New Evidence for Structural Integration across the Cartilage-Vertebral Endplate Junction and its Relation to Herniation

Publication date: Available online 31 August 2018

Source: The Spine Journal

Author(s): Nurul Haiza Sapiee, Ashvin Thambyah, Peter A. Robertson, Neil D. Broom

Abstract

BACKGROUND CONTEXT

Both cartilaginous and bony material present in herniated tissue suggests that failure can involve both cartilaginous and vertebral-endplates. How structural integration is achieved across the junction between these two distinct tissue regions via its fibril and mineral components is clearly relevant to the modes of endplate failure that occur.

PURPOSE

To understand how structural integration is achieved across the cartilage-vertebral endplate junction.

STUDY DESIGN

A micro- and fibril-level structural analysis of the cartilage-vertebral endplate region was carried out using healthy, mature ovine motion segments.

METHODS

Oblique vertebra-annulus-vertebra samples were prepared such that alternate layers of lamellar fibers extended from vertebra to vertebra. The endplate region of each sample was then decalcified in a targeted manner before being loaded in tension along the fiber direction to achieve incomplete rupture within the region of the endplate. The failure regions were then analyzed with differential interference contrast microscopy and scanning electron microscopy.

RESULTS

Microstructural analysis revealed that failure within the endplate region was not confined to the cement line alone. Instead, rupture continued into the underlying vertebral endplate with bony material still attached to the now unanchored annular bundles. Ultrastructural analysis of the partially ruptured regions of the cement line revealed clear evidence of blending/interweaving relationships between the fibrils of the annular bundles, the calcified cartilage and the bone with no one pattern of association appearing dominant. These findings suggest that fibril-based structural cohesion exists across the cement line at the site of annular insertion, with strengthening via a mechanism somewhat analogous to steel-reinforced concrete. The fibrils are brought into a close intermingling association with interfibril forces mediated via the mineral component.

CONCLUSIONS

This study provides clear evidence of structural connectivity across the cartilaginous-vertebral endplate junction by the intermingling of their fibrillar components and mediated by the mineral phase. This is consistent with the clinical observation that in some disc herniations bony material can be still attached to the extruded soft tissue.

https://ift.tt/2wDtdab

Incidental Durotomy in Degenerative Lumbar Spine Surgery – A register study of 64,431 operations

Publication date: Available online 30 August 2018

Source: The Spine Journal

Author(s): Fredrik Strömqvist, Freyr Gauti Sigmundsson, Björn Strömqvist, Bo Jönsson, Magnus K. Karlsson

Abstract

Background

Incidental durotomy (ID) is one of the most common intraoperative complications seen in spine surgery. Conflicting evidence has been presented regarding whether or not outcomes are affected by the presence of an ID.

Purpose

To evaluate whether outcomes following degenerative spine surgery are affected by ID and the incidence of ID with different diagnoses and different surgical procedures.

Material

By using SweSpine, the national Swedish Spine Surgery Register, preoperative, surgical and postoperative 1 year follow up data were obtained for 64,431 surgeries. All patients were surgically treated due to spinal stenosis (LSS) without or with concomitant degenerative spondylolisthesis (DS) or lumbar disc herniation (LDH) between 2000-2015. Gender, age, smoking habits, walking distance, consumption of analgesics, back and leg pain (VAS), quality of life (EQ5D, SF-36) and disability (ODI) were recorded.

Results

Overall, incidence of ID during the study period was 5.0%. For the LDH, LSS, and DS subgroups it was 2.8%, 6.5%, and 6.5%, respectively. Laminectomy was associated with higher incidence of ID than discectomy (p<0.001). ID was more common in all three subgroups if the patient had previously been subjected to spine surgery and with increasing age of the patients (p<0.001). LDH patients with an ID reported a higher degree of residual leg pain, inferior mental quality of life (SF-36 MCS) and higher disability (ODI) than LDH patients without ID (all p<0.001) one-year after surgery. LSS patients with an ID reported inferior SF-36 MCS (p<0.001) and DS patients with an ID had inferior SF-36 MCS and higher ODI compared to patients with the same diagnosis but without an ID (p<0.001). However, these numerical differences are well below references for MCID, for all 3 subgroups. ID was associated with a higher frequency of patients being dissatisfied with the surgical outcome at one year follow up. In patients who did not improve in back-and leg pain following surgery (delta-value), ID was less common than in patients reporting improved back- and legpain from before as compared to following surgery.

Conclusions

The overall occurrence of ID in the present study was 5%, with higher figures in LSS and DS and lower figures in LDH. Higher age of the patient and previous surgery was associated with higher frequencies of ID. The outcome at one year following surgery was not affected to a clinically relevant extent when an ID. However, ID was associated with a higher degree of patient dissatisfaction and a longer hospital length of stay.

https://ift.tt/2CaRiLT

Clinical effect of early bisphosphonate treatment for pyogenic vertebral osteomyelitis with osteoporosis: An analysis by the Cox proportional hazard model

Publication date: Available online 30 August 2018

Source: The Spine Journal

Author(s): Jihye Kim, Seung Bo Jang, Seok Woo Kim, Jae-Keun Oh, Tae-Hwan Kim

Abstract

Background Context

Patients with pyogenic vertebral osteomyelitis (PVO) are expected to have an increased risk of bone loss. Therefore, early bisphosphonate therapy would be clinically effective for PVO patients with osteoporosis.

Purpose

To investigate the effect of bisphosphonate on clinical outcomes of PVO patients with osteoporosis. Study Design/Setting: A retrospective comparative study.

Patient Sample

PVO patients with osteoporosis Outcome measures: Four events of interest for Cox proportional hazard model included surgical treatment, recurrence of infection, subsequent fracture of adjacent vertebral bodies, and death.

Methods

PVO patients were divided into three groups: group A (initiation of bisphosphonate within 6 weeks after PVO diagnosis), group B (initiation of bisphosphonate between 6 weeks and 3 months after PVO diagnosis), and group C (no treatment for osteoporosis). Cox proportional hazard model was used for the four events of interest.

Results

A total of 360 PVO patients with osteoporosis were investigated for the four events of interest. Group A had significantly lower hazard ratios for undergoing later (>6 weeks after diagnosis) surgery than group C (p=0.014) despite similar occurrences of overall surgery. A significant difference was also observed in the occurrence of subsequent fractures at adjacent vertebral bodies (p=0.001 for model 1 and p=0.002 for model 2). Groups A and B had significantly lower hazard ratios for subsequent fracture than group C. No significant differences were observed in the hazard ratios of recurrence and death among the three groups.

Conclusions

Early bisphosphonate treatment in PVO patients with osteoporosis was associated with a significantly lower occurrence of subsequent vertebral fracture at adjacent vertebral bodies and lower occurrence of subsequent surgery.

https://ift.tt/2MKTChc

Robotic-assisted pedicle screw placement fails to reduce overall postoperative complications in fusion surgery

Publication date: Available online 29 August 2018

Source: The Spine Journal

Author(s): Alexander M. Lieber, Gregory J. Kirchner, Yehuda E. Kerbel, Amrit S. Khalsa

Abstract

BACKGROUND CONTEXT

Surgeons have increasingly adopted robotic-assisted lumbar spinal fusion due to indications that robotic-assisted surgery can reduce pedicle screw misplacement. However, the impact of robotic-assisted spinal fusion on patient outcomes is less clear.

PURPOSE

This study aimed to compare rates of perioperative complications between robotic-assisted and conventional lumbar spinal fusion.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

A total of 520 patients undergoing lumbar fusion were analyzed. The average ages of patients in the robotic-assisted versus conventional groups were 60.33 and 60.31, respectively (p=.987). Patients with a diagnosis of fracture, traumatic spinal cord injury, spina bifida, neoplasia, or infection were excluded.

OUTCOME MEASURES

This study compared the rates perioperative major and minor complications for elective lumbar fusion between each cohort.

METHODS

This study screened hospital discharges in the United States from 2010 to 2014 using the National Inpatient Sample and the Nationwide Inpatient Sample (NIS). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify 209,073 patients who underwent conventional lumbar fusion (ICD 81.04-8) and 279 patients who underwent robotic-assisted lumbar fusion (ICD 81.04-8 and ICD 17.41, 17.49). Major and minor complications were identified using ICD-9-CM diagnosis codes. The robotic-assisted and conventional fusion groups were statistically matched on age, year, sex, indication, race, hospital type, and comorbidities. Univariate and multivariate logistic regression were used to compare risks of major and minor complications.

RESULTS

We matched 257 (92.11%) robotic-assisted patients with an equal number of patients undergoing conventional lumbar fusion. Minor complications occurred in 16.73% of cases in the conventional group and 31.91% of cases in the robotic-assisted group (p<.001). Major complications occurred in 6.61% of the conventional cases compared to 8.17% of robotic-assisted cases (p=.533). For robotic-assisted fusion, multivariate analysis revealed that there was no difference in the likelihood of major complications (OR=0.834, 95% CI=0.214–3.251) or minor complications (OR = 1.450, 95% CI=0.653–3.220).

CONCLUSIONS

In a statistically matched cohort, patients who underwent robotic-assisted lumbar fusion had similar rates of major and minor complications compared to patients who underwent conventional lumbar fusion.

https://ift.tt/2CbuBqS

Alterations in 90-day morbidity, mortality, and readmission rates following spine surgery in Medicare Accountable Care Organizations (2009–2014)

Publication date: Available online 27 August 2018

Source: The Spine Journal

Author(s): Andrew J. Schoenfeld, Daniel J. Sturgeon, Justin A. Blucher, Adil H. Haider, James D. Kang

Abstract

BACKGROUND CONTEXT

The impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality, and readmissions, has not been substantially investigated, especially following spine surgery.

PURPOSE

To evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery.

STUDY DESIGN

Retrospective review of national Medicare claims data (2009–2014).

PATIENT SAMPLE

Patients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO.

OUTCOME MEASURES

The development of in-hospital mortality, complications or hospital readmission within 90 days of the surgical procedure.

METHODS

The primary outcome measures included postsurgical complications and readmissions at 90 days following surgery. In-hospital mortality and 30-day outcomes were considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs, namely, sociodemographic characteristics, medical co-morbidities, hospital teaching status, bed size, and location.

