Assessing adherence to inhaled corticosteroids in asthma patients using an integrated measure based on primary and secondary adherence

Abstract

Purpose

There are very few studies on primary adherence (i.e., first filling of a prescription) to inhaled corticosteroids (ICS) in asthma patients; two have involved children. Moreover, adherence can be overestimated when considering only secondary adherence (i.e., following the medication recommendations for a defined period) and ignoring primary adherence. We aimed thus to evaluate the real-world primary and secondary adherence to ICS and to develop an integrated primary and secondary adherence (IPSA) measure.

Methods

From two clinical databases of pediatric and adult asthma patients, we included 198 children and 206 adults with one ICS prescription recorded in their medical chart between 2010 and 2012 and follow-up data for ≥12 months. Adherence was estimated from written prescriptions and prescription claims data. Primary adherence was defined as filling the ICS prescription at a pharmacy within 12 months. Secondary adherence was defined as the proportion of days covered (PDC) in subjects who filled their prescription at least once. The IPSA was based on the PDC with a correction factor for primary adherence.

Results

Primary adherence to ICS at 12 months was 89.4 % in children and 69.4 % in adults. Secondary adherence at 12 months in children was 33.9 %, and the IPSA was 30.3 %. These values were 52.8 and 36.6 %, respectively, in adults.

Conclusions

Primary adherence to ICS is low in adults and secondary adherence is poor in children and adults. Using the PDC as a unique measure of adherence led to significant overestimation in adults; IPSA leads to more valid estimates of adherence to ICS.

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Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging

Abstract

Purpose

The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure.

Methods

From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5 mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30 min after injection.

Results

Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100 %) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3 %) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4 %), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging.

Conclusions

The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.

http://ift.tt/2cIcnv1

Long-term functional follow-up after anterior rectal resection for cancer

Abstract

Purpose

This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders.

Method

Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire.

Results

A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery.

Conclusions

Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.

http://ift.tt/2dyn7Ck

Impact of Delta Hemoglobin on Provider Transfusion Practices and Post-operative Morbidity Among Patients Undergoing Liver and Pancreatic Surgery

Abstract

Background

Delta hemoglobin (ΔHb) is defined as the difference between the preoperative Hb and the lowest post-operative Hb level. We sought to define the impact of ΔHb relative to nadir Hb levels on the likelihood of transfusion, as well as characterize the impact of ΔHb and nadir Hb on morbidity among a large cohort of patients undergoing complex hepatopancreatobiliary (HPB) surgery.

Methods

Patients who underwent pancreatic or hepatic resection between January 1, 2009 and June 30, 2015 at Johns Hopkins Hospital were identified. Data on the perioperative ΔHb, nadir Hb, as well as blood utilization were obtained and analyzed. Multivariable logistic regression models were used to identify the factors associated with ΔHb and the impact of ΔHb on perioperative morbidity. A Bayesian model was used to evaluate the correlation of ΔHb and nadir Hb with the likelihood of transfusion, as well as the impact on morbidity.

Results

A total of 4363 patients who underwent hepatobiliary (n = 2200, 50.4 %) or pancreatic (n = 2163, 49.6 %) surgery were identified. More than one quarter of patients received at least one unit of packed red blood cells (PRBC) (n = 1187, 27.2 %). The median nadir Hb was 9.2 (IQR 7.9–10.5) g/dL resulting in an average ΔHb of 3.4 mg/dL (IQR 2.2–4.7) corresponding to 26.3 %. Both ΔHb and nadir Hb strongly influenced provider behavior with regards to use of transfusion. Among patients with the same nadir Hb, ΔHb was strongly associated with use of transfusion; among patients who had a nadir Hb ≤6 g/dL, the use of transfusion was only 17.9 % when the ΔHb = 10 % versus 49.1 and 80.9 % when the ΔHb was 30 or 50 %, respectively. Perioperative complications occurred in 584 patients (13.4 %) and were more common among patients with a higher value of ΔHb, as well as patients who received PRBC (both P < 0.001).

Conclusions

The combination of the Hb trigger with ΔHb was associated with transfusion practices among providers. Larger ΔHb values, as well as receipt of transfusion, were strongly associated with risk of perioperative complication following HPB surgery.

http://ift.tt/2derLSO

Camera calibration: a personal retrospective

http://ift.tt/2der8fg

Cacogenic Cartographies: Space and Place in the Eugenic Family Study

Abstract

Though only one component product of the larger eugenics movement, the eugenic family study proved to be, by far, its most potent ideological tool. The Kallikak Family, for instance, went through eight editions between 1913 and 1931. This essay argues that the current scholarship has missed important ways that the architects of the eugenic family studies theorized and described the subjects of their investigation. Using one sparsely interrogated work (sociologist Frank Wilson Blackmar's "The Smoky Pilgrims") and one previously unknown eugenic family study (biologist Frank Gary Brooks' untitled analysis of the flood-zone Oklahomans) from the Southern Plains, this essay aims to introduce "environment" as a schema that allows for how the subjects of the eugenic family study were conceptualized with respect to their surroundings. Geospatially and environmentally relevant constructions of scientific knowledge were central to the project of eugenics during its formative years, but remain largely and conspicuously absent from the critical literature which engages this project to separate the fit from the unfit in American society. The dysgenic constituted a unique human geography, giving us significant insight into how concatenations of jurisprudence as well as cultural and social worth were tied to the land.

http://ift.tt/2dhFl7K

Sustained Depolarization of the Resting Membrane Potential Regulates Muscle Progenitor Cell Growth and Maintains Stem Cell Properties In Vitro

