risk factors. A thorough physical and neurologic exam is important, with close attention to features that could suggest secondary headache pathology. Neuroimaging and other testing should only be performed if there is concern for secondary headache.

http://ift.tt/2CDUJFI

Pain States, the Opioid Epidemic, and the Role of Radiologists

Abstract

Purpose of Review

The prevalence of chronic pain and prescription opioid abuse has resulted in epidemic problems for patients and clinicians. The consequences are taking a heavy toll on patients, physicians, and society. Specific to radiology, a significant need exists for best practice assessment and treatment approaches for pain management, as patients with chronic pain often undergo radiological tests of unclear clinical relevance.

Recent Findings

The USA is amid an opioid-prescribing epidemic and resultant overdose public health emergency. A variety of reasons, which are examined in this manuscript, have contributed to the dramatic increase in the use of chronic opioid therapy for chronic non-cancer pain. This increase of opioid prescriptions and related deaths is based on many factors including the perception that there was systemic undertreatment of pain, the philosophical approach of advocacy groups for pain relief, promotion by the pharmaceutical industry, Joint Commission's Fifth Vital Sign, and permissive regulations by boards of medical licensures promoting excessive use of opioids. Overall, opioid treatment has been based on subjective pain relief and radiographic findings, which may not correlate with the source of pain generation.

Summary

Radiologists, along with interventionalists, frequently interact with patients on chronic opioid therapy and at times take responsibility for patients with chronic pain. Beyond reading studies, diagnostic radiologists provide care to larger percentages of patients taking narcotics than ever before. This manuscript focuses on chronic pain, escalating opioid therapy, and adverse consequences, including the epidemic of overdoses and deaths. Radiologists' expertise can potentially reduce unnecessary radiological tests and inappropriate prescribing of medications.

http://ift.tt/2EMXTg6

The Opioid Crisis: a Comprehensive Overview

Abstract

Purpose of Review

The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4 years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances.

Recent Findings

Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10–50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use.

Summary

The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.

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Post-Ocular Trauma Corneal Staphyloma in a Child Living in an Underdeveloped Region of Eastern Indonesia

Ocular trauma occurring in children often leads to visual impairment or blindness when it is not properly managed. This often occurs in underdeveloped regions with difficult access to professional care at local health facilities. We report a case of post-trauma corneal staphyloma in an underdeveloped region of eastern Indonesia to illustrate the importance of proper management of ocular trauma in areas lacking such expertise and where patients have difficulty accessing even basic health care. During a community health outreach in Southwest Sumba, eastern Indonesia in May 2017, a 7-year-old boy presented with white protrusion of the left eye of 3 years' duration following an event of sharp trauma. The patient lived in an inaccessible and impoverished area. Upon contemporary examination, visual acuity of the left eye was 1/300 while that of the right eye was 6/6. Anterior examination revealed corneal staphyloma of the left eye, and its posterior segment could not be evaluated. The patient was transported to an eye care center in Jakarta, receiving a stock prosthesis implant while awaiting a corneal evisceration procedure with dermofat graft. Ocular trauma is one of the most common causes of visual impairment in children. This case illustrates the consequences of inadequate post-trauma management and the importance of prevention of infection.
Case Rep Ophthalmol 2018;9:24–29

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An intrapancreatic accessory spleen presenting as a rapidly growing pancreatic mass after splenectomy in a patient with hereditary spherocytosis: a case report and literature review

Abstract

The case of a 16-year-old boy with an intrapancreatic accessory spleen presenting as a rapidly growing pancreatic mass after splenectomy for splenomegaly due to hereditary spherocytosis is reported herein. When he was 15 years old, the patient visited at a hospital due to jaundice and radiological examinations showed a huge spleen with a 2-cm mass near or in the pancreatic tail. Sonazoid-enhanced ultrasonography showed hypervascularity in the mass located near the pancreatic tail, which was suspicious for an accessory spleen. During splenectomy by laparotomy, the mass could not be found by inspection or intraoperative ultrasonography. One year after the splenectomy, the mass grew rapidly to 4 cm. Laparoscopic surgery was performed to aid in the differential diagnosis of the mass, and a laparoscopic ultrasonogram revealed that the mass was located in the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy and was discharged uneventfully on the 11th postoperative day.