RESULTS

In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012–2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs.

CONCLUSIONS

Our study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.

https://ift.tt/2PVcKqK

Minimum clinically important difference of the health-related quality of life scales in adult spinal deformity calculated by latent class analysis: is it appropriate to use the same values for surgical and nonsurgical patients?

Publication date: Available online 27 August 2018

Source: The Spine Journal

Author(s): Selcen Yuksel, Selim Ayhan, Vugar Nabiyev, Montse Domingo-Sabat, Alba Vila-Casademunt, Ibrahim Obeid, Francisco Sanchez Perez-Grueso, Emre Acaroglu, European Spine Study Group (ESSG)

Abstract

BACKGROUND CONTEXT

Health-related quality of life (HRQOL) parameters have been shown to be reliable and valid in patients with adult spinal deformity (ASD). Minimum clinically important difference (MCID) has become increasingly important to clinicians in evaluating patients with a threshold of improvement that is clinically relevant.

PURPOSE

To calculate MCID and minimum detectable change (MDC) values of total scores of the Core Outcome Measures Index (COMI), Oswestry Disability Index (ODI), Physical Component Summary (PCS), Mental Component Summary (MCS) of the Short Form 36 (SF-36), and Scoliosis Research Society 22R (SRS-22R) in surgically and nonsurgically treated ASD patients who have completed an anchor question at pretreatment and 1-year follow-up.

STUDY DESIGN/SETTING

Prospective cohort.

PATIENT SAMPLE

Surgical and nonsurgical patients from a multicenter ASD database.

OUTCOME MEASURES

Self-reported HRQOL measures (COMI, ODI, SF-36, SRS-22R, and anchor question).

METHODS

A total of 185 surgical and 86 nonsurgical patients from a multicenter ASD database who completed pretreatment and 1-year follow-up HRQOL scales and the anchor question at the first year follow-up were included. The anchor question was used to determine MCID for each HRQOL measure. MCIDs were calculated by an anchor-based method using latent class analysis (LCA) and MDCs by a distribution-based method.

RESULTS

All differences between means of baseline and first year postoperative total score measures for all scales demonstrated statistically significant improvements in the overall population as well as the surgically treated patients but not in the nonsurgical group. The calculated MDC and MCID values of HRQOL parameters in the entire study population were 1.34 and 2.62 for COMI, 10.65 and 14.31 for ODI, 6.09 and 7.33 for SF-36 PCS, 6.14 and 4.37 for SF-36 MCS, and 0.42 and 0.71 for SRS-22R. The calculated MCID values for surgical and non-surgical treatment groups were 2.76 versus 1.20 for COMI, 14.96 versus 2.45 for ODI, 7.83 versus 2.15 for SF-36 PCS, 5.14 versus 2.03 for SF-36 MCS, and 0.94 versus 0.11 for SRS-22R; the MDC values for surgical and nonsurgical treatment groups were 1.22 versus 1.51 for COMI, 10.27 versus 9.45 for ODI, 5.16 versus 6.77 for SF-36 PCS, 6.05 versus 5.67 for SF-36 MCS, and 0.38 versus 0.43 for SRS-22R.

CONCLUSIONS

This study has demonstrated that MCID calculations for the HRQOL scales in ASD using LCA yield values comparable to other studies that had used different methodologies. The most important finding was the significantly different MCIDs for COMI, ODI, SF-36 PCS and SRS-22 in the surgically and nonsurgically treated cohorts. This finding suggests that a universal MCID value, inherent to a specific HRQOL for an entire cohort of ASD may not exist. Use of different MCIDs for surgical and nonsurgical patients may be warranted.

https://ift.tt/2wDkWTR

European evidence-based guidelines on pancreatic cystic neoplasms

Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. The guideline discussed in this podcast is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy.

Listen to the discussion between the Education Editor of Gut, Mairi McLean, and Marco del Chiaro, from The European Study Group on Cystic Tumours of the Pancreas. And read the details of the guidelines on the Gut website: https://ift.tt/2wAPS7a.

https://ift.tt/2MIbmdd

Asteroid Hyalosis

A 54-year-old woman with type 2 diabetes mellitus presented to the ophthalmology clinic for a routine dilated fundus examination. She had a history of cataracts, which had been treated successfully with posterior-chamber intraocular lenses in both eyes. Slit-lamp examination of the left eye…

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Accuracy of seizure semiology obtained from first-time seizure witnesses

Little is known of how accurately a first-time seizure witness can provide reliable details of a semiology. Our goal was to determine how accurately first-time seizure witnesses could identify key elements of ...

https://ift.tt/2wKf1fZ

Prevalence of Human Sapovirus in Low and Middle Income Countries

Background. Sapovirus (SV) infection is a public health concern which plays an important role in the burden of diarrhoeal diseases, causing acute gastroenteritis in people of all ages in both outbreaks and sporadic cases worldwide. Objective/Study Design. The purpose of this report is to summarise the available data on the detection of human SV in low and middle income countries. A systematic search on PubMed and ScienceDirect database for SV studies published between 2004 and 2017 in low and middle income countries was done. Studies of SV in stool and water samples were part of the inclusion criteria. Results. From 19 low and middle income countries, 45 published studies were identified. The prevalence rate for SV was 6.5%. A significant difference (P=0) in SV prevalent rate was observed between low income and middle income countries. Thirty-three (78.6%) of the studies reported on children and 8 (19%) studies reported on all age groups with diarrhoea. The majority (66.7%) of studies reported on hospitalised patients with acute gastroenteritis. Sapovirus GI was shown as the dominant genogroup, followed by SV-GII. Conclusion. The detection of human SV in low and middle income countries is evident; however the reports on its prevalence are limited. There is therefore a need for systematic surveillance of the circulation of SV, and their role in diarrhoeal disease and outbreaks, especially in low and middle income countries.

https://ift.tt/2oxujRo

Issue Information ‐ Masthead

Annals of Neurology, Volume 84, Issue 1, July 2018.


https://ift.tt/2PpfcF5

Issue Information ‐ TOC

Annals of Neurology, Volume 84, Issue 1, July 2018.


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Issue Information ‐ Copyright

Annals of Neurology, Volume 84, Issue 1, July 2018.


https://ift.tt/2PtgYor

Annals of Neurology: Volume 84, Number 1, July 2018

Annals of Neurology, Volume 84, Issue 1, July 2018.


https://ift.tt/2NfJJrD

Heuristic Evaluation: Comparing Generic and Specific Usability Heuristics for Identification of Usability Problems in a Living Museum Mobile Guide App

This paper reports on an empirical study that compares two sets of heuristics, Nielsen's heuristics and the SMART heuristics in the identification of usability problems in a mobile guide smartphone app for a living museum. Five experts used the severity rating scales to identify and determine the severity of the usability issues based on the two sets of usability heuristics. The study found that Nielsen's heuristics set is too general to detect usability problems in a mobile application compared to SMART heuristics which focuses on the smartphone application in the product development lifecycle instead of the generic Nielsen's heuristics which focuses on a wide range of interactive system. The study highlights the importance of utilizing domain specific usability heuristics in the evaluation process. This ensures that relevant usability issues were successfully identified which could then be given immediate attention to ensure optimal user experience.

https://ift.tt/2LOeMGa

Gamma-Glutamyltransferase and Risk of Acute Coronary Syndrome in Young Chinese Patients: A Case-Control Study

Background. Serum gamma-glutamyltransferase (GGT) is a biomarker of hepatic disease. Recent studies have shown that GGT may also associate with the risk of coronary artery disease. However, the underlying mechanisms of this association are still unclear. Methods. This study included 216 young patients with acute coronary syndrome (aged ≤55years) and 227 age-matched controls with normal findings by coronary angiography or coronary computed tomography angiography. We use standard colorimetric techniques and sandwich enzyme-linked immunosorbent assay to measure the levels of GGT and oxidized low-density lipoprotein (ox-LDL), respectively. Traditional risk factors of coronary artery disease, including smoking, diabetes mellitus, hypertension, dyslipidemia, and obesity/overweight, were evaluated according to the current guidelines. Results. The levels of GGT were significantly correlated with body mass index and levels of triglyceride, fasting plasma glucose, aspartate aminotransferase, and ox-LDL (all ). Multivariate logistic regression analysis showed that GGT was significantly associated with the risk of acute coronary syndrome in young Chinese patients (OR = 1.53, 95% CI = 1.09–2.15) after adjusting for traditional risk factors, including sex, age, quantity of smoking, hypertension, diabetes, body mass index, dyslipidemia, and high-sensitivity C-reactive protein. However, this association was significantly attenuated (OR = 1.20, 95% CI = 0.91–1.58) after further adjusting for the levels of ox-LDL. Conclusions. GGT was associated with the risk of ACS in relatively young patients. The link between GGT and the risk of ACS may be dependent on ox-LDL levels, indicating that the prooxidant action is an important pathway for GGT in the development of cardiovascular disease.

https://ift.tt/2LN4k1q

Association between MnSOD Val16Ala Polymorphism and Cancer Risk: Evidence from 33,098 Cases and 37,831 Controls

Manganese superoxide dismutase (MnSOD) plays a critical role in the defense against reactive oxygen species. The association between MnSOD Val16Ala polymorphism and cancer risk has been widely studied, but the results are contradictory. To obtain more precision on the association, we performed the current meta-analysis with 33,098 cases and 37,831 controls from 88 studies retrieved from PubMed, Embase, Chinese National Knowledge Infrastructure (CNKI), and Wanfang databases. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess the strength of association. We found that the polymorphism was associated with an increased overall cancer risk (homozygous: , 95% CI = 1.00–1.19; heterozygous: , 95% CI = 1.02–1.12; dominant: , 95% CI = 1.02–1.14; and allele comparison: , 95% CI = 1.02–1.11). Stratification analysis further showed an increased risk for prostate cancer, Asians, Caucasians, population-based studies, hospital-based studies, low quality and high quality studies. However, the increased risk for MnSOD Val16Ala polymorphism among Asians needs further validation based on the false-positive report probability (FPRP) test. To summarize, this meta-analysis suggests that the MnSOD Val16Ala polymorphism is associated with significantly increased cancer risk, which needs further validation in single large studies.