Abstract

It is important to maintain the myogenic properties of muscle progenitor cells (MPCs) during in vitro expansion for stem cell therapies and tissue engineering applications. Controlling cell fate for biomedical interventions will require insight on all aspects that influence cellular properties. The resting membrane potential (Vmem) has proven to be a key parameter involved in cell proliferation, migration and differentiation. This current work is focused on elucidating the impact of sustained depolarization on MPC growth and differentiation in vitro. Cultures were treated with either potassium gluconate or the sodium-potassium pump blocker ouabain and evaluated for proliferation, DNA content using propidum iodide staining, and differentiation. Cell proliferation measurements showed a modest stimulatory effect at certain concentration ranges for each agent, but higher concentrations of potassium gluconate strongly inhibited growth in a dose dependent manner. Cell cycle analysis with flow cytometry demonstrated an increase in the number of cells in S phase, but increasing concentrations of potassium gluconate arrested cells at G₁. Immunostaining, Western blot analysis and light microscopy revealed that potassium gluconate exposure delayed cell fusion and maintained a higher population of cells expressing the muscle stem cell marker Pax7. The impairment on cell fusion was transient and myotube formation recovered after the treatments were removed. Taken together, this work suggests that transmembrane voltage gradients can be used as a powerful regulator of MPC properties in vitro. Examination of how these physiological parameters modulate cell behavior will reveal a new set of tools that can be capitalized on in tissue engineering and regenerative medicine.

http://ift.tt/2duxWQy

Treatment-Related Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis: A Comprehensive Review of Current Evidence and Future Needs

Abstract

Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection of the central nervous system caused by the John Cunningham virus (JCV) that has been associated with therapeutic immunosuppression in patients with multiple sclerosis (MS). So far, more than 600 cases of PML have been reported in association with natalizumab administration. There have also been confirmed cases of PML in individuals who received fingolimod and dimethyl fumarate without previous natalizumab treatment. The new licensed disease-modifying therapies for MS carry the risk of immunosuppressant and so of JCV reactivation. Various factors have been identified with increased risk of developing PML, including a positive JCV serology, natalizumab administration for >2 years, and prior use of immunosuppressive agents. Clinicians can employ such tools for patients' risk stratification, but the incidence of PML among patients receiving natalizumab therapy has not changed. In this review we outline the current state of understanding of PML pathogenesis and patients' risk stratification. The landscape of MS is dramatically changing and knowledge of the side effects of the licensed therapies is imperative to enable optimal decision making.

http://ift.tt/2cS3HFP

Pleiotropic regulations of neutrophil receptors response to sepsis

Abstract

Introduction

Sepsis is a complex clinical condition that causes a high mortality rate worldwide. Numerous studies on the pathophysiology of sepsis have revealed an imbalance in the inflammatory network, thus leading to tissue damage, organ failure, and ultimately death. The impairment of neu­trophil migration is associated with the outcome of sepsis.

Methods

Literature review was performed on the roles of neutrophil recruitment and neutrophil receptors as pleiotropic regulators during sepsis. Additionally, we systematically classify neutrophil receptors with regard to the neutrophil response during sepsis and discuss the clinical implications of these receptors for the treatment of sepsis.

Results

Increasing evidence suggests that there is significant dysfunction in neutrophil recruitment during sepsis, characterized by the failure to migrate to the site of infection. Neutrophil receptors, as pleiotropic regulators, play important roles in the neutrophil response during sepsis.

Conclusions

Neutrophil receptors play key roles in chemotactic neutrophil migration and may prove to be suitable targets in future pharmacological therapies for sepsis.

http://ift.tt/2duyEgE

The Therapist’s Role in Effective Marriage and Family Therapy Practice: The Case for Evidence Based Therapists

Abstract

In this paper we argue that the therapist is a crucial change variable in psychotherapy as a whole and in couple, marital, and family therapy specifically. Therapists who work with complex systems require more skills to negotiate demanding therapy contexts. Yet, little is known about what differentiates effective couple, marital, and family therapists from those who are less effective, what innate therapy skills they possess, how they learn, and how they operationalize their knowledge in the therapy room. We discuss the need to emphasize evidence based therapists (as opposed to therapies), and implications of the importance of the role therapists for training, practice, research priorities, and policy.

http://ift.tt/2dkbUlo

Clinicopathological characteristics of patients with amyotrophic lateral sclerosis resulting in a totally locked-in state (communication Stage V)

Abstract

In the present study, we performed a comprehensive analysis to clarify the clinicopathological characteristics of patients with amyotrophic lateral sclerosis (ALS) that had progressed to result in a totally locked-in state (communication Stage V), in which all voluntary movements are lost and communication is impossible. In 11 patients, six had phosphorylated TAR DNA-binding protein 43 (pTDP-43)-immunoreactive (ir) neuronal cytoplasmic inclusions (NCI), two had fused in sarcoma (FUS)-ir NCI, and three had copper/zinc superoxide dismutase (SOD1)-ir NCI. The time from ALS onset to the need for tracheostomy invasive ventilation was less than 24 months in ten patients. Regardless of accumulated protein, all the patients showed common lesions in the pallido–nigro–luysian system, brainstem reticular formation, and cerebellar efferent system, in addition to motor neurons. In patients with pTDP-43-ir NCI, patients with NCI in the hippocampal dentate granule neurons (DG) showed a neuronal loss in the cerebral cortex, and patients without NCI in DG showed a preserved cerebral cortex. By contrast, in patients with FUS-ir NCI, patients with NCI in DG showed a preserved cerebral cortex and patients without NCI in DG showed marked cerebral degeneration. The cerebral cortex of patients with SOD1-ir NCI was preserved. Together, these findings suggest that lesions of the cerebrum are probably not necessary for progression to Stage V. In conclusion, patients with ALS that had progressed to result in communication Stage V showed rapidly-progressed symptoms, and their common lesions could cause the manifestations of communication Stage V.