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Toxic association between an intestinal myxoma and a mesenteric lipoma in a child: a case report

Abstract

Intestinal myxoma is among the rarest presentations of this benign tumour. Moreover, the association of an intestinal myxoma and a mesenteric lipoma is even more surprising. Intestinal tumours are often diagnosed inadvertently: a routine physical exam may identify these tumours or an abdominal computed tomography scan or abdominal ultrasound for another indication. Acute intestinal obstruction is rare. We hereby report the case of a 6-year-old boy who presented in the emergency room of our institution with acute intestinal obstruction and the management of this case.

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A case report of squamous cell carcinoma in a suprapubic urinary catheter tract: surgical excision and simultaneous colostomy formation

Abstract

Squamous cell carcinoma (SCC) arising from a suprapubic cystostomy tract is a rare complication of long-term suprapubic catheterization (SPC). A 53-year-old man with paraplegia secondary to spina bifida presented with a painful granulomatous lesion around his SPC site that was being treated with silver nitrate cauterization in the community. Consequently, he developed a sacral pressure sore due to reduced mobility from the pain. He also had increasing difficulties with defaecation secondary to his spina bifida. His sacral pressure sore was secondary to a cryptoglandular fistula with coccygeal osteomylelitis. Post-operative pathology revealed infiltrative SCC involving full thickness of the specimen from skin to the bladder wall with clear surgical margins. We describe the first case requiring a simultaneous suprapubic tract SCC excision and colostomy formation. We recommend early investigation of lesions arising from a long-term suprapubic tract especially in patients with spinal cord injuries or congenital defects.

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Migraine and Autonomic Dysfunction: Which Is the Horse and Which Is the Jockey?

Abstract

Purpose of Review

Symptoms of autonomic dysfunction are common in patients with migraine, both during and between migraine attacks. Studies evaluating objective autonomic testing in patients have found significant, though somewhat conflicting results. The purposes of this review are to summarize and interpret the key findings of these studies, including those evaluating heart rate variability, autonomic reflex testing, and functional imaging in patients with migraine. The neuroanatomy of the central autonomic network as it relates to migraine is also reviewed.

Recent Findings

Several studies have evaluated autonomic balance in migraineurs, with conflicting results on the magnitude of sympathetic versus parasympathetic dysfunction. Most studies demonstrate sympathetic impairment, with a lesser degree of parasympathetic impairment.

Summary

Three trends have emerged: (1) migraine with aura tends to produce more significant autonomic dysfunction than migraine without aura, (2) sympathetic impairment is more common than parasympathetic impairment, and (3) sympathetic impairment is common in the interictal period, with increased sympathetic responsiveness during the ictal period, suggesting adrenoreceptor hypersensitivity.

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Cognitive Behavioral Therapy (CBT) for Subacute Low Back Pain: a Systematic Review

Abstract

Purpose of Review

Chronic low back pain (CLBP) is a major source of physical and psychiatric morbidity and mortality, and the current overreliance on opioid analgesics has contributed to a burgeoning epidemic in the USA. Cognitive behavioral therapy (CBT) is an empirically supported treatment for CLBP, but little information exists regarding its potential efficacy for CLBP's precursor condition, subacute low back pain (sALBP), defined here as having a 7–12-week duration. Earlier intervention with CBT at the sALBP stage could produce larger clinical benefits. This systematic review was undertaken to characterize and highlight this knowledge gap.

Recent Findings

Of 240 unique articles identified by comprehensive database searches, only six prospective, sALBP-focused, randomized controlled trials (RCTs) published within the past 20 years met criteria for inclusion in this review. These studies varied widely in their sample sizes, precise definition of sALBP, nature of CBT intervention, and outcome measures. Five of the six showed significant improvements associated with CBT, but the heterogeneity of the studies prevented quantitative comparisons.