https://ift.tt/2wyyjWa

Phase 2 Trial of Ibudilast in Progressive Multiple Sclerosis

Even though more than a dozen therapies have been approved for the treatment of relapsing forms of multiple sclerosis, only the monoclonal antibody ocrelizumab and the chemotherapy agent mitoxantrone are approved for progressive multiple sclerosis. Ibudilast is a small molecule available in Asia…

https://ift.tt/2N7Xd8w

Case 27-2018: A 3-Year-Old Boy with Seizures

Presentation Of Case. Dr. Caitlin E. Naureckas Li (Pediatrics): A 3-year-old boy was admitted to this hospital during the summer because of a seizure. The patient had been well until 3 days before admission, when one episode of emesis occurred. The following evening, he was fussy, and on the third…

https://ift.tt/2PTbioW

Immunotherapy for Melanoma Metastatic to the Brain

Most practicing physicians will recall from their training that the average prognosis for patients with central nervous system (CNS) metastases from melanoma was death within a matter of weeks to months. This reflected the natural history of a disease on which systemic treatment had a negligible…

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Free Drug Samples and the Opioid Crisis

To the Editor: Malpractice on the part of some pharmaceutical companies has been established as a key driver of the opioid crisis. Powerful painkillers are offered under attractive conditions to poorly educated patients who are not aware of the risk of addiction and who eventually die from drug…

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Combined Nivolumab and Ipilimumab in Melanoma Metastatic to the Brain

Brain metastases are a common complication of solid tumors and remain a major cause of disabling neurologic complications and death in patients with cancer. Among primary cancers in adults, melanoma has one of the highest propensities to metastasize to the brain. More than one third of patients…

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Acute Viral Encephalitis

Encephalitis is a syndrome characterized by altered mental status and various combinations of acute fever, seizures, neurologic deficits, cerebrospinal fluid (CSF) pleocytosis, and neuroimaging and electroencephalographic (EEG) abnormalities. The syndrome has many causes; the most commonly…

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Opioid Prescribing Limits for Acute Pain — Striking the Right Balance

U.S. legislators have recently unveiled numerous bills aimed at combating the opioid epidemic through prevention, harm-reduction, and treatment measures. One of them, the Comprehensive Addiction and Recovery Act (CARA) 2.0, was a bipartisan proposal advancing several evidence-based strategies,…

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Deficiency of micronutrients in patients affected by chronic atrophic autoimmune gastritis: A single-institution observational study

Chronic atrophic autoimmune gastritis (CAAG) leads to vitamin B12 deficiency, but other micronutrient deficiencies are largely understudied.

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THYROID DYSFUNCTION AND ITS ROLE AS A RISK FACTOR FOR NON-ALCOHOLIC FATTY LIVER DISEASE: WHAT’S NEW

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Recommendations for the Evaluation for Autoimmune Liver Disease in Nonalcoholic Fatty Liver Disease

Hepatology, EarlyView.


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Design and Endpoints for Clinical Trials in Primary Sclerosing Cholangitis

Hepatology, EarlyView.


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When is “brainstem death” brain death? The case for ancillary testing in primary infratentorial brain lesion

The biological concept of the irreversible cessation of brain function (brain death, BD) occurring while cardiorespiratory function is maintained has been issued already by M. F. Xavier Bichat (1800) and Harvey Cushing (1902), and was systematically developed since the 1950's (Mollaret et al., 1959; Wertheimer et al., 1959; Beecher, 1968, Wijdicks et al., 2010). The primary goal was to establish medico-legal criteria for the termination of mechanical ventilation and intensive medical care in severely brain damaged patients with irreversible coma and fatal outcome.

https://ift.tt/2Pqguj2

EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video)

Postoperative pancreatic leakage and fistulae (jointly referred as POPF) are a leading adverse event after partial pancreatic resection. Treatment algorithms are currently not standardized. Evidence regarding the role of endoscopy is scarce.

https://ift.tt/2PrHNcQ

Producing Gene Deletions in Escherichia coli by P1 Transduction with Excisable Antibiotic Resistance Cassettes

Here we present a protocol for the use of pre-existing antibiotic resistance-cassette deletion constructs as a basis for making deletion mutants in other E. coli strains. Such deletion mutations can be mobilized and inserted into the corresponding locus of a recipient strain using P1 bacteriophage transduction.

https://ift.tt/2PUE4pc

Investigating Mammalian Axon Regeneration: In Vivo Electroporation of Adult Mouse Dorsal Root Ganglion

Electroporation is an effective approach to deliver genes of interests into cells. By applying this approach in vivo on the neurons of adult mouse dorsal root ganglion (DRG), we describe a model to study axon regeneration in vivo.

https://ift.tt/2PoIVxV

Disentangling High Strength Copolymer Aramid Fibers to Enable the Determination of Their Mechanical Properties

The primary goal of the study is to develop a protocol to prepare consistent specimens for accurate mechanical testing of high strength copolymer aramid fibers, by removing a coating and disentangling the individual fiber strands without introducing significant chemical or physical degradation.

https://ift.tt/2ordXK6

Classical Short-Delay Eyeblink Conditioning in One-Year-Old Children

This protocol describes an eyeblink conditioning paradigm appropriate for experiments with one-year-old infants. Commercial or custom-made equipment can be used to deliver the stimuli, and data collection and analysis should be performed on the video recordings.

https://ift.tt/2NDbtmS

Stereotactic Adoptive Transfer of Cytotoxic Immune Cells in Murine Models of Orthotopic Human Glioblastoma Multiforme Xenografts

Here, we present a protocol for the preparation and the stereotaxic administration of allogeneic human lymphocytes in immunodeficient mice carrying orthotopic human primary brain tumors. This study provides a proof-of-concept for both the feasibility and the antitumor efficacy of intrabrain-delivered cellular immunotherapies.

https://ift.tt/2PwpoMb

Isolation of Human Endometrial Stromal Cells for In Vitro Decidualization

This study presents a validated and optimized procedure for the isolation and culture of human endometrial stromal cells to conduct in vitro decidualization assay. Further, this study provides a detailed method to efficiently knockdown a specific gene using siRNAs in human endometrial stromal cells.

https://ift.tt/2N6opED

Current and Emerging Treatment Modalities for Leber’s Hereditary Optic Neuropathy: A Review of the Literature

Abstract

Introduction

The purpose of this review is to present the current and emerging treatment alternatives for Leber's hereditary optic neuropathy (LHON), emphasizing the most recent use of idebenone and stem cells or gene therapy.

Methods

A comprehensive literature review was performed at the PubMed database regarding the various treatment modalities for LHON.

Results

Treatment modalities for LHON include nutritional supplements, activators of mitochondrial biogenesis, brimonidine, and symptomatic and supportive treatment, but nowadays attention is being paid to idebenone and gene therapy or stem cells.

Conclusion

The treatment of LHON remains challenging, given the nature of the disease and its prognosis.

https://ift.tt/2PY7MtE

Impact of endoscopic ultrasound‐guided fine needle biopsy on the diagnosis of subepithelial tumors: a propensity score matching analysis

Digestive Endoscopy, Volume 0, Issue ja, -Not available-.


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Endoscopy robotics: current and future applications

Digestive Endoscopy, Volume 0, Issue ja, -Not available-.


https://ift.tt/2Ca17cQ

Construction of a risk model for the development of metachronous squamous cell carcinoma after endoscopic resection of esopahageal squamous cell carcinoma

Abstract

Background

Previously, we identified that rs1229984 in ADH1B, rs671 in ALDH2, and smoking status were independently associated with the risk of developing metachronous squamous cell carcinoma (SCC) after endoscopic resection (ER) for esophageal SCC (ESCC). However, this analysis included cases with short-term follow-up. In the present study, we investigated the environmental and genetic factors associated with developing metachronous SCC using long-term follow-up observation after ER for ESCC.

Methods

One hundred and thirty ESCC patients who underwent treatment with ER were followed up using endoscopy for ≥ 30 months. We investigated the incidence of, and genetic/environmental factors associated with, metachronous SCC development after ER for ESCC. We also analyzed the potential risk factors for multiple metachronous SCC development using Cox's proportional hazards model. Moreover, we constructed a risk model for the development of metachronous SCC after ER for ESCC.

Results

Male, rs1229984, rs671, alcohol consumption (> 20 g/day), smoking, and multiple Lugol-voiding lesions (LVLs) significantly affected the incidence of multiple metachronous SCCs. Multiple Cox proportional analysis revealed that rs1229984, rs671, alcohol consumption, smoking, and multiple LVLs were independently associated with the risk of developing metachronous SCC. Patients who had ≤ 2 risk factors did not develop metachronous SCC, and the risk of developing metachronous SCC in patients with ≥ 3 risk factors was significantly higher than in patients with ≤ 2 risk factors.

Conclusion

The risk model using these 5 genetic and environmental factors is useful as an indication for multiple metachronous development in ESCC patients.

https://ift.tt/2wz6Aot

Quiz: How much do you know about sepsis?

Take our 5-minute quiz to find out how your assessment skills measure up

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Optimization of the culture condition of Bacillus mucilaginous using Agaricus bisporus industrial wastewater by Plackett–Burman combined with Box–Behnken response surface method

In the present study, conditions for Bacillus mucilaginous fermentation using Agaricus bisporus wastewater as culture medium were optimized. We analyzed the total number of living B. mucilaginous in the fermentat...

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Factors influencing developmental delay among young children in poor rural China: a latent variable approach

Objectives

The aims of the study were to determine the prevalence of suspected developmental delay in children living in poor areas of rural China and to investigate factors influencing child developmental delay.

Design

A community-based, cross-sectional survey was conducted.

Eighty-three villages in Shanxi and Guizhou Provinces, China.

Participants

A total of 2514 children aged 6–35 months and their primary caregivers.

Outcome measures

Suspected child developmental delay was evaluated using the Ages & Stages Questionnaires-Chinese version. Caregivers' education and age, wealth index, child feeding index, parent-child interaction, number of books and Zung Self-Rating Depression Scale were reported by the primary caregivers. Haemoglobin levels were measured using a calibrated, automated analyser. Birth weight was obtained from medical records.