http://ift.tt/2dGxdwW

Neglektbehandlung: neue Therapieansätze

Zusammenfassung

Neglekt ist eine supramodale, relevante klinische Störung, die in den verschiedenen Sinnesmodalitäten sowie der mentalen Repräsentation auftritt. Die unterschiedlichen Manifestationen des Neglekts variieren inter- und intraindividuell. Es existieren einige raum- sowie aufmerksamkeitsbezogene Therapieansätze, welche zu einer mehr oder weniger stark ausgeprägten Verbesserung der Neglektsymptomatik führen, aber oft nicht zeitlich überdauernd und in den Alltag übertragbar sind. Repräsentationale Defizite oder körperbezogene Aspekte zur Modifikation eines personalen Neglekts sind meist nicht primärer Ansatzpunkt gängiger Therapien. Aus unserer Sicht liegt die Zukunft der Neglektbehandlung aufgrund des multisensorisch-motorischen Funktionsausfalls in einem kombinierten Therapieansatz aus visueller Explorationstherapie, motorischer Imagination kombiniert mit intensiver motorischer Therapie der sensomotorischen Defizite, wahrscheinlich am besten verstärkt durch eine kontinuierliche Nackenmuskelvibration bzw. Aufmerksamkeitszuwendung der vernachlässigten Seite.

http://ift.tt/2dCAMrw

Transport of CMC-Stabilized nZVI in Saturated Sand Column: the Effect of Particle Concentration and Soil Grain Size

Abstract

A considerable number of studies have been conducted to investigate the effect of physical and chemical variables on the transport of nanoscale zerovalent iron (nZVI) in granular media. However, the role of soil grain size as a crucial factor in nanoparticle mobility is less understood. The present research work sought to examine the simultaneous effects of soil grain size and particle concentration on the transport of nZVI coated with carboxymethyl cellulose (CMC-nZVI), using saturated sand packed column experiments. To this end, a total of 12 tests were conducted by combining four different particle concentrations (C = 10, 200, 3000, 10,000 mg/l) and three grain sizes (dc = 0.297–0.5 mm, 0.5–1 mm, 1–2 mm). The effluent nZVI concentration and water pressure drop along the column were measured. The results showed that during the injection time, decreasing the grain size and increasing the particle concentration reduces the mobility of CMC-nZVI due to ripening phenomena, while during the flushing time (introducing deionized water), such changes in grain size and particle concentration increase the mobility of CMC-nZVI due to a release from the secondary energy minimum well (in the DLVO theory).

http://ift.tt/2dGozOV

Aromatase inhibitors: A comprehensive review in mechanisms of action, side effects and treatment in postmenopausal early breast cancer patients

Abstract

The best adjuvant treatment for hormone receptor-positive breast cancer, especially in the postmenopausal population, is not an unexceptionable decision and depends on several and many times unequal parameters. Apart from the mechanisms of action which are more or less the same among different agents, the two major factors for consideration are the potential side effects and treatment benefits of the selected drug. The last fifteen years have clearly shown that aromatase inhibitors (AIs) are significantly more effective than tamoxifen in preventing recurrence in this group of patients, but they seem to have no beneficial effect on overall survival. The analysis and results of major controlled randomized trials are taken into consideration every time we are called upon to select the best effective adjuvant treatment for well surgically-controlled early breast cancer in a postmenopausal woman. In the present review, we attempt a comprehensive review of the recent English literature in order to unfold the potent aspects for this decision.

http://ift.tt/2duiR1c

Pancreaticoduodenectomy in advanced cholangiocarcinoma

Abstract

Cholangiocarcinoma is the most common primary malignancy of the biliary tract and can be classified as intrahepatic or extrahepatic. There are definitive risk factors for this carcinoma. It is difficult to diagnose due to its silent clinical character. We present the case report of a 42-year-old woman with advanced perihilar carcinoma. She was admitted with obstructive jaundice and high bilirubin levels. A pancreaticoduodenectomy was performed. Given that a tumour at advanced stage requires duodenal and common bile duct resection, pancreaticoduodenectomy seemed to be the optimal solution. We believe that pancreaticoduodenectomy not only offers the necessary anastomoses but also the radicality.

http://ift.tt/2cRTnxk

Comparison of primary resection and anastomosis with Hartmann’s procedure in management of acute sigmoid volvulus

Abstract

Background

Sigmoid volvulus is a common surgical emergency in many regions of the world that carries significant morbidity and mortality. Volvulus occurs when an air-filled segment of the colon twists about its mesentery. In developing countries, it is a major cause of colonic obstruction. The sigmoid colon is involved in up to 90% of cases. It can be present as acute, sub-acute or chronic. Acute sigmoid volvulus requires emergency surgery. Various methods are used in its management.

Aim

The purpose of our study was to evaluate the comparative study of single-stage resection and anastomosis with Hartmann's procedure for management of acute left-sided colonic obstruction due to acute sigmoid volvulus.

Methods

This prospective study was conducted in a consecutive series of 122 patients with acute sigmoid volvulus, admitted to the department of general surgery at M.K.C.G Medical College. All 122 patients were submitted to laparotomy. In different groups, 87 patients underwent primary resection of the affected sigmoid colon with anastomosis while 35 patients underwent surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy (Hartmann's procedure). The outcome of the two procedures was analysed in terms of mortality, postoperative complications and hospital stay.

Results

This study clearly shows that there is no statistically significant result between the two procedures, other than a slightly longer hospital stay recorded for the resection and anastomosis group than that of the Hartmann's group.

Conclusion

This study demonstrated that the outcome of two procedures are the same. Resection and anastomosis should be performed safely in uncomplicated acute sigmoid; in complicated cases, Hartmann's procedure is the surgery of choice.

http://ift.tt/2duknk1

Congenital adult transmesenteric hernia as small bowel obstruction

Abstract

Aim-Background

Internal hernias are a rare cause of intestinal obstruction in adults with few reported cases in the published literature. Congenital transmesenteric hernias constitute only an estimated 5-10% of all internal hernias. We report the rare case of a 16-year-old female with a spontaneous transmesenteric hernia of the jejunum and proximal ileum due to a congenital mesenteric defect. We also conducted a review of the literature to establish the rarity of the condition and the management of emergency cases.

