Σφακιανάκης Αλέξανδρος
ΩτοΡινοΛαρυγγολόγος
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00302841026182
00306932607174
alsfakia@gmail.com

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Τετάρτη 22 Ιουνίου 2016

OtoRhinoLaryngology & Medicine,New Articles,June 22nd,2016,afternoon

  • High-Sensitive C-Reactive Protein Predicts Recurrent Stroke and Poor Functional Outcome: Subanalysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events Trial [Original Contribution]2016-06-22 15:49:01 PM
    Minor stroke and transient ischemic attack are common disorders with high rate of subsequent disabling stroke. We aim to investigate the role of high-sensitive C-reactive protein (hsCRP) in predicting recurrent stroke and poor functional outcome.
    Methods—
    In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, 3044 (59%) consecutive patients from 73 (64%) prespecified centers had hsCRP levels measured. The primary outcome was any stroke within 90 days. The secondary outcome included combined vascular events and dependence or death defined as modified Rankin Scale score of 2 to 6 at 90 days and a new vascular event during 1-year follow-up. The associations of hsCRP with recurrent stroke and functional outcome were analyzed by using Cox proportional hazards and logistic regression models.
    Results—
    Elevated hsCRP (>3.0 mg/L) was observed in 32% of the study population. Patients with hsCRP >3 mg/L had an increased risk of recurrent stroke (adjusted hazard ratio, 1.46; 95% confidence interval, 1.08–1.98; P=0.039), ischemic stroke and combined vascular events, and poor functional outcome (adjusted odds ratio, 1.68; 95% confidence interval, 1.22–2.32; P=0.002) compared with those with hsCRP <1 mg/L within 90-day follow-up period. High hsCRP levels also independently predicted recurrent stroke during 1-year follow-up. There was no interaction of hsCRP levels with randomized antiplatelet therapy.
    Conclusions—
    High hsCRP levels predict recurrent stroke and poor functional outcome in acute patients with minor stroke or transient ischemic attack.
    Clinical Trial Registration—
    URL: http://ift.tt/PmpYKN. Unique identifier: NCT00979589.
  • ACR Appropriateness Criteria® Locoregional therapy for resectable oropharyngeal squamous cell carcinomas2016-06-22 15:48:52 PM

    Abstract

    Background

    There are no level I studies to guide treatment for resectable oropharyngeal squamous cell carcinoma (SCC). Treatment toxicities influence management recommendations. Ongoing investigations are examining deintensified treatments for human papillomavirus (HPV)-associated oropharyngeal SCC.

    Methods

    The Appropriateness Criteria panel, using modified Delphi methodology, produced a literature summary, an assessment of treatment recommendations, and cases to illustrate their use.

    Results

    A multidisciplinary team produces optimum results. Based on HPV status, smoking history, and staging, patients are divided into groups at low, intermediate, and high-risk of death. In the future, treatment recommendations may be influenced by HPV status, which has changed the epidemiology of oropharyngeal SCC.

    Conclusion

    T1 to T2N0M0 resectable oropharyngeal SCC can be treated with surgery or radiation without chemotherapy. Patients with T1-2N1-2aM0 disease can receive radiation, chemoradiation, or transoral surgery with neck dissection and appropriate adjuvant therapy. Patients with T1-2N2b-3M0 disease should receive chemoradiation or transoral surgery with neck dissection and appropriate adjuvant therapy. Concurrent chemoradiation is preferred for T3 to T4 disease. © 2016 American College of Radiology. Head Neck, 2016
  • The efficacy of submucosal corticosteroid injection and dilatation in subglottic stenosis of different aetiology2016-06-22 15:48:44 PM

    Main Articles

    The efficacy of submucosal corticosteroid injection and dilatation in subglottic stenosis of different aetiology

    M Wierzbickaa1 c1, M Tokarskia1, M Puszczewicza2 and W Szyftera1

    a1 Department of Otolaryngology, Head and Neck Surgery, Poznan University of Medical Sciences, Poland
    a2 Department of Rheumatology and Internal Medicine, Poznan University of Medical Sciences, Poland
    Abstract
    Objective: To determine the long-term efficacy of submucosal corticosteroid injection plus dilatation for subglottic stenosis as a single modality treatment in granulomatosis with polyangiitis and relapsing polychondritis, as compared with idiopathic subglottic stenosis and traumatic subglottic stenosis.
    Method: Patients who underwent dilatation for autoimmune causes were identified. Corticosteroid injection into the submucosa of a stenotic segment was followed by serial dilatation. Definitive improvement was defined as good airway patency for more than 24 months with no further procedures needed. Clinical, demographic and procedural data were recorded.
    Results: Patients (n = 45) were divided into three subglottic stenosis groups: traumatic (n = 24), idiopathic (n = 9) and autoimmune (n = 12). Patients were treated with dilatations, with a median follow-up time of 76 months. Six patients were tracheostomy-dependent. There were no statistical differences in the number of final improvements between autoimmune, idiopathic and traumatic groups, with values of 75, 56 and 71 per cent, respectively. There was no statistical difference between granulomatosis with polyangiitis plus relapsing polychondritis and idiopathic subglottic stenosis in terms of decannulation rates.
    Conclusion: Granulomatosis with polyangiitis and relapsing polychondritis patients have better improvement rates than patients with other subglottic stenosis types.
  • Cell origin in the macula flava of the human newborn vocal fold2016-06-22 15:48:39 PM