Summary

CBT has not been adequately studied as a potential early intervention treatment for sALBP patients. None of the six identified papers studied US civilians or leveraged innovations such as teletherapy—able to reach patients in remote or underserved areas—underscoring critical gaps in current back pain treatment. Given the severity of the US opioid epidemic, non-pharmacologic options such as CBT should be rigorously explored in the sALBP population.

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A different perspective: anesthesia for extreme premature infants is there an age limitation or how low should we go?

Purpose of review To put in perspective, the various challenges that faces pediatric anesthesiologists because of the recently lowered limits with regards to the viability of a fetus. Both medical and ethical considerations will be highlighted. Recent findings Issues related to: who should anesthetize these tiny babies; can we provide adequate and legal monitoring during the anesthetic; does these immature babies need hypnosis and amnesia and the moral/ethical implications associated with being involved with care of doubtful long-term outcome are reviewed. Summary There does currently not exist sufficient research data to provide any evidence-based guidelines for the anesthetic handling of extreme premature infants. Current practice relies on extrapolations from other patient groups and from attempting to preserve normal physiology. Thus, focused research initiatives within this specific field of anesthesia should be a priority. Furthermore, in-depth multiprofessional ethical discussions regarding long-term outcome of aggressive care of extremely premature babies are urgently needed, including the new concepts of disability-free survival and number-need-to-suffer. Correspondence to Per-Arne Lönnqvist, MD, DEAA, FRCA, PhD, Paediatric Anaesthesia, PICU & ECMO Services, Karolinska University Hospital, Solna, SE 171 76 Stockholm, Sweden. Tel: +46 70 721 06 50; fax: +46 8 5177 7260; e-mail: per-arne.lonnqvist@ki.se Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The opioid epidemic and the current prevalence of substance use disorder in anesthesiologists

Purpose of review There has been a substantial increase in prescription and illicit opioid abuse in the general population observed over the last two decades. Initially fueled by an influx of prescription opioid medications, the opioid epidemic now includes increasingly potent heroin and illicit fentanyl. Younger anesthesiologists, those currently in training or recent graduates, have come of age in a society where opioid abuse is much more prevalent. Recent findings The current prevalence of substance use disorder (SUD) in the physician population is slightly higher than in the general population and appears to be increasing. Although most anesthesiologists with SUD will abuse alcohol as their drug of choice, the incidence of opioid and nonopioid anesthetic agent abuse, especially propofol, is increasing. The incidence of SUD among the anesthesia resident population decreased somewhat during the 1990s but has been steadily increasing since the year 2000. Summary The increasing incidence of substance use disorder in anesthesia residents may reflect the significantly increased number of persons addicted to opioids and other drugs of abuse in the general population. Despite educational and surveillance programs put in place to prevent diversion, susceptible individuals with access are still abusing anesthetic agents. Correspondence to Ethan O. Bryson, MD, Department of Anesthesiology, Pain Management and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, Box 1010, One Gustave L Levy Place, New York, NY 10029, USA. Tel: +1 212 241 9240; fax: +1 212 876 3906; e-mail: ethan.bryson@mountsinai.org Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Chronic pain after hysterectomy

Purpose of review Hysterectomy is a common surgical procedure with a low risk of major complications. However, some women experience long-lasting complications, including chronic postsurgical pain, which can have a negative impact on their quality of life. This review aims to present the recent literature on chronic pain following hysterectomy for benign indications. Recent findings Chronic pain following hysterectomy is reported in 10–50% of women. Risk factors include preoperative pelvic pain, pain elsewhere, acute postoperative pain, surgical procedure, and psychological factors such as anxiety and depression. The pain may be neuropathic in 5–50% of cases. Summary Chronic pain may occur after hysterectomy. Preoperative screening tools, including psychological screening for depression and anxiety, may identify women at risk of developing chronic postsurgical pain, and future studies should examine perioperative interventions aimed at preventing the development of chronic pain after hysterectomy. Correspondence to Birgitte Brandsborg, Department of Anaesthesiology, Aarhus University Hospital, THG, Tage-Hansens Gade 2, bldg.2, 2., 8000 Aarhus C, Denmark. Tel: +45 26844438; e-mail: birbrand@rm.dk Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Occupational stress, burnout and personality in anesthesiologists