Results

Overall, 35.7% of the surveyed children aged 6–35 months demonstrated suspected developmental delay. The prevalence of suspected developmental delay was inversely associated with age, with the prevalence among young children aged 6–11 months being almost double that of children aged 30–35 months (48.0% and 22.8%, respectively). Using a structural equation model, it was demonstrated that caregiver's care and stimulus factors and child's haemoglobin level were directly correlated, while caregiver's sociodemographic factors were indirectly associated with suspected developmental delay.

Conclusions

The prevalence of suspected developmental delay is high in poor rural areas of China, and appropriate interventions to improve child development are needed.

https://ift.tt/2N9EOIC

Convergent parallel mixed-methods study to understand information exchange in paediatric critical care and inform the development of safety-enhancing interventions: a protocol study

Introduction

The effective exchange of clinical information is essential to high-quality patient care, especially in the critical care unit (CCU) where communication failures can have profoundly negative impacts on critically ill patients with limited physiological capacity to tolerate errors. A comprehensive systematic characterisation of information exchange within a CCU is needed to inform the development and implementation of effective, contextually appropriate interventions. The objective of this study is to characterise when, where and how healthcare providers exchange clinical information in the Department of Critical Care Medicine at The Hospital for Sick Children and explore the factors that currently facilitate or counter established best rounding practices therein.

Methods and analysis

A convergent parallel mixed-methods study design will be used to collect, analyse and interpret quantitative and qualitative data. Naturalistic observations of rounds and relevant peripheral information exchange activities will be conducted to collect time-stamped event data on workflow and communication patterns (time–motion data) and field notes. To complement observational data, the subjective perspectives of healthcare providers and patient families will be gathered through surveys and interviews. Departmental metrics will be collected to further contextualise the environment. Time–motion data will be analysed quantitatively; patterns in field note, survey and interview results will be examined based on themes identified deductively from literature and/or inductively based on the data collected (thematic analysis). The proactive triangulation of these systemic, procedural and contextual data will inform the design and implementation of efficacious interventions in future work.

Ethics and dissemination

Institutional research ethics approval has been acquired (REB #1000059173). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will be presented to stakeholders including interdisciplinary staff, departmental management and leadership and families to highlight the strengths and weaknesses of the exchange of clinical information in its current state and develop user-centred recommendations for improvement.

https://ift.tt/2PrpowN

Progress in voluntary medical male circumcision for HIV prevention supported by the US Presidents Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data

Objective

This article provides an overview and interpretation of the performance of the US President's Emergency Plan for AIDS Relief's (PEPFAR's) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017.

Design

Longitudinal collection of routine programme data and disaggregations.

Setting

14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes.

Participants

Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above.

Main outcome measures

Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance.

Results

PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision.

Conclusions

Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020.

https://ift.tt/2N5BjTq

Efficacy of cloxacillin versus cefazolin for methicillin-susceptible Staphylococcus aureus bacteraemia (CloCeBa): study protocol for a randomised, controlled, non-inferiority trial

Introduction

Methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia is a common and severe disease responsible for approximately 65 000 deaths every year in Europe. Intravenous antistaphylococcal penicillins (ASP) such as cloxacillin are the current recommended antibiotics. However, increasing reports of toxicity and recurrent stock-outs of ASP prompted healthcare providers to seek for alternative antibiotic treatment. Based on retrospective studies, cefazolin, a first-generation cephalosporin, is recommended in patients at risk of severe ASP-associated toxicity.

We hypothesised that cefazolin has a non-inferior efficacy in comparison to cloxacillin, with a better safety profile for the treatment of MSSA bacteraemia.

Methods and analysis

The CloCeBa trial is an open-label, randomised, controlled, non-inferiority trial conducted in academic centres throughout France. Eligible patients are adults with MSSA bacteraemia without intravascular device or suspicion of central nervous system infection. Patients will be randomised (1:1) to receive either cloxacillin or cefazolin by the intravenous route, for the first 14 days of therapy. The evaluation criteria is a composite criteria of negative blood cultures at day 5, survival, absence of relapse and clinical success at day 90 after randomisation. Secondary evaluation criteria include both efficacy and safety assessments. Three ancillary studies are planned to describe the epidemiology of β-lactamase encoding genes, the ecological impact and pharmacokinetic/pharmacodynamic parameters of cefazolin and cloxacillin. Including 300 patients will provide 80% power to demonstrate the non-inferiority of cefazolin over cloxacillin, assuming 85% success rate with cloxacillin and taking into account loss-to-follow-up, with a 0.12 non-inferiority margin and a one-sided type I error of 0.025.

Ethics and dissemination

This protocol received authorisation from the ethics committee Sud-Est I on 13 November 2017 (2017-87-PP)and French National Agency for Medicines and Health Products (170661A-43). Results will be disseminated to the scientific community through congresses and publication in peer-reviewed journals.

Trial registration number

NCT03248063 and 2017-003967-36.

https://ift.tt/2PshvXT

Organisation and delivery of liaison psychiatry services in general hospitals in England: results of a national survey

Objectives

To describe the current provision of hospital-based liaison psychiatry services in England, and to determine different models of liaison service that are currently operating in England.

Design

Cross-sectional observational study comprising an electronic survey followed by targeted telephone interviews.

Setting

All 179 acute hospitals with an emergency department in England.

Participants

168 hospitals that had a liaison psychiatry service completed an electronic survey. Telephone interviews were conducted for 57 hospitals that reported specialist liaison services additional to provision for acute care.

Measures

Data included the location, service structures and staffing, working practices, relations with other mental health service providers, policies such as response times and funding. Model 2-based clustering was used to characterise the services. Telephone interviews identified the range of additional liaison psychiatry services provided.

Results

Most hospitals (141, 79%) reported a 7-day service responding to acute referrals from the emergency department and wards. However, under half of hospitals had 24 hours access to the service (78, 44%). One-third of hospitals (57, 32%) provided non-acute liaison work including outpatient clinics and links to specialist hospital services. 156 hospitals (87%) had a multidisciplinary service including a psychiatrist and mental health nurses. We derived a four-cluster model of liaison psychiatry using variables resulting from the electronic survey; the salient features of clusters were staffing numbers, especially nursing; provision of rapid response 24 hours 7-day acute services; offering outpatient and other non-acute work, and containing age-specific teams for older adults.

Conclusions

This is the most comprehensive study to date of liaison psychiatry in England and demonstrates the wide availability of such services nationally. Although all services provide an acute assessment function, there is no uniformity about hours of coverage or expectation of response times. Most services were better characterised by the model we developed than by current classification systems for liaison psychiatry.

https://ift.tt/2N7EKsB

The role of osteopathy in the Swiss primary health care system: a practice review

Objectives

The aim of this study was to describe osteopathic activity and scope of practice to understand the current and future role of osteopathy in the Swiss healthcare system.

Design

A questionnaire survey that included a patient record-based retrospective clinical audit.

Setting/population

Osteopaths with a national diploma (n=1086) were invited by mail to participate in an online survey. Osteopathic assistants (n=84) were identified through their national association.

Questionnaire

The survey was constructed from previous surveys and tested for face validity with experts, osteopaths and patient representatives. The questionnaires were completed online in English, German and French between April and August 2017. Osteopaths anonymously reported information about themselves, their practice, and the treatment and care for four randomly selected patients they managed in 2016.

Results

The response rate from the survey was 44.5% (521/1171). Data on osteopathic care were collected for 1144 patients and 3449 consultations. In 2016, osteopaths saw approximately 6.8% of the Swiss population for 1700 000 consultations and an overall estimated cost of 200 million Swiss francs. 76% of patients sought care directly without a referral from another care provider. Few osteopaths (<1%) work in a hospital setting and 46% work in isolation in private practice. Infants (under 2 years old) made up 10% of all patients and 9% of patients were ≥65 years. Patients most commonly sought treatment for musculoskeletal conditions (81%) with the spine being the most frequent location (66%). Treatments also included exercise advice (34.2%) and lifestyle management (35.4%). Fewer than 1 patient out of 10 were referred to another health profession or provider.

Conclusions

In Switzerland, osteopathic care represents an important first line management for musculoskeletal conditions that alleviates some of the burden of care in the Swiss primary healthcare system.

https://ift.tt/2CjgShR

Prevalence of long-term health conditions in adults with autism: observational study of a whole country population

Objectives

To investigate the prevalence of comorbid mental health conditions and physical disabilities in a whole country population of adults aged 25+ with and without reported autism.

Design

Secondary analysis of Scotland's Census, 2011 data. Cross-sectional study.

Setting

General population.

Participants

94% of Scotland's population, including 6649/3 746 584 adults aged 25+ reported to have autism.

Main outcome measures

Prevalence of six comorbidities: deafness or partial hearing loss, blindness or partial sight loss, intellectual disabilities, mental health conditions, physical disability and other condition; ORs (95% CI) of autism predicting these comorbidities, adjusted for age and gender; and OR for age and gender in predicting comorbidities within the population with reported autism.

Results

Comorbidities were common: deafness/hearing loss—17.5%; blindness/sight loss—12.1%; intellectual disabilities—29.4%; mental health conditions—33.0%; physical disability—30.7%; other condition—34.1%. Autism statistically predicted all of the conditions: OR 3.3 (95% CI 3.1 to 3.6) for deafness or partial hearing loss, OR 8.5 (95% CI 7.9 to 9.2) for blindness or partial sight loss, OR 94.6 (95% CI 89.4 to 100.0) for intellectual disabilities, OR 8.6 (95% CI 8.2 to 9.0) for mental health conditions, OR 6.2 (95% CI 5.8 to 6.6) for physical disability and OR 2.6 (95% CI 2.5 to 2.8) for other condition. Contrary to findings within the general population, female gender predicted all conditions within the population with reported autism, including intellectual disabilities (OR=1.4).

Conclusions

Clinicians need heightened awareness of comorbidities in adults with autism to improve detection and suitable care, especially given the added complexity of assessment in this population and the fact that hearing and visual impairments may cause additional difficulties with reciprocal communication which are also a feature of autism; hence posing further challenges in assessment.

https://ift.tt/2N5Ba2k

Rare association of tetralogy of Fallot with absent pulmonary valve syndrome with anomalous origin of right pulmonary artery from ascending aorta

Description 

A 2-month-old boy presented to the paediatric cardiology department with cyanosis and feeding difficulties. Chest radiograph revealed cardiomegaly, right-sided aortic knuckle and dilated pulmonary artery segment along with mild indentation on the lower trachea and diffusely narrowed left main bronchus (figure 1A). A diagnosis of tetralogy of Fallot (TOF) with absent pulmonary valve syndrome was made on transthoracic echocardiogram; however, origin of right pulmonary artery (RPA) was not well visualised. The patient further underwent CT angiography (CTA) to delineate the cardiac as well as any extracardiac abnormalities.