Methods

We report the case of 16-year-old female who presented to the emergency department complaining of sudden generalized abdominal pain, non-passage of faeces and flatus, and a 2-day history of multiple episodes of bilious vomiting. There was no history of surgery and no comorbidities. An emergency laparotomy was performed. The mesenteric defect, measuring 3 cm in size, was detected in the terminal ileum at about 2 feet from the ileocaecal region. The gangrenous bowel along with the mesenteric defect was resected and a primary ileo-ileal anastomosis was performed. In May 2016, we also conducted a search of the PubMed database. All case reports and case series were included without restriction in terms of language or publication status.

Results

Only 18 adult case reports (7:11 male to female ratio) of bowel obstruction secondary to congenital mesenteric defects had been documented in the published literature up to May 2016, of which one was diagnosed at autopsy, and seven were recorded as having developed bowel ischaemia.

Conclusion

Transmesenteric hernia is a rare cause of small bowel obstruction as it constitutes only 8% of internal hernias. A congenital mesenteric defect should be considered as one of the differential diagnoses in a relatively young patient with bowel obstruction without an external hernia, previous abdominal surgery or trauma. Surgical decision-making is made on the basis of clinical findings of intestinal strangulation or ischaemia, and emergency laparotomy should be performed without preoperative diagnosis of such a rare disease.

http://ift.tt/2cRSwwT

An unusual foreign body in the urinary bladder: The art of management

Abstract

Introduction

Foreign bodies in the urinary bladder have been widely reported in the medical literature and include needles, bullets etc. However, a mobile phone charger cable in the bladder has not yet been reported. We report the case of a patient with a mobile charger cable in the urinary bladder. The patient was not able to retrieve it later because of knotting. Beyond primary management, the role of the surgeon also extends to educating such patients against repeating similar acts in the future. They should also refer the patient to a complete psychiatric evaluation and at the same time investigate the emotional background and circumstances under which the act was committed.

Case Presentation

A 36-year-old male patient was admitted to our department complaining of haematuria and the inability to void. On examination, the cable end could not be seen at the external urethral meatus. A plain X-ray of the KUB region revealed a radiopaque cable knotted within the urinary bladder.

Discussion

Foreign bodies inside the urinary bladder can be classified as migratory, iatrogenic and inserted. They may present with features of bladder obstruction, irritation as well as haematuria and complications that include recurrent infections, urinary retention, fistulae and even death due to sepsis.Diagnostic modalities include X-rays and ultrasonography, as well as urography and cystoscopy in selected cases.

Conclusion

A wide multitude of foreign bodies can be inserted into the urinary bladder. Such patients usually suffer from psychiatric problems, hence a thorough psychiatric assessment is needed. Endoscopic removal is the treatment of choice with open surgical removal reserved for endoscopic failure cases.

http://ift.tt/2dujojM

Evaluation of intracorporeal knotting and endoloop closure in laparoscopic appendicectomy

Abstract

Background

Laparoscopic appendicectomy has become popular nowadays, especially among laparoscopic surgeons, due to the benefits of minimal invasive surgery and the simplicity of this technique. Some laparoscopic surgeons apply ligatures owing to their lower cost and feasibility while others use endoloops and clips. The ideal method should be safe, applicable and cheap. The most appropriate method remains controversial. In this study, we applied intracorporeal ligature (knotting) during laparoscopic appendicectomy for secure closure of the base of the appendix and mesoappendix in one group of patients, and used endoloops in the second group of patients.

Aim and objectives

The aim of this work was to evaluate the application of both techniques, i.e. the use of knotting and endoloops, and record any specific complications related to each.

Settings and design

This was a prospective, randomized, double-blinded study.

Patients and methods

One hundred laparoscopic appendicectomy patients, of whom 64 were female and 36 male, were included in this study from February 2013 to January 2015 at MMIMSR Hospital. Their overall average age was 27.4 years. Patients were divided into two equal groups (group A and group B): group A underwent intracorporeal knotting of the base of appendix with silk while in group B, the appendix base was secured with the use of endoloops.

Results

The mean operative time was 45 min for group A and 37 min for group B (P < 0.05). The mean hospital stay was 2.07 days and 2 days, respectively, which was not statistically significant (P > 0.05). No major complications were recorded for either of the two groups. The technique used in group A was more cost-effective than that applied to group B.

Conclusion

In our study, both the intracorporeal knotting and endoloop closure technique were safe, successful and feasible. We concluded that if the patient cannot afford the harmonic-like material, silk could be used for the base of the appendix. Hence, in rural locations or where instruments are not affordable to the surgeon, or in financially compromised patients, silk can be used without any complication.

http://ift.tt/2cRSOUd

Pelvic actinomycosis: A rare presentation

Abstract

Pelvic actinomycosis is a rare presentation which may present as a diagnostic dilemma when it mimics pelvic malignancy or sometimes may be overlooked because of its non-specific nature. We present the case of a 37-year-old female patient who presented with tubo-ovarian actinomycosis without a history of IUD use. She presented with abdominal pain and bilateral tubo-ovarian masses. Postoperative histopathology revealed actinomycosis.

http://ift.tt/2duj7xn

Evaluation of the role of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers: a prospective comparative study

Abstract

Aim/Objectives

This prospective study aims to assess the efficacy of hyperbaric oxygen therapy in diabetic foot ulcers in relation to standard wound care.