Purpose of review There is a growing awareness of the problem of occupational stress and burnout among anesthesiologists. Occupational stress was found to be related to burnout, a process that is supposed to be moderated by personality. This article will discuss the topic of stress and burnout in relationship to anesthesiologists' personality based on recent literature. Recent findings Studies among anesthesiologists are in concordance with the broader body of literature on this topic. Personality consistently influences stress appraisal and coping and consequently the development of burnout. Neuroticism, negative affectivity and cooperativeness all contribute to burnout. Summary Strategies to alleviate stress and hence the development of burnout should not only be directed at adapting occupational or organizational factors but also at equipping anesthesiologists with psychological tools to deal with occupational stress. Furthermore, personality traits that predispose for development of burnout could be taken into consideration in resident selection procedures. Correspondence to Raymond A.B. van der Wal, MD, Anesthesiologist, Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Internal Postal Code 717, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands. Tel: +31 24 361 4406; fax: +31 24 354 0462; e-mail: Raymond.vanderwal@radboudumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Anesthesia and analgesia for gynecological surgery

Purpose of review High-quality analgesia has been linked to improved patient satisfaction as well as improved short-term and long-term postoperative outcomes. Acute surgical pain is a modifiable risk factor for development of chronic postoperative pain, which is reported by up to 26% of gynecologic surgical patients. In other surgical populations, multimodal analgesia has shown improved pain control and decreased reliance on opioids. This review examines recent evidence for various analgesic modalities applied specifically to the gynecologic surgical population. Recent findings Nonopioid agents like acetaminophen, nonsteroidal anti-inflammatories, and gamma-aminobutyric acid analogs resulted in reduction in postoperative pain and opioid consumption. Application of regional anesthetic techniques had a favorable effect that persisted beyond the immediate recovery period. Preemptive analgesia remains unproven. The best evidence for effective combinations comes from ERAS studies that incorporated multimodal analgesia into a systemic approach geared towards early discharge. Summary Multimodal analgesia had demonstrated advantages for all types of gynecological surgeries in terms of improving postoperative pain control and minimizing opioid-related adverse effects. Multimodal analgesia includes acetaminophen, NSAIDS, and gamma-aminobutyric acid analogs combined with intraoperative nonopioid analgesics such as ketamine, regional anesthesia or intrathecal morphine. Further research should focus on determining most effective combinations and doses of multimodal analgesia. Correspondence to Dr Ronald B. George, MD, FRCPC, Department of Women's and Obstetric Anesthesia, IWK Health Centre, 5850/5980 University Avenue, P.O. Box 9700, Halifax, NS B3K 6R8, Canada. Tel: +1 902 470 6627; fax: +1 902 470 6626; e-mail: rbgeorge@dal.ca,@Ron_George Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Technology as friend or foe? Do electronic health records increase burnout?

Purpose of review To summarize recent relevant studies regarding the use of electronic health records and physician burnout. Recent findings Recently acquired knowledge regarding the relationship between electronic health record use, professional satisfaction, burnout, and desire to leave clinical practice are discussed. Summary Adoption of electronic health records has increased across the United States and worldwide. Although electronic health records have many benefits, there is growing concern about the adverse consequences of their use on physician satisfaction and burnout. Poor usability, incongruent workflows, and the addition of clerical tasks to physician documentation requirements have been previously highlighted as ongoing concerns with electronic health record adoption. In multiple recent studies, electronic health records have been shown to decrease professional satisfaction, increase burnout, and the likelihood that a physician will reduce or leave clinical practice. One interventional study demonstrated a positive effect of a dedicated electronic health record entry clerk on physicians working in an outpatient practice. Correspondence to Jesse M. Ehrenfeld, MD, MPH, Professor of Anesthesiology, Surgery, Biomedical Informatics & Health Policy, Director, Education Research – Office of Health Sciences Education, Director, Program for LGBTI Health, Associate Director, Vanderbilt Anesthesiology & Perioperative Informatics Research Division, Vanderbilt University School of Medicine, 1301 Medical Center Drive, Suite TVC 4648, Nashville, TN 37232, USA. E-mail: jesse.ehrenfeld@vanderbilt.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Effect of platelets-rich plasma on scalp hair diameter

Summary

Objectives

To measure the effects of platelet-rich plasma (PRP) on hair diameter in Pakistani population.