Figure 1

Frontal chest radiograph (A) reveals cardiomegaly, right-sided aortic knuckle and dilated pulmonary artery segment along with mild indentation on the lower trachea and diffusely narrowed left main bronchus. Sagittal oblique maximum intensity projection (B) shows presence of features of tetralogy of Fallot, that is, right ventricular hypertrophy, perimembranous ventricular septal defect and pulmonary annular stenosis....

https://ift.tt/2N9Npea

Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis

Despite being straightforward to collect and key to providing patient-centred, individualised care, the routine use of patient reported outcome measures (PROMs) remains limited in the National Health Service. Herein is described the case of a 69-year-old woman who presented to secondary care with osteoarthritis. Web-based PROMs were used to track the patient's symptoms and function. Lifestyle changes were recommended to manage the osteoarthritis. Monitoring enabled the patient to take control of her disease management. Two years later, she continues to manage her knee symptoms conservatively, recording progress by using a web-based system. This case illustrates how web-based PROMs can be used to support conservative management of knee osteoarthritis by both empowering patients and minimising the burden on secondary care outpatient services.

https://ift.tt/2Cjf1tp

New endoscopic technique for retrieval of large colonic foreign bodies and an endoscopy-oriented review of the literature

Colorectal foreign bodies (FB) are challenging issues for the endoscopist especially if the mostly used methods (polypectomy snare, biopsy forceps or wire-guided 40 mm dilation balloon) failed. We report a case of a 31-year-old man who was admitted in the emergency department for the impaction of a 60 cm long and large-size FB in the sigmoid colon. We failed to remove the FB using several different standard technique because of the rigidity, the smoothness and the size of the object. After all these attempts, we built up a 'home-made' device inserting a 0.035 inch non-hydrophilic guidewire (Metro WireGuide, Cook Medical) doubled into an 8.5 Fr stent-pusher-catheter (Cook Medical) serving as an outer sheet in order to create a noose and we finally succeeded in the endoscopic extraction of the device. We suggest this new technique as a valid option to remove large FBs from the colon and rectum when standard endoscopic methods for FB's extraction fail.

https://ift.tt/2PSid1P

Acute regrowth and dissemination of a mature spinal cord teratoma after partial resection

A 23-year-old man presented with difficulty walking and leg pain and numbness. MRI revealed a cystic mass at Th11–12 and a pineal-region tumour. The patient underwent surgery to resect the thoracic-level mass. The tumour adhered strongly to the neural tissue and could only be partially resected. On pathological examination, the resected tumour was diagnosed as a mature teratoma. The tumour regrew and disseminated within 3 months after resection. Both the spinal cord tumour and the tumour in the pineal region shrank significantly after chemotherapy and radiotherapy. Although the tumour was pathologically diagnosed as a mature teratoma, we suspect that the residual tumour contained an immature or malignant component. Thus, careful follow-up observation is mandatory after partial resection of a mature teratoma. In addition, because teratomas can disseminate in the central nervous system, the presence of teratoma should prompt an examination of both the spinal cord and brain.

https://ift.tt/2C78fqb

Correction: Spontaneous ovarian heterotopic pregnancy

Stanley R, Nair A, Fiallo F. Spontaneous ovarian heterotopic pregnancy. BMJ Case Rep 2018.doi: 10.1136/bcr-2018-225619 [Epub ahead of print 9 Aug 2018].

This article contains an error in the authors list. The correct order of authors is:

Russell Stanley, Francisco Fiallo, and Anjana Nair.

https://ift.tt/2N5rTY2

The changing face of cancer treatments

This case demonstrates the effectiveness and ongoing potential of novel lung cancer therapies, specifically immunotherapy agents such as nivolumab, a T-cell programmed death 1 (PD-1) receptor inhibitor. In this case study, our patient had a significant burden of disease with nodal involvement above and below the diaphragm at the time of diagnosis. They were commenced on standard of care therapy: cisplatin and pemetrexed. Despite five cycles of treatment with these agents, their disease progressed significantly with the development of brain metastasis. The patient was switched to a novel immunotherapy agent, nivolumab, and had a complete response to it. Currently, there is no active disease—the lymph nodes have all regressed, the brain metastases have disappeared (with the help of stereotactic surgery) and no further metastases have developed. The patient is tolerating the treatment well and has had no significant adverse reactions to the immunotherapy agent.

https://ift.tt/2NCaH9v

Rapidly growing cardiac tumour in the right ventricle

Description 

A 77-year-old man with a history of Her2 negative, pancytokeratin-positive gastric cancer and synchronous grade 3a stage 2a follicular lymphoma (FLIPI score 3 at presentation) treated with chemotherapy was referred for transthoracic echocardiography (TTE) after a CT of the abdomen demonstrated an incidental low-density lesion in the right ventricle (RV) concerning for malignancy or thrombus. There was no mass present on TTE 2 months prior. Repeat TTE (figure 1) demonstrated a large echogenic mass causing right ventricular inflow and outflow tract (RVOT) obstruction. A cardiac MRI (figure 2) confirmed the presence of a heterogeneous mass with adherent superficial thrombus in the RV and extending into the RVOT, consistent in appearance with a tumour. On further review, a PET/CT performed 1 month prior to presentation showed a hypermetabolic node at the RV apex (maximum Standardized Uptake Value 5.7) felt to represent an initial metastatic focus, with...

https://ift.tt/2PWfnc4

Klebsiella oxytoca tricuspid valve endocarditis in an elderly patient without known predisposing factors

A 73-year-old man with history of nephrolithiasis was admitted after a witnessed cardiac arrest. In the emergency department, the patient had several runs of ventricular fibrillation treated with defibrillation and amiodarone infusion. Echocardiography revealed reduced ejection fraction with multiple mobile structures attached to the tricuspid valve leaflets. Due to concern for possible endocarditis, the patient was started on broad-spectrum antibiotics. On the following day, a renal ultrasound was performed for acute kidney injury followed by a non-contrast CT scan that revealed an obstructing 21 mm left-sided ureteral stone with pyohydronephrosis. He underwent emergent nephrostomy tube placement. Blood and urine cultures subsequently demonstrated the growth of Klebsiella oxytoca. A follow-up transoesophageal echocardiogram confirmed multiple mobile, hyperechoic masses consistent with vegetations. The suspected source for the endocarditis was from the pyelonephritis. The patient's clinical condition improved after a course of intravenous antibiotics and was discharged on oral antibiotics.

https://ift.tt/2C783qX

Pathological complete response in pancreatic adenocarcinoma with FOLFIRINOX

The report describes a patient who presented to our centre with abdominal pain and significant weight loss due to adenocarcinoma of the tail of the pancreas. The cancer was deemed as 'resectable disease associated with morbid surgical outcomes' due to the local involvement of the vessels and adjacent organs. Given the patient's excellent performance status, the patient underwent neoadjuvant chemotherapy with folinic acid, fluorouracil, irinotecan and oxaliplatin to downstage the tumour for less morbid surgical resection. The patient underwent 12 cycles of chemotherapy with serial imaging which demonstrated positive response to treatment and surgical resection was performed. Surgical pathology revealed no residual tumour and imaging was negative for any extrapancreatic tumour metastasis. This is an unusual case as pancreatic malignancy is usually lethal with poor survival outcomes.

https://ift.tt/2wyYZW1

Oesophageal narrowing during combination chemotherapy in Ewings sarcoma: Is vincristine a culprit?

Vincristine is a widely used chemotherapeutic agent in paediatric oncology. A 7-year-old boy was diagnosed with non-metastatic Ewing's sarcoma of the pelvis. He was started on chemotherapy with vincristine–cyclophosphamide–adriamycin alternate with ifosfamide–etoposide. He developed recurrent vomiting after three cycles of chemotherapy. Evaluation showed oesophageal stricture involving the middle and lower third part. Biopsy was non-conclusive. His symptoms improved with dilatation. A chemotherapy-induced neuropathic dysmotility was suspected, and his chemotherapy was continued with serial dilatation. Vincristine, being neurotoxic, was suspected to be the reason of this morbidity. His need of dilatation decreased, and symptoms improved remarkably after completion of chemotherapy.

Vincristine-induced oesophageal dysmotility is a rare side effect. There is no consensus on management. Omission of this effective agent in such situation is debatable.

https://ift.tt/2Q0W2qe

Simultaneous occurrence of hepatic hydatid cyst and mucinous cystadenoma of the liver in a middle-aged female patient: report of a rare case

We present a rare case of simultaneous occurrence of mucinous cystadenoma of the liver (MCN-L) and a hepatic hydatid cyst (HD-L) in a middle-aged female patient. This is the first case report of a common disease (HD-L) and a rare condition (MCN-H) occurring concurrently. MCN-H of the left lobe was inadequately resected in a rural centre leading to recurrence. She presented with a large upper abdominal lump and upper gastrointestinal symptoms. Radiological investigations and an ultrasound revealed a multilobulated cyst involving both lobes of the liver. There was no ascites. Liver function, basic haematology and renal function were normal. The recurrent MCN-L was removed totally. There was no communication between the MCN-L and the right lobe cyst, which turned out to be a hydatid cyst. The hydatid cyst was evacuated. She was discharged on albendazole and is asymptomatic with no recurrence at 8 months.

https://ift.tt/2wAZxdU

Mitotane-induced dyspnoea: an unusual side effect

Mitotane is a cytostatic antineoplastic agent that is used in the treatment of adrenocortical carcinoma and Cushing's syndrome. The commonly reported side effects associated with mitotane are anorexia, nausea, vomiting, diarrhoea, decreased memory, rash, gynaecomastia, arthralgias and leucopenia. We present a case of a 68-year-old female who developed gradual dyspnoea concurrent with the use of mitotane for the treatment of adrenocortical carcinoma. To the best of our knowledge and literate review, this is the first reported case of dyspnoea associated with the use of this medication. The purpose of this case report is to raise awareness about this uncommon adverse effect of mitotane that may have gone unrecognised on postmarketing surveillance because of under-reporting, lack of case follow-up or other comorbidities masking shortness of breath.