Methods

This was a single centre prospective study conducted from January 2007 to March 2015 by the department of surgery. In total, 240 consenting patients with foot ulcers of at least two weeks duration were randomized with the help of a random number generator into two groups each comprising 120 patients: the HBOT group (to receive hyperbaric oxygen therapy along with standard wound care) and the ASD group (to receive standard wound care only). The six-week treatment phase was followed by a six-week follow-up phase. Wounds were monitored using the Bates-Jensen Wound assessment scale. For all statistical analysis, a p-value of less than 0.05 was taken to indicate a significant difference.

Results

Of the 240 patients, 164 were male and 36 female. The duration of diabetes was not statistically significant (p-value 0.707). In the study group, the wounds of 22 (88) (73.3%) patients healed in less than eight weeks (i.e. 56 days), vs. only 4(16) (13.3%) patients in the control group, which was statistically significant (p value <0.001)

Conclusion

This study further supports and recommends HBOT for the management of diabetic foot ulcers as there is marked increase in the rate of wound healing as compared to standard wound care and dressings alone.

http://ift.tt/2cRTkSf

Role of diagnostic laparoscopy in patients with non-specific abdominal pain and its correlation with clinical and radiographic findings

Abstract

Aim/Objectives

This study aims to evaluate the role of laparoscopy in patients presenting with chronic non-specific abdominal pain and also correlate the laparoscopic findings with clinical and radiographic findings in all such patients.

Materials and methods

This was a single-centre prospective cohort study conducted by the department of surgery from January 2001 to December 2014. One hundred fifty consecutive cases of chronic non-specific abdominal pain of unknown aetiology referred or admitted to surgical unit 6 were recruited in the study. After a detailed clinical history and examination, all patients were subjected to imaging studies and diagnostic laparoscopy. All the data was tabulated and analysed. Mean and standard deviation was calculated for continuous variables. Frequency distribution was depicted in the form of statistical tables.

Results

Out of 150 patients, chronic non-specific abdominal pain was most prevalent in the 41–50 years age group. There were 60 male and 90 female patients. The mean duration of pain was 10.92±6.80. Ultrasonography was normal in most of the patients (52%). Dilated bowel loops with free fluid was the most frequent positive finding (12%). Abdominal tuberculosis was the most common final diagnosis (32%) followed by affections of the female genital tract (26%). No diagnosis could be ascertained in 6% of the cases. USG and laparoscopy also showed a high degree of unison in picking up mass lesions and strictures. Re-exploration was the only complication.

Conclusion

Laparoscopy, apart from being a gold standard in diagnosis of non-specific abdominal pain, also extends the benefit of addressing the pathology at the same time.

http://ift.tt/2duiRhX

Isolated common bile duct injury after abdominal trauma

Abstract

We report the rare case of a self-inflicted stab injury involving the isolated common bile duct without any other vascular or visceral injury. A 35-year-old male with a history of self-inflicted stab injuries to the abdomen presented with features of localized peritonitis. Laparotomy revealed an isolated rent in the common bile duct which was repaired over a T-tube.

http://ift.tt/2cRRX5T

Gastrointestinal weight loss surgery for the management of type 2 diabetes: A view from Greece

Abstract

Several gastrointestinal operations of bariatric surgery, originally designed to achieve and maintain weight loss, can also induce long-term remission of type 2 diabetes mellitus as well as improve other metabolic conditions including hypertension and dyslipidaemia. Moreover, bariatric surgery is increasingly being explored for the treatment of diabetes in moderately obese and non-obese diabetic patients, with positive results. The differences observed amongst the types of bariatric surgery in better control (i.e. sleeve gastrectomy) versus full remission (i.e. Roux-en-Y gastric bypass) of diabetes postoperatively constitute a significant field of study. How surgical gastrointestinal interventions achieve these changes is of a great interest to research, and is evolving rapidly. Several studies have provided evidence that surgical procedures bypassing parts of the small intestine improve glucose homeostasis through mechanisms beyond reduced food intake and body weight. The two major hypotheses put forth to explain these mechanisms are the 'foregut' and the 'hindgut' hypothesis, focusing on the changes of the secretion pattern of gastrointestinal hormones and neuroendocrine signals observed after surgical manipulation of the gastrointestinal tract. Research to elucidate such weight-independent anti-diabetes mechanisms should facilitate the design of novel anti-diabetic gastrointestinal manipulations, devices and pharmacotherapeutics for obese and non-obese diabetic patients.

http://ift.tt/2duj197

Gastric outlet and duodenal/ileal obstruction due to gastric phytobezoar

Abstract

We herein present the case of an 83-year-old man, ASA status III, with a fragmented gastric phytobezoar causing obstruction in different parts of the gastrointestinal tract. The initial mass was obviously in the stomach, and due to continuing coughing and vomiting the bezoar was fragmented. The apex of the bezoar moved through the deformed pyloric channel, temporarily occluding first the duodenojejunal flexure and afterwards the ileus, while the larger remnants repeatedly sealed off causing gastric outlet obstruction. At emergent laparotomy, a gastrojejunostomy was created through which both bezoars were extracted, and the operation was completed with a vagotomy. The patient had an uneventful postoperative outcome and is doing well at 12-month follow-up. Complicated bezoars require emergent surgical removal.

http://ift.tt/2cRULzW

Primary cutaneous melanoma of the breast region

Abstract

Background

Primary cutaneous malignant melanoma of the breast is a rare entity, accounting for less than 5% of all malignant melanomas.

Description of Case

A 74-year-old woman was seen for a lesion in the breast. Clinical examination and laboratory results confirmed the diagnosis of a primary cutaneous melanoma of the breast. The tumour was excised along with the axillary lymph nodes and supraclavicular lymph nodes. All tissues were sent for histological evaluation.