Materials and methods

The study was conducted in a private setup in the adult patients undergoing PRP treatment. Baseline platelets count was noted for each patient. PRP was prepared using a commercial kit. Three PRP injections were administered in the scalp at 0, 1, and 3 months of interval. The hair caliber was measured in the mid-scalp area using a separate stencil for each patient. The diameter of 10 hair (1 cm sq) was measured randomly using the caliper (2 hair on each side of the square and 4 in the center). After 6 months of 3rd injection, the hair caliber was measured and the results were analyzed statistically using Mann-Whitney's test.

Results

Seven men and 3 women were included in the study. The mean age of the patients was 24.2 years (26.3 years in males and 19.3 in females). The average platelets count was found to be 283,580/μL. The mean hair caliber was 37.3 μm (39.1 μm in men and 33.0 μm in women). At the end of the study, the mean hair caliber was found to be 52.3 μm (P < .01). The mean hair caliber was 53.9 μm in men and 48.7 μm in women (P < .01). The increase in the hair caliber was noted to be 27.5% more in men and 31.3% more in women (P < .01).

Conclusion

The PRP injections can increase the hair diameter.

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Level of agreement between laboratory and point-of-care prothrombin time in patients after stopping or continuation of acenocoumarol anticoagulation: A comparison of diagnostic accuracy

BACKGROUND Procedures requiring optimisation of the coagulation status of patients using vitamin K antagonists are frequently postponed due to the late availability of laboratory international normalised ratio (INR) test results. A point-of-care (POC) alternative may facilitate early decision-making in peri-operative patients. OBJECTIVES To assess the level of agreement between the POC-INR and the laboratory INR in patients who continue or stop vitamin K antagonists to determine whether the POC test may be a good alternative to the laboratory INR. DESIGN Study of diagnostic accuracy. SETTING Single-centre study at Zaans Medical Centre, The Netherlands. PATIENTS Included patients were scheduled for cardioversion (these continued taking vitamin K antagonists), or a surgical procedure (these stopped taking vitamin K antagonists). MAIN OUTCOME MEASURES The level of agreement and clinical acceptability of the laboratory and POC-INR results, evaluated by Bland–Altman analysis and error grid analysis. RESULTS The surgical and cardioversion groups consisted of 47 and 46 patients, respectively. The bias in the INR in the surgical group was −0.12 ± 0.09 with limits of agreement of −0.29 to 0.05, whereas the cardioversion group showed a bias in the INR of −0.22 ± 0.36 with limits of agreement from −0.93 to 0.48. The percentage errors between methods in the surgical and cardioversion groups were 16 and 21%, respectively. Error grid analysis showed that the diagnostic accuracy of the POC prothrombin time is clinically acceptable as the difference did not lead to a different clinical decision in the surgical group with INR values less than 1.8. CONCLUSION The current study shows a good level of agreement and clinical accuracy between the laboratory and POC-INR in patients who stopped anticoagulation intake for surgery. However, in patients who continued their anticoagulation therapy, the agreement between the two methods was less accurate. Correspondence to Elisabeth A.J. de Vos, MD, Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands Tel: +31 20 4443830; e-mail: e.devos@vumc.nl © 2018 European Society of Anaesthesiology

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Improving detection of patient deterioration in the general hospital ward environment