https://ift.tt/2MDN8AR

NUT carcinoma: a rare and devastating neoplasm

Description 

A 45-year-old woman with no significant medical history had 1 month of productive cough empirically treated with azithromycin and dyspnoea on exertion. She was never a smoker and denied any constitutional symptoms, including unexpected weight loss. A CT of the chest was performed after she developed haemoptysis, which demonstrated a 6.3x4.6 cm right hilar mass with hilar, subcarinal and cardiophrenic adenopathy (figure 1A). She underwent bronchoscopy which revealed complete occlusion of the right middle lobe by a tumour extending into the bronchus intermedius. Debridement of this mass was performed, with re-establishment of airway patency to the right lower lobe. Pathology from the debrided tumour as well as the subcarinal lymph node was consistent with poorly differentiated non-small cell lung carcinoma with Thyroid Transcription Factor 1 (TTF-1) and Programmed Death-Ligand 1 (PD-L1) negativity. Due to high clinical suspicion, the tissue samples were transferred to another facility for additional assessment. MRI...

https://ift.tt/2wA14kt

Cancers, Vol. 10, Pages 300: Targeted UPLC-MS Metabolic Analysis of Human Faeces Reveals Novel Low-Invasive Candidate Markers for Colorectal Cancer

Cancers, Vol. 10, Pages 300: Targeted UPLC-MS Metabolic Analysis of Human Faeces Reveals Novel Low-Invasive Candidate Markers for Colorectal Cancer

Cancers doi: 10.3390/cancers10090300

Authors: Joaquin Cubiella Marc Clos-Garcia Cristina Alonso Ibon Martinez-Arranz Miriam Perez-Cormenzana Ziortza Barrenetxea Jesus Berganza Isabel Rodríguez-Llopis Mauro D'Amato Luis Bujanda Marta Diaz-Ondina Juan M. Falcón-Pérez

Low invasive tests with high sensitivity for colorectal cancer and advanced precancerous lesions will increase adherence rates, and improve clinical outcomes. We have performed an ultra-performance liquid chromatography/time-of-flight mass spectrometry (UPLC-(TOF) MS)-based metabolomics study to identify faecal biomarkers for the detection of patients with advanced neoplasia. A cohort of 80 patients with advanced neoplasia (40 advanced adenomas and 40 colorectal cancers) and 49 healthy subjects were analysed in the study. We evaluated the faecal levels of 105 metabolites including glycerolipids, glycerophospholipids, sterol lipids and sphingolipids. We found 18 metabolites that were significantly altered in patients with advanced neoplasia compared to controls. The combinations of seven metabolites including ChoE(18:1), ChoE(18:2), ChoE(20:4), PE(16:0/18:1), SM(d18:1/23:0), SM(42:3) and TG(54:1), discriminated advanced neoplasia patients from healthy controls. These seven metabolites were employed to construct a predictive model that provides an area under the curve (AUC) median value of 0.821. The inclusion of faecal haemoglobin concentration in the metabolomics signature improved the predictive model to an AUC of 0.885. In silico gene expression analysis of tumour tissue supports our results and puts the differentially expressed metabolites into biological context, showing that glycerolipids and sphingolipids metabolism and GPI-anchor biosynthesis pathways may play a role in tumour progression.

https://ift.tt/2MJY6Vy

Cancers, Vol. 10, Pages 302: Regulation of Ovarian Cancer Prognosis by Immune Cells in the Tumor Microenvironment

Cancers, Vol. 10, Pages 302: Regulation of Ovarian Cancer Prognosis by Immune Cells in the Tumor Microenvironment

Cancers doi: 10.3390/cancers10090302

Authors: Drakes Stiff

It is estimated that in the United States in 2018 there will be 22,240 new cases of ovarian cancer and 14,070 deaths due to this malignancy. The most common subgroup of this disease is high-grade serous ovarian cancer (HGSOC), which is known for its aggressiveness, high recurrence rate, metastasis to other sites, and the development of resistance to conventional therapy. It is important to understand the ovarian cancer tumor microenvironment (TME) from the viewpoint of the function of pre-existing immune cells, as immunocompetent cells are crucial to mounting robust antitumor responses to prevent visible tumor lesions, disease progression, or recurrence. Networks consisting of innate and adaptive immune cells, metabolic pathways, intracellular signaling molecules, and a vast array of soluble factors, shape the pathogenic nature of the TME and are useful prognostic indicators of responses to conventional therapy and immunotherapy, and subsequent survival rates. This review highlights key immune cells and soluble molecules in the TME of ovarian cancer, which are important in the development of effective antitumor immunity, as well as those that impair effector T cell activity. A more insightful knowledge of the HGSOC TME will reveal potential immune biomarkers to aid in the early detection of this disease, as well as biomarkers that may be targeted to advance the design of novel therapies that induce potent antitumor immunity and survival benefit.

https://ift.tt/2wFJc82

Cancers, Vol. 10, Pages 301: HIV-1 Envelope Protein gp120 Promotes Proliferation and the Activation of Glycolysis in Glioma Cell

Cancers, Vol. 10, Pages 301: HIV-1 Envelope Protein gp120 Promotes Proliferation and the Activation of Glycolysis in Glioma Cell

Cancers doi: 10.3390/cancers10090301

Authors: Gabriel Valentín-Guillama Sheila López Yuriy V. Kucheryavykh Nataliya E. Chorna Jose Pérez Jescelica Ortiz-Rivera Michael Inyushin Vladimir Makarov Aníbal Valentín-Acevedo Alfredo Quinones-Hinojosa Nawal Boukli Lilia Y. Kucheryavykh

Patients infected with human immunodeficiency virus (HIV) are more prone to developing cancers, including glioblastomas (GBMs). The median survival for HIV positive GBM patients is significantly shorter than for those who are uninfected, despite the fact that they receive the same treatments. The nature of the GBM&ndash;HIV association remains poorly understood. In this study, we analyzed the effect of the HIV envelope glycoprotein gp120 on GBM cell proliferation. Specifically, we performed cell cycle, western blot, protein synthesis and metabolomics analysis as well as ATP production and oxygen consumption assays to evaluate proliferation and metabolic pathways in primary human glioma cell line, U87, A172 cells and in the HIVgp120tg/GL261 mouse model. Glioma cells treated with gp120 (100 ng/mL for 7&ndash;10 days) showed higher proliferation rates and upregulation in the expression of enolase 2, hexokinase and glyceraldehyde-3-phosphate dehydrogenase when compared to untreated cells. Furthermore, we detected an increase in the activity of pyruvate kinase and a higher glycolytic index in gp120 treated cells. Gp120 treated GBM cells also showed heightened lipid and protein synthesis. Overall, we demonstrate that in glioma cells, the HIV envelope glycoprotein promotes proliferation and activation of glycolysis resulting in increased protein and lipid synthesis.

https://ift.tt/2MFQ9kj

Cancers, Vol. 10, Pages 303: Cerium Oxide Nanoparticles Sensitize Pancreatic Cancer to Radiation Therapy through Oxidative Activation of the JNK Apoptotic Pathway

Cancers, Vol. 10, Pages 303: Cerium Oxide Nanoparticles Sensitize Pancreatic Cancer to Radiation Therapy through Oxidative Activation of the JNK Apoptotic Pathway

Cancers doi: 10.3390/cancers10090303

Authors: Melissa S. Wason Heng Lu Lin Yu Satadru K. Lahiri Debarati Mukherjee Chao Shen Soumen Das Sudipta Seal Jihe Zhao

Side effects of radiation therapy (RT) remain the most challenging issue for pancreatic cancer treatment. Cerium oxide nanoparticles (CONPs) are currently being tested in pre-clinical trials as an adjuvant to sensitize pancreatic cancer cells to RT and protect normal tissues from the harmful side effects. CONPs were not able to significantly affect RT-induced DNA damage in cancer cells, thereby ruling out sensitization through increased mitotic catastrophe. However, activation of c-Jun terminal kinase (JNK), a key driver of RT-induced apoptosis, was significantly enhanced by co-treatment with CONPs and RT in pancreatic cancer cells in vitro and human pancreatic tumors in nude mice in vivo compared to CONPs or RT treatment alone. Further, CONP-driven increase in RT-induced JNK activity was associated with a marked increase in Caspase 3/7 activation, indicative of apoptosis. We have previously shown that CONPs increase reactive oxygen species (ROS) production in cancer cells. ROS has been shown to drive the oxidation of thioredoxin 1 (TRX1) which results in the activation of apoptosis signaling kinase 1 (ASK1). The increase in ASK1 activation following the co-treatment with CONPs followed by RT suggests that the increased JNK activation is the result of increased TRX1 oxidation. The ability of CONPs to sensitize pancreatic cancer cells to RT was mitigated when the TRX1 oxidation was prevented by mutagenesis of a cysteine residue or when the JNK activation was blocked by an inhibitor. Taken together, these data demonstrate an important mechanism for CONPs in specifically killing cancer cells and provide novel insights into the utilization of CONPs as a radiosensitizer and therapeutic agent for pancreatic cancer.

https://ift.tt/2wBOBgg

Hardware removal or preservation? Decision making based on a newly developed rating scale

Publication date: Available online 31 August 2018

Source: Injury

Author(s): Yong Zhao, Bai-wen Qi, Yao-qing Wang, Di Liu, Fan Chen, Zhen Huang, Zhen-yu Pan

Abstract

Hardware exposure following open reduction and internal fixation(ORIF) surgery is a tricky problem. It is always hard for surgeons to decide whether to keep or remove the hardware. In this study, a rating scale and corresponding clinical path is developed based on former published paper as well as our own experience. New admitted patients are first evaluated and scored once they enter the department. Based on the score they get, patients are assigned to different therapeutic schedule, i.e. 1) hardware preservation with pedicel flap transplantation, 2) debridement for further reevaluation and 3) hardware removal with external fixation. Satisfying clinical outcome is achieved that is characterized with high osseous consolidation rate and low complication rate. The result showed that this newly developed rating scale and the related therapeutic schedule could be an available tool to help surgeons to make decisions in the treatment of hardware exposure.