Conclusion

Despite its rareness, primary cutaneous melanoma of the breast region can be managed using the same techniques as for other skin parts. Wide three-dimensional local excision and sentinel lymph node biopsy is the selected treatment.

http://ift.tt/2duiMKT

Rectourethral fistula: A challenging management problem

Abstract

Aim

To describe the problems and management of rectourethral fistulas.

Background

Rectourethral fistula constitutes a rare entity that poses a challenging management problem. The condition is either congenital or acquired. The clinical findings suggestive of RUF include pneumaturia, faecaluria, and urine leakage per rectum.

Methods

This study was based on English research literature, mainly by searching PubMed bibliographic database.

Results

Diagnosis of a rectourethral fistula is difficult and often based on history alone. In rare cases, non-operative management has been successful, but the majority of patients require surgical intervention. A wide variety of procedures have been described for RUF repair.

Conclusion

Rectourethral fistula represents a complex management problem for any surgeon. Surgical treatment of RUF is technically demanding and requires collaboration with rectal surgeons.

http://ift.tt/2cRTitA

A typical case of a widespread metastatic breast carcinoma

Abstract

Cutaneous metastasis is an uncommon manifestation of visceral malignancy. Among all malignancies, the highest incidence of cutaneous metastasis is seen in breast cancer. Cutaneous metastasis can be the initial presentation of breast carcinoma. However, it usually presents a few months or years after the primary disease has been diagnosed and treated. Cutaneous metastases develop most commonly at the same time as internal metastases.^3,8 The incidence of cutaneous metastases for all types of carcinomas ranges from 0.7% to 10.0%.^3,5 A more recent meta-analysis demonstrated the overall incidence to be closer to 5.3%.^4,5 We present herein a case of carcinoma breast in a 55-year-old female presenting initially with skin lesions on the chest wall. Further evaluation identified a bilateral breast mass with axillary metastasis and multiple nodules over the trunk and right thigh. There was also evidence of metastasis to the lungs, bilateral adrenals and mesenteric lymph nodes. FNAC of all the nodules revealed infiltrating duct carcinoma of the breast which was confirmed by excision biopsy.

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Tyrosine Hydroxylase Expression in Type II Cochlear Afferents in Mice

Abstract

Acoustic information propagates from the ear to the brain via spiral ganglion neurons that innervate hair cells in the cochlea. These afferents include unmyelinated type II fibers that constitute 5 % of the total, the majority being myelinated type I neurons. Lack of specific genetic markers of type II afferents in the cochlea has been a roadblock in studying their functional role. Unexpectedly, type II afferents were visualized by reporter proteins induced by tyrosine hydroxylase (TH)-driven Cre recombinase. The present study was designed to determine whether TH-driven Cre recombinase (TH-2A-CreER) provides a selective and reliable tool for identification and genetic manipulation of type II rather than type I cochlear afferents. The "TH-2A-CreER neurons" radiated from the spiral lamina, crossed the tunnel of Corti, turned towards the base of the cochlea, and traveled beneath the rows of outer hair cells. Neither the processes nor the somata of TH-2A-CreER neurons were labeled by antibodies that specifically labeled type I afferents and medial efferents. TH-2A-CreER-positive processes partially co-labeled with antibodies to peripherin, a known marker of type II afferents. Individual TH-2A-CreER neurons gave off short branches contacting 7–25 outer hair cells (OHCs). Only a fraction of TH-2A-CreER boutons were associated with CtBP2-immunopositive ribbons. These results show that TH-2A-CreER provides a selective marker for type II versus type I afferents and can be used to describe the morphology and arborization pattern of type II cochlear afferents in the mouse cochlea.

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Co-management in geriatric hip fractures

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Hypertrophic scar of the conjunctiva presenting as an eyelid mass: an unusual complication after surgical treatment of a chalazion

To present a rare case of a conjunctival hypertrophic scar presenting as eyelid mass after surgical treatment of a chalazion.

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Analgesic Drug Prescription Patterns on Five International Paediatric Wards

Abstract

Aim

Analgesic and anti-inflammatory drugs are frequently prescribed in paediatrics. Prescribing and dosing patterns in hospitalised children are not well known. This study explores analgesic drug utilisation on five paediatric wards and discusses its findings in comparison with World Health Organization (WHO) guidelines.

Method

A sub-analysis of a prospective, multicentre, observational cohort study was undertaken. Prescription data of children aged up to ≤18 years were collected between October 2008 and December 2009 on paediatric general medical wards in five hospitals in Australia, Germany, the United Kingdom (UK), Hong Kong (HK) and Malaysia. Analgesic drug prescriptions were analysed for prescribing patterns in terms of dosing, frequency and route of administration. Dosing data were compared with local recommendations and WHO guidelines for children.

Results

In the study cohort, 56.8 % (726/1278) of paediatric patients received at least one analgesic drug prescription (1227 prescriptions). The median age of patients with analgesics was 2.2 years [interquartile range (IQR) 0.8–7.3], and the median number of prescriptions per patient was one (IQR 1–2). The most commonly prescribed drugs were oral paracetamol (45.9 %, 563/1227) and oral ibuprofen (19.9 %, 244/1227). Daily doses of paracetamol ranged from 30 mg/kg/day in Germany to 67–68 mg/kg/day in the UK and HK (p < 0.05). For ibuprofen, single doses ranged from 5–6 mg/kg in HK and the UK to 10 mg/kg in Germany and Australia (p < 0.001). Opioid use prevalence was statistically different between the centres and ranged from 0 to 17.6 % (p < 0.001).

Conclusion

This study provides a comprehensive overview of analgesic drug use of hospitalised children. Similar to primary care data, paracetamol is the most commonly used analgesic. As recommended by WHO guidelines, oral medication was favoured and opioids used in addition to paracetamol and ibuprofen. Overall drug utilisation was in line with local recommendations and WHO guidelines. Differences in use of paracetamol and ibuprofen among countries were seen, indicating that safety concerns are perceived differently. More large-scale safety studies are needed.