Patient monitoring on low acuity general hospital wards is currently based largely on intermittent observations and measurements of simple variables, such as blood pressure and temperature, by nursing staff. Often several hours can pass between such measurements and patient deterioration can go unnoticed. Moreover, the integration and interpretation of the information gleaned through these measurements remains highly dependent on clinical judgement. More intensive monitoring, which is commonly used in peri-operative and intensive care settings, is more likely to lead to the early identification of patients who are developing complications than is intermittent monitoring. Early identification can trigger appropriate management, thereby reducing the need for higher acuity care, reducing hospital lengths of stay and admission costs and even, at times, improving survival. However, this degree of monitoring has thus far been considered largely inappropriate for general hospital ward settings due to device costs and the need for staff expertise in data interpretation. In this review, we discuss some developing options to improve patient monitoring and thus detection of deterioration in low acuity general hospital wards. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://ift.tt/OBJ4xP Correspondence to Dr Jean-Louis Vincent, Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium E-mail: jlvincent@intensive.org © 2018 European Society of Anaesthesiology

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Opioid-related genetic polymorphisms do not influence postoperative opioid requirement: A prospective observational study

BACKGROUND Among the various factors that may influence the pharmacological response to opioids, genetic polymorphisms [single nucleotide polymorphisms (SNP)] have generated some interest. OBJECTIVES To examine the influence on morphine dose requirements and adverse events in the postoperative period of four SNP [opioid receptor mu1 (OPRM1), ATP-binding cassette subfamily B, member 1 (ABCB1) ex-21 and ex-26, catechol-o-methyltransferase (COMT)] in candidate genes involved in morphine pharmacodynamics and pharmacokinetics. DESIGN A single centre prospective study. SETTING University Hospital, Paris, France, from 2 January 2007 to 15 November 2011. PATIENTS A total of 438 white adults scheduled for major orthopaedic surgery (spine, hip and knee) under general anaesthesia. The main exclusion criteria were receiving opioids for chronic pain, nonopioid drugs within 2 days prior to surgery, pregnancy, renal insufficiency, sleep apnoea obstruction syndrome, morbid obesity, severe hepatic impairment, cognitive dysfunction. INTERVENTIONS Assays of plasma concentrations of morphine and metabolites (morphine 3-glucuronide and morphine 6-glucuronide) were performed and common polymorphisms in four candidate genes [OPRM1 A118G rs1799971; P-glycoprotein (ABCB1) T3435C (rs1045642) and G2677T/A (rs2032582); COMT Val 158 Met (rs4680)] were analysed. Morphine was titrated by staff in the postanaesthesia care unit (PACU) and in the ward patient-controlled intravenous analgesia was used for 24 h. MAIN OUTCOME MEASURES The dose of morphine required to achieve pain relief and the influence of SNP in genes involved in morphine pharmacodynamics and kinetics on morphine dose requirements. Secondary endpoints were the concentrations of morphine, morphine 6-glucuronide and morphine 3-gluguronide, the proportion of patients requiring a rescue analgesic and the proportion of morphine-related adverse events. RESULTS A total of 404 patients completed the study to final analysis. The mean ± SD morphine dose to achieve pain relief was 15.8 ± 8.8 mg in the PACU and 22.7 ± 18.6 mg during patient-controlled intravenous administration. Morphine-related adverse events were observed in 37%. There was no relationship between any genetic polymorphisms and morphine dose, morphine 3-gluguronide and morphine 6-glucuronide concentration, morphine-related adverse events or pain level. In the PACU only, P-glycoprotein polymorphisms (ex-21; ex-26) were significantly associated with morphine concentration but the prediction of the model was poor (R2 = 0.04) CONCLUSION No major relationship has been demonstrated between SNP of OPRM1, ABCB1, COMT and morphine requirement, pain level or adverse effects in the postoperative period. TRIAL REGISTRATION NCT00822549 (www.clinicaltrials.gov). Correspondence to Frédéric Aubrun, Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, 103 Boulevard de La Croix Rousse, 69004 Lyon, France E-mail: frederic.aubrun@chu-lyon.fr 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/2ylyqmW). © 2018 European Society of Anaesthesiology

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