https://ift.tt/2osTTXz

Scleral buckling in the management of rhegmatogenous retinal detachment: patient selection and perspectives

https://ift.tt/2PqlrII

Effect of quantitative intraocular pressure reduction on visual field defect progression in normal tension glaucoma under medical therapy applying Markov model

https://ift.tt/2ouPTGd

Selective laser trabeculoplasty vs micropulse laser trabeculoplasty in open-angle glaucoma

https://ift.tt/2wEzBxY

Cancers, Vol. 10, Pages 298: Rare Genetic Diseases with Defects in DNA Repair: Opportunities and Challenges in Orphan Drug Development for Targeted Cancer Therapy

Cancers, Vol. 10, Pages 298: Rare Genetic Diseases with Defects in DNA Repair: Opportunities and Challenges in Orphan Drug Development for Targeted Cancer Therapy

Cancers doi: 10.3390/cancers10090298

Authors: Sonali Bhattacharjee Saikat Nandi

A better understanding of mechanistic insights into genes and enzymes implicated in rare diseases provide a unique opportunity for orphan drug development. Advances made in identification of synthetic lethal relationships between rare disorder genes with oncogenes and tumor suppressor genes have brought in new anticancer therapeutic opportunities. Additionally, the rapid development of small molecule inhibitors against enzymes that participate in DNA damage response and repair has been a successful strategy for targeted cancer therapeutics. Here, we discuss the recent advances in our understanding of how many rare disease genes participate in promoting genome stability. We also summarize the latest developments in exploiting rare diseases to uncover new biological mechanisms and identify new synthetic lethal interactions for anticancer drug discovery that are in various stages of preclinical and clinical studies.

https://ift.tt/2PmLjoP

Cancers, Vol. 10, Pages 299: Metabolic Syndrome and the Risk of Breast Cancer and Subtypes by Race, Menopause and BMI

Cancers, Vol. 10, Pages 299: Metabolic Syndrome and the Risk of Breast Cancer and Subtypes by Race, Menopause and BMI

Cancers doi: 10.3390/cancers10090299

Authors: Daniel T. Dibaba Dejana Braithwaite Tomi Akinyemiju

The objective of this study was to investigate the association of metabolic syndrome (MetS) with the risk of invasive breast cancer and molecular subtypes across race, menopause, and body mass index (BMI) groups. We examined the association of metabolic syndrome and its components with risk of invasive breast cancer among 94,555 female participants of the National Institute of Health-American Association of Retired Persons (NIH-AARP) Diet and Health Study, accounting for ductal carcinoma in situ as a competing risk. Cox proportional hazard regression with the Fine and Gray method was used to generate hazard ratios (HR) and 95% confidence intervals (CI) adjusting for baseline sociodemographic, behavioral, and clinical covariates. During a mean follow-up of 14 years, 5380 (5.7%) women developed breast cancer. Overall, MetS at baseline was associated with a 13% increased risk of breast cancer compared to women without MetS (HR: 1.13, 95% CI: 1.00, 1.27); similar estimates were obtained among postmenopausal women (HR: 1.14, 95% CI: 1.01, 1.29). MetS was associated with a slight but non-significantly increased risk of breast cancer among those with both normal weight and overweight/obesity, and those with estrogen receptor positive breast cancer subtype. In the NIH-AARP cohort, MetS was associated with an increased risk of breast cancer. Further studies are needed to definitively evaluate the association of MetS with triple negative breast cancer subtypes across all levels of BMI.

https://ift.tt/2otTW5q

Cancers, Vol. 10, Pages 297: The p53 Pathway in Glioblastoma

Cancers, Vol. 10, Pages 297: The p53 Pathway in Glioblastoma

Cancers doi: 10.3390/cancers10090297

Authors: Ying Zhang Collin Dube Myron Gibert Nichola Cruickshanks Baomin Wang Maeve Coughlan Yanzhi Yang Initha Setiady Ciana Deveau Karim Saoud Cassandra Grello Madison Oxford Fang Yuan Roger Abounader

The tumor suppressor and transcription factor p53 plays critical roles in tumor prevention by orchestrating a wide variety of cellular responses, including damaged cell apoptosis, maintenance of genomic stability, inhibition of angiogenesis, and regulation of cell metabolism and tumor microenvironment. TP53 is one of the most commonly deregulated genes in cancer. The p53-ARF-MDM2 pathway is deregulated in 84% of glioblastoma (GBM) patients and 94% of GBM cell lines. Deregulated p53 pathway components have been implicated in GBM cell invasion, migration, proliferation, evasion of apoptosis, and cancer cell stemness. These pathway components are also regulated by various microRNAs and long non-coding RNAs. TP53 mutations in GBM are mostly point mutations that lead to a high expression of a gain of function (GOF) oncogenic variants of the p53 protein. These relatively understudied GOF p53 mutants promote GBM malignancy, possibly by acting as transcription factors on a set of genes other than those regulated by wild type p53. Their expression correlates with worse prognosis, highlighting their potential importance as markers and targets for GBM therapy. Understanding mutant p53 functions led to the development of novel approaches to restore p53 activity or promote mutant p53 degradation for future GBM therapies.

https://ift.tt/2PrsDEf

Treating Diffuse Large B Cell Lymphoma in the Very Old or Frail Patients

Opinion statement

R-CHOP has been the standard of care for diffuse large B cell lymphoma (DLBCL), curing approximately 60% of patients for more than 2 decades. However, the optimal treatment of patients who are too frail to tolerate this regimen and/or are not candidates for anthracycline therapy continues to be debated. MInT and GELA trials established addition of rituximab to CHOP in DLBCL but excluded patients older than 80 years. Multiple regimens have been tried with varying success in the very elderly, including R-mini-CHOP, R-mini CEOP, R-split CHOP, pre-phase strategies, and R-GCVP. However, there has not been a randomized trial among these strategies. Although addition of novel agents including ibrutinib, brentuximab vedotin, lenalidomide, and many others on the horizon holds promise in this population, none have been tested in a randomized setting or have results awaited. There is also a lack of a validated and easy to use clinical tool in this population to predict patients who will not tolerate R-CHOP. Identifying patients who will not tolerate R-CHOP early with the help of tools like CGA, along with integrating biology-based treatment (ibrutinib, lenalidomide in activated B cell type DLBCL) is being investigated in this population.

https://ift.tt/2wyamhQ

Metastatic Colorectal Cancer to the Peritoneum: Current Treatment Options

Opinion statement

Peritoneal metastases (PM) are common in advanced-stage colorectal cancer (CRC) patients representing the second most common metastatic site of CRC. In the past, this clinical situation was treated with palliative intent. The introduction of new chemotherapeutic and targeted biologic agents has improved the prognosis of patients with metastatic colorectal cancer. However, the inclusion of treatment options such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as inherent components of a multidisciplinary treatment was evolving for the management of these patients. Notably, the surgical approach of CRS/HIPEC has been effective offering a prolonged survival with curative intent in patients with colorectal PM. This article reviews and highlights the recent evidence of CRS and HIPEC as well as current research going on in this form of locoregional treatment in the setting of peritoneal metastases of colorectal cancer.

https://ift.tt/2PviSoX

Predictive potential and need for standardization of PD-L1 immunohistochemistry

Abstract

Checkpoint inhibitors targeting the PD-1/PD-L1 axis are a promising treatment option in several tumor types. PD-L1 expression detected by immunohistochemistry is the first clinically validated predictive biomarker for response to PD-1/PD-L1 inhibitors, though its predictive value varies significantly between tumor types. With the approval of pembrolizumab monotherapy for treatment-naïve, advanced non-small cell lung cancer, PD-L1 testing has to become broadly available in pathology laboratories. When PD-L1 testing started to be introduced in routine pathology practice, there were several open issues, which needed to be addressed in order to provide accurate results. This review will discuss the complex biological background of PD-L1 as predictive biomarker, summarize relevant clinical trials in NSCLC illustrating the origin of different PD-L1 expression cutoffs and scorings, and address issues important for PD-L1 testing including the analytical comparability of the different clinical trial-validated PD-L1 immunohistochemistry assays, the potential of laboratory-developed tests, and an overview of the different scoring algorithms.

https://ift.tt/2LJKjZz

Adjuvant treatment for high-risk renal-cell carcinoma: the jury is still out

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Bile Acids, the Microbiome, Immunity, and Liver Tumors

Hepatocellular carcinoma is among the leading causes of tumor-related death, and the liver is among the most common sites of cancer metastasis. Several types of immune cells surveil the liver to detect and kill premalignant and malignant cells and to prevent the development of cancer. At the…

https://ift.tt/2NCFzXF

Digesting New Developments in Biosensors

The inner workings of the human body are largely invisible to the unaided eye, which is possibly why, in the era of the "quantified self," the instinct to measure them is almost impossible to resist. Of course, millions of Americans have tried (and most have abandoned) using wearable devices that…

https://ift.tt/2C7JxpN

Clinical Course and Management of Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM), the most common monogenic cardiovascular disorder, is diverse in presentation and natural history, frequently misunderstood, and often underrecognized in clinical practice. A comprehensive clinical description of the disease was first made 55 years ago by the…

https://ift.tt/2PWxSgj

Clinical Course and Management of Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM), the most common monogenic cardiovascular disorder, is diverse in presentation and natural history, frequently misunderstood, and often underrecognized in clinical practice. A comprehensive clinical description of the disease was first made 55 years ago by the…

https://ift.tt/2PWxSgj

Labor Induction versus Expectant Management in Low-Risk Nulliparous Women

Recommendations regarding the timing of delivery are founded on a balancing of maternal and perinatal risks. Delivery before 39 weeks 0 days of gestation without medical indication is associated with worse perinatal outcomes than delivery at full term. For women who are at 41 weeks of gestation or…

https://ift.tt/2PpdeUW

Opioid Prescribing Limits for Acute Pain — Striking the Right Balance

U.S. legislators have recently unveiled numerous bills aimed at combating the opioid epidemic through prevention, harm-reduction, and treatment measures. One of them, the Comprehensive Addiction and Recovery Act (CARA) 2.0, was a bipartisan proposal advancing several evidence-based strategies,…

https://ift.tt/2CdUuWK

Anesthesia in a Patient with a Large Mediastinal Mass

To the Editor: Large mediastinal masses increase the risks associated with general anesthesia. The most feared complication is airway collapse, which precludes ventilation despite intubation. There is limited understanding of the dynamic behavior of extrinsically compressed airways during…

https://ift.tt/2N8DeXd

Early warning scores in the perioperative period: applications and clinical operating characteristics