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Population Pharmacokinetics of Necitumumab in Cancer Patients

Abstract

Necitumumab is a second-generation, recombinant, human immunoglobulin G1, epidermal growth factor (EGFR) receptor antibody that specifically blocks the ligand binding site of EGFR. Necitumumab potentially acts by blocking ligand epidermal growth factor (EGF) binding-mediated activation of the EGFR signaling pathway, inhibiting tumor growth, angiogenesis, and anti-apoptotic mechanisms. Necitumumab inhibited the interaction of EGF and EGFR with a concentration that inhibits binding by 50 % of approximately 0.9 nM (0.13 mg/L) and demonstrated antitumor activity during in vivo experiments associated with trough plasma concentrations of approximately 40 mg/L. This work describes the population pharmacokinetics of necitumumab in cancer patients when administered with or without concomitant chemotherapy and evaluates patient characteristics that may guide dosing. Nonlinear mixed-effects modeling of serum concentration data across five clinical studies (phases I–III) indicated that necitumumab exhibited target-mediated drug disposition, commonly observed with monoclonal antibodies, and that pharmacokinetics were expected to be linear in the studied dose ranges when administered as repeated infusions. No age, sex, race, or concomitant medication factors were found influential, while weight was a statistically significant factor for both distribution and elimination. Simulations from the final model indicated that only a limited reduction in patient drug exposure variability would be achieved by weight- or body surface area-based dosing. Necitumumab effective half-life was estimated to approximately 2 weeks, and steady state was achieved within three to four cycles of treatment. The phase III dosing schedule of 800 mg dosed on days 1 and 8 of a 21-day schedule resulted in serum concentrations that exceeded the 40-mg/L threshold indicated by preclinical experiments.

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Toxin A-negative toxin B-positive ribotype 017 Clostridium difficile is the dominant strain type in patients with diarrhoea attending tuberculosis hospitals in Cape Town, South Africa

Abstract

The molecular epidemiology of C. difficile strains causing disease in South Africa is currently unknown. Previously, multidrug resistant ribotype (RT)017 strains were those most commonly isolated from patients with diarrhoea attending Groote Schuur Hospital in Cape Town, South Africa. This larger study aimed to investigate the molecular epidemiology and antibiotic susceptibility profiles of C. difficile strains in the greater Cape Town and regional areas. C. difficile strains were isolated from patients with diarrhoea attending hospitals in the Western Cape region of South Africa that tested positive using the GeneXpert CDiff diagnostic test. Ribotyping and multilocus variable-number tandem-repeat analysis (MLVA) were used to type isolates, and their susceptibilities to several antibiotics were determined by gradient diffusion test strips. A total of 269 non-repeat C. difficile isolates were obtained. A large proportion of isolates (64.3 %) belonged to the RT017 group, many of which were clonally related when investigated by MLVA. RT017 strains were particularly prevalent in patients attending specialist tuberculosis (TB) hospitals. The majority of RT017 isolates were co-resistant to moxifloxacin and rifampicin, two antibiotics which are used intensively during anti-TB therapy. Non-RT017 strains were generally susceptible to both antibiotics. Resistance to erythromycin was observed for both groups of strains. RT017 C. difficile strains are the most commonly isolated strains from patients attending healthcare facilities in the greater Cape Town and regional areas. The presence of multidrug resistant RT017 strains in patients with diarrhoea attending local TB hospitals reflects a potential reservoir for future infections.

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Clostridium difficile infection in children: epidemiology and risk of recurrence in a low-prevalence country

Abstract

Clostridium difficile infection (CDI) is increasingly found in children worldwide, but limited data are available from children living in southern Europe. A 6-year retrospective study was performed to investigate the epidemiology, clinical features, treatment, and risk of recurrence in Italy. Data of children with community- and hospital-acquired CDI (CA-CDI and HA-CDI, respectively) seen at seven pediatric referral centers in Italy were recorded retrospectively. Annual infection rates/10,000 hospital admissions were calculated. Logistic regression was used to investigate risk factors for recurrence. A total of 177 CDI episodes was reported in 148 children (83 males, median age 55.3 months), with a cumulative infection rate of 2.25/10,000 admissions, with no significant variability over time. The majority of children (60.8 %) had CA-CDI. Children with HA-CDI (39.2 %) had a longer duration of symptoms and hospitalization (p = 0.003) and a more common previous use of antibiotics (p = 0.0001). Metronidazole was used in 70.7 % of cases (87/123) and vancomycin in 29.3 % (36/123), with similar success rates. Recurrence occurred in 16 children (10.8 %), and 3 (2 %) of them presented a further treatment failure. The use of metronidazole was associated with a 5-fold increase in the risk of recurrence [odds ratio (OR) 5.18, 95 % confidence interval (CI) 1.1–23.8, p = 0.03]. Short bowel syndrome was the only underlying condition associated with treatment failure (OR 5.29, 95 % CI 1.17–23.8, p = 0.03). The incidence of pediatric CDI in Italy is low and substantially stable. In this setting, there is a limited risk of recurrence, which mainly concerns children treated with oral metronidazole and those with short bowel syndrome.

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An Update on Treatment and Management of Pediatric Systemic Lupus Erythematosus

Abstract

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder in which 20 % of patients are diagnosed in childhood. Childhood-onset SLE is associated with higher morbidity and mortality than adult-onset SLE. The aims of disease management with early immunosuppression are to decrease disease activity and improve quality of life. A multidisciplinary approach is necessary due to the complexity of lupus in pediatric patients. It is important to provide patients with high quality of care and to instill ownership of their disease process from a young age to prepare them to manage this life-long illness. This article reviews current management of SLE in children.