Purpose of review Early warnings scores are designed to detect clinical deterioration and promote intervention at the earliest possible moment. Although the ultimate effects on patient outcomes are unclear, early warning scores are now legally mandated in several countries. Here, we review the performance of early warning scores in surgical and perioperative populations. Recent findings Early warning scores can be used to screen for postoperative deterioration and surgical complications. We describe a framework to evaluate the balance between missed events and warning signals that are not followed by an adverse event (nonevents). In large surgical cohort studies, the missed event rates ranged between 19 and 69% and the nonevent rates ranged between 72 and 99% for 'optimal' threshold early warning sores. Recent investigations have shown that there may be a substantial discrepancy between the theoretical benefits shown in validation studies and the practical clinical implementation of early warning scores, which may partly explain the absence of measurable benefit from these systems. Summary Early warning scores may facilitate protocolized escalation of care for patients at risk of adverse events and can be used in surgical and postoperative patients, but high nonevent rates and practical implementation problems can restrict their usefulness. Correspondence to Harm-Jan de Grooth, MD, Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands. Tel: +31 6 46 37 15 07; e-mail: h.degrooth@vumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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What we can learn from Big Data about factors influencing perioperative outcome

Purpose of review This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. Recent findings The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. Summary Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising. Correspondence to Jurgen C. de Graaff, MD, Department of Anesthesiology, Medical Center, SB-3646, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 10 704 34964; e-mail: j.degraaff@erasmusmc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2N5ehvU

Perioperative cognitive evaluation

Purpose of review This article reviews the recent clinical evidence published between January 2017 and June 2018 – related to perioperative cognitive evaluation. Namely, new insights into risk factors, prevention, diagnosis and diagnostic tools and treatment. Recent findings Several risk factors (preoperative, intraoperative and postoperative) have been found to be associated with the development of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). Short-term and long-term postoperative consequences can be reduced by targeting risk factors, introducing preventive strategies and including frequent cognitive monitoring. Administration of medications such as ketamine, opioids and benzodiazepines are associated with increased cognitive dysfunction. Prevention of POD/POCD starts with creating an environment, which promotes return to preoperative baseline functioning. This includes frequent monitoring of cognitive status, access to rehabilitation and psychological and social supports, and avoiding polypharmacy. In addition, patients should have early access to their sensory aids and maintain normal circadian rhythm. Treatment of POD/POCD has pharmacological and nonpharmacological approaches. Summary Clinical evidence on POD/POCD is continuously evolving, which is essential in guiding clinical management to provide the highest quality of clinical care. Correspondence to Federico Bilotta, MD, PhD, Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University, Rome, Italy. Tel: +39 6 8608273; fax: +39 6 8608273; e-mail: bilotta@tiscali.it Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2PkB5VO

Correction to: An in vitro and in vivo study of the combination of the heat shock protein inhibitor 17-allylamino-17-demethoxygeldanamycin and carboplatin in human ovarian cancer models

The corresponding author of this article has informed us of concerns about the immunoblots in Fig. 2 which were carried out in the collaborating laboratory of Professor Ann Jackman.

https://ift.tt/2otm1d9

Healthcare professionals’ level of medication knowledge in Africa: A systematic review

British Journal of Clinical Pharmacology, Volume 0, Issue ja, -Not available-.


https://ift.tt/2NCWtW2

Cancers, Vol. 10, Pages 296: Heated Intraperitoneal Chemotherapy in the Management of Advanced Ovarian Cancer

Cancers, Vol. 10, Pages 296: Heated Intraperitoneal Chemotherapy in the Management of Advanced Ovarian Cancer

Cancers doi: 10.3390/cancers10090296

Authors: Andrea Jewell Megan McMahon Dineo Khabele

Heated intraperitoneal chemotherapy (HIPEC) has several potential benefits. Higher doses of chemotherapy can be used with HIPEC because the plasma-peritoneal barrier results in little absorption into the blood stream. HIPEC offers higher peritoneal penetration in comparison to an intravenous (IV) regimen and does not have the traditional normothermic intraperitoneal (IP) regimen limitation of post-operative adhesions. Hyperthermia itself has cytotoxic effects and can potentiate antineoplastic effects of chemotherapy in part by increasing the depth of tumor penetration by up to 3 mm. For the treatment of ovarian cancer, HIPEC has been evaluated in the recurrent setting with secondary cytoreduction. Recent studies, including a prospective trial, have evaluated its role in primary management of ovarian cancer. This review summarizes previous and ongoing studies regarding the use of HIPEC in the management of ovarian cancer.

https://ift.tt/2NG2a5I

Preoperative Salivary Cortisol AM/PM Ratio Predicts Early Postoperative Cognitive Dysfunction After Noncardiac Surgery in Elderly Patients

BACKGROUND: The diagnosis of postoperative cognitive dysfunction (POCD) requires complicated neuropsychological testing and is often delayed. Possible biomarkers for early detection or prediction are essential for the prevention and treatment of POCD. Preoperative screening of salivary cortisol levels may help to identify patients at elevated risk for POCD. METHODS: One hundred twenty patients >60 years of age and undergoing major noncardiac surgery underwent neuropsychological testing 1 day before and 1 week after surgery. Saliva samples were collected in the morning and the evening 1 day before surgery. POCD was defined as a Z-score of ≤−1.96 on at least 2 different tests. The primary outcome was the presence of POCD. The primary objective of this study was to assess the relationship between the ratio of AM (morning) to PM (evening) salivary cortisol levels and the presence of POCD. The secondary objective was to assess the relationship between POCD and salivary cortisol absolute values in the morning or in the evening. RESULTS: POCD was observed in 17.02% (16 of 94; 95% confidence interval [CI], 9.28%–24.76%) of patients 1 week after the operation. A higher preoperative AM/PM salivary cortisol ratio predicted early POCD onset (odds ratio [OR], 1.56; 95% CI, 1.20–2.02; P = .001), even after adjusting for the Mini-Mental Sate Examination score (odds ratio, 1.55; 95% CI, 1.19–2.02; P = .001). The area under the receiver operating characteristic curve for the salivary cortisol AM/PM ratio in individuals with POCD was 0.72 (95% CI, 0.56–0.88; P = .006). The optimal cutoff value was 5.69, with a sensitivity of 50% and specificity of 91%. CONCLUSIONS: The preoperative salivary cortisol AM/PM ratio was significantly associated with the presence of early POCD. This biomarker may have potential utility for screening patients for an increased risk and also for further elucidating the etiology of POCD. Accepted for publication July 18, 2018. Funding: Supported by the National Natural Science Foundation of China (81720108013, 81571059); Jiangsu Provincial Special Program of Medical Science (BL2014029); Scientific Research Innovation Project for Graduate Students of Jiangsu Universities, Jiangsu, China (SJZZ16_0290); and China Postdoctoral Science Foundation Funded Project (Project No: 2015M580473). 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 (https://ift.tt/KegmMq). Y. Han, L. Han, and M.-M. Dong contributed equally to this work and share first authorship. Reprints will not be available from the authors. Address correspondence to Jun-Li Cao, MD, PhD, Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai Rd, Quanshan District, Xuzhou City 221002, Jiangsu Province, China. Address e-mail to caojl0310@aliyun.com. © 2018 International Anesthesia Research Society

https://ift.tt/2ouybTe

A Prospective Observational Cohort Study of Calls for Help in a Tertiary Care Academic Operating Room Suite

While significant literature exists on hospital-based "code calls," there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1–1.8), corresponding to a rate of 5.0 (3.8–6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR. Accepted for publication June 11, 2018. 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 (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Cameron J. Ricks, MD, Department of Anesthesiology and Perioperative Care, University of California, Irvine School of Medicine, 333 The City Blvd W, Suite 2150, Orange, CA 92868. Address e-mail to cricks@uci.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2LLVu43

Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents

BACKGROUND: Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Secondgeneration drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS: The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS: A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0.90, 91–180, 181–365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0–90 days and 3.4 (0.8 to 15.3) at 91–180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS: The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT. Accepted for publication March 9, 2018. 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 (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Gregory A. Nuttall, MD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Address e-mail to Gnuttall@mayo.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2wzzsg9

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial

BACKGROUND: Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. METHODS: This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 and 10 μg/kg or an equal volume of saline. RESULTS: Visual analog scale scores were significantly better (P2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P

https://ift.tt/2LLMlbR

Caution in Using Gadolinium-Based Contrast Agents in Interventional Pain Procedures

No abstract available

https://ift.tt/2ouzDVO

Reversal of Deep Pipecuronium-Induced Neuromuscular Block With Moderate Versus Standard Dose of Sugammadex: A Randomized, Double-Blind, Noninferiority Trial

BACKGROUND: Certain surgical interventions may require a deep neuromuscular block (NMB). Reversal of such a block before tracheal extubation is challenging. Because anticholinesterases are ineffective in deep block, sugammadex 4 mg/kg has been recommended for the reversal of rocuronium- or vecuronium-induced deep NMB. However, this recommendation requires opening 2 vials of 200 mg sugammadex, which results in an increase in drug costs. Therefore, we sought a less expensive solution for the induction and reversal of deep NMB. Although the optimal dose of sugammadex for antagonism of deep block from pipecuronium has not been established, data pertaining to moderate block are available. Accordingly, we hypothesized that sugammadex 2 mg/kg would be a proper dose to reverse deep pipecuronium block, enabling us to avoid cost increases. In the present study, we compared sugammadex 2 mg/kg with the standard dose of 4 mg/kg for reversal of deep block from pipecuronium. METHODS: This single-center, randomized, double-blind, 2 parallel-arms, noninferiority study comprised 50 patients undergoing general anesthesia with propofol, sevoflurane, fentanyl, and pipecuronium. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch SX). Noninferiority margin was specified beforehand as an increase in reversal time of no

https://ift.tt/2LLV9hN