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Aortale Bildgebung als Schlüssel zur Therapie genetischer Aortenerkrankungen

Zusammenfassung

Hintergrund

Die bildgebende Diagnostik spielt in der Betreuung von Patienten mit genetischen Aortenerkrankungen wie dem Marfan-Syndrom, dem vaskulären Ehlers-Danlos-Syndrom oder dem Loeys-Dietz-Syndrom sowohl bei Diagnose der genetischen Aortenerkrankung im stabilen Stadium als auch bei der Notfalldiagnostik akuter Aortensyndrome eine essenzielle Rolle. Die bildgebenden Modalitäten zur elektiven Diagnostik und Akutdiagnostik umfassen die transthorale Echokardiographe, die transösophageale Echokardiographie, die CT mit CT-Angiographie und die Magnetresonanztomographie (MRI) mit MR-Angiographie (MRA).

Fragestellung

Stellenwert der M‑Mode-echokardiographischen Bildsegmentationsmethode zur Messung von Steifigkeitsveränderungen der Aorta.

Material und Methoden

Studie zur Steifheitsmessung der Aorta bei Marfan-Syndrom im Vergleich zu gesunden Probanden.

Ergebnisse

Mit der nichtinvasiven, semiautomatisierten M‑Mode-echokardiographischen Bildsegmentationsmethode kann die Verminderung der elastischen Eigenschaften der Aorta bei jungen Patienten mit Marfan-Syndrom genau und objektiv erfasst werden.

Schlussfolgerungen

Bildgebende Verfahren sind zur Risikostratifikation und zur Akutdiagnostik genetischer Aortensyndrome unverzichtbar. Aus Strahlenschutzgründen sollen für Verlaufsuntersuchungen junger Patienten bevorzugt Echokardiographie und MRT eingesetzt werden.

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Is tailored treatment superior to non-tailored treatment for pain and disability in women with non-specific neck pain? A randomized controlled trial

Abstract

Background

The evidence for the effect of treatments of neck pain is modest. In the absence of causal treatments, a possibility is to tailor the treatment to the individuals' functional limitations and symptoms. The aim was to evaluate treatment effects of a tailored treatment versus a non-tailored treatment. Our hypothesis was that tailored treatment (TT) would have better effect on pain intensity and disability than either non-tailored treatment (NTT) (same treatment components but applied quasi-randomly) or treatment-as-usual (TAU) (no treatment from the study, no restrictions). We further hypothesized that TT and NTT would both have better effect than TAU.

Method

One hundred twenty working women with subacute and chronic non-specific neck pain were allocated to 11 weeks of either TT, NTT or TAU in a randomized controlled trial with follow-ups at 3, 9 and 15 months. The TT was designed from a decision model based on assessment of function and symptoms with defined cut-off levels for the following categories: reduced cervical mobility, impaired neck-shoulder strength and motor control, impaired eye-head-neck control, trapezius myalgia and cervicogenic headache. Primary outcomes were pain and disability. Secondary outcomes were symptoms, general improvement, work productivity, and pressure pain threshold of m. trapezius.

Results

Linear mixed models analysis showed no differences between TT and NTT besides work productivity favoring TT at 9- and 15-months follow-ups. TT and NTT improved significantly more than TAU on pain, disability and symptoms at 3-month follow-up. General improvement also favored TT and NTT over TAU at all follow-ups.

Conclusion

Tailored treatment according to our proposed decision model was not more effective than non-tailored treatment in women with subacute and chronic neck pain. Both tailored and non-tailored treatments had better short-term effects than treatment-as-usual, supporting active and specific exercise therapy, although therapist-patient interaction was not controlled for. Better understanding of the importance of functional impairments for pain and disability, in combination with a more precise tailoring of specific treatment components, is needed to progress.

Trial registration

Current Controlled Trials ISRCTN 49348025. Registered 2 August 2011.

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Focus on Bioinformatics, Software, and MS-Based “Omics,” Honoring Dr. Michael J. MacCoss, Recipient of the 2015 ASMS Biemann Medal

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Long-term response to gluten-free diet as evidence for non-celiac wheat sensitivity in one third of patients with diarrhea-dominant and mixed-type irritable bowel syndrome

Abstract

Purpose

Irritable bowel syndrome (IBS) is common but therapies are unsatisfactory. Food is often suspected as cause by patients, but diagnostic procedures, apart from allergy testing, are limited. Based on the hypothesis of non-celiac wheat sensitivity (WS) in a subgroup of IBS patients, we tested the long-term response to a gluten-free diet (GFD) and investigated HLA-DQ2 or -DQ8 expression as a diagnostic marker for WS in diarrhea-dominant (IBS-D) and mixed-type IBS (IBS-M).

Methods

The response to a GFD served as reference test for WS and HLA-DQ2/8 expression was determined as index test. Patients were classified as responders if they reported complete or considerable relief of IBS symptoms on at least 75 % of weeks over a 4-month period of gluten-free diet. Established questionnaires (IBS-Quality of Life (IBS-QoL), IBS Symptom Severity Scale (IBS-SSS), European Quality of Life-5 Dimensions (EQ-5D)) were used for secondary outcome measures.

Results

Thirty-five patients finished the study. Of these, 12 (34 %) were responders and classified as having WS (95 % CI 21–51 %). HLA-DQ2/8 expression had a specificity of 52 % (95 % CI 33–71 %) and sensitivity of 25 % (95 % CI 8–54 %) for WS. Responders showed improvement in quality of life and symptom scores. At 1-year follow-up, all responders and 55 % of non-responders were still on GFD and reported symptom relief.

Conclusion

Using strict criteria as recommended for IBS studies, about one third of patients with IBS-D or IBS-M are wheat sensitive, with a similar proportion in both IBS types. Expression of HLA-DQ2/8 is not useful as diagnostic marker for WS. Long-term adherence to a GFD is high and can sustain symptomatic improvement.

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