    Main Articles

    Cell origin in the macula flava of the human newborn vocal fold

    K Satoa1 c1, S Chitosea1, T Kuritaa1 and H Umenoa1

    a1 Department of Otolaryngology – Head and Neck Surgery, Kurume University School of Medicine, Japan
    Abstract
    Background: There is growing evidence to suggest that cells in the maculae flavae are tissue stem cells of the human vocal fold and maculae flavae are a stem cell niche.
    Methods: Three newborn vocal folds were investigated. Immunoreactivity to antibodies directed to cytokeratin, desmin, glial fibrillary acidic protein, vimentin, cluster of differentiation 34, cluster of differentiation 45, collagen type I, telomerase reverse transcriptase, SOX17 and stage-specific embryonic antigen 3 was investigated.
    Results: The cells in the newborn maculae flavae expressed haematopoietic markers (cluster of differentiation 34, cluster of differentiation 45) and collagen type I, which are the major makers of bone marrow derived circulating fibrocytes. The cells expressed epithelium, muscle, neural and mesenchymal cell associated proteins, and endodermal marker, indicating that they are undifferentiated and express proteins of all three germ layers. The cells also expressed stage-specific embryonic antigen 3 and telomerase reverse transcriptase.
    Conclusion: The cells in the newborn maculae flavae are undifferentiated cells arising from the differentiation of bone marrow cells. The results of this study are consistent with the hypothesis that the cells in maculae flavae are tissue stem cells.
  • Economic impact of recurrent respiratory papillomas in a UK adult population2016-06-22 15:48:27 PM

    Main Articles

    Economic impact of recurrent respiratory papillomas in a UK adult population

    A Harrisona1 c1, J Montgomerya2 and F B Macgregora3

    a1 Department of Otolaryngology, North Manchester General Hospital, Pennine Acute Trust, UK
    a2 Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
    a3 Department of Otolaryngology, Gartnavel General Hospital, Glasgow, Scotland, UK
    Abstract
    Objective: To calculate the financial burden of recurrent respiratory papilloma. This study is UK-based, where up until now no financial estimates have been calculated for this group of patients.
    Background: Recurrent respiratory papilloma is caused by the human papilloma virus (subtypes 6 and 11). The burden for the patient and the healthcare system is significant given the recurrent nature of the disease.
    Methods: Data were collected, using a questionnaire completed during routine clinical follow up, from a single centre managing recurrent respiratory papilloma in Glasgow, Scotland. Cost information was sourced from the Scottish Government's Information Services Division.
    Results: Fourteen patients with active recurrent respiratory papilloma between 2013 and 2014 were identified. The direct measurable cost to NHS Greater Glasgow and Clyde amounted to £107 478.
    Conclusion: Recurrent respiratory papilloma is a benign condition, but the financial implications of diagnosis are significant. Recurrent respiratory papilloma has a natural history of relapse and remission, and patients may require healthcare input over a period of several years.
  • Management of isolated cricopharyngeal dysfunction: systematic review2016-06-22 15:48:18 PM

    Review Articles

    Management of isolated cricopharyngeal dysfunction: systematic review

    A Ashmana1 c1, O T Dalea2 and D L Baldwina1

    a1 ENT Department, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, UK
    a2 ENT Department, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, UK
    Abstract
    Objective: A systematic review was performed to evaluate the safety and efficacy of different therapeutic interventions available for the management of isolated cricopharyngeal dysfunction.
    Methods: Studies were identified using the following databases: Ovid (Medline, Embase), the Cochrane Library, PubMed and Google Scholar. An initial search identified 339 articles. All titles and abstracts were reviewed. Fifty-six relevant articles were inspected in more detail; of these, 47 were included in the qualitative analysis.
    Results: No relevant randomised trials were found. A range of case series were used to perform a qualitative analysis. Botulinum toxin A injection and cricopharyngeal dilatation were associated with a higher risk of recurrence, but appear to be more suitable in elderly and co-morbid patients. In those patients requiring formal myotomy, endoscopic approaches appear to be as effective but less morbid when compared with classical open surgery.
    Conclusion: There is good evidence for the safety and efficacy of the different therapeutic options for isolated cricopharyngeal dysfunction. However, further studies are required to compare the efficacy of the various treatment modalities.
  • Optimal outcomes for hearing preservation in the management of small vestibular schwannomas2016-06-22 15:48:09 PM

    Review Articles

    Optimal outcomes for hearing preservation in the management of small vestibular schwannomas

    K A Penga1 and E P Wilkinsona1 c1

    a1 House Clinic, Los Angeles, California, USA
    Abstract
    Objective: To undertake a systematic review of the role of microsurgery, in relation to observation and stereotactic radiation, in the management of small vestibular schwannomas with serviceable hearing.
    Methods: The Medline database was searched for publications that included the terms 'vestibular schwannoma' and/or 'acoustic neuroma', occurring in conjunction with 'hearing'. Articles were manually screened to identify those concerning vestibular schwannomas under 1.5 cm in greatest dimension. Thereafter, only publications discussing both pre-operative and post-operative hearing were considered.
    Results: Twenty-six papers were identified. Observation is an acceptable strategy for small tumours with slow growth where hearing preservation is not a consideration. In contrast, microsurgery, including the middle fossa approach, may provide excellent hearing outcomes, particularly when a small tumour has begun to cause hearing loss. Immediate post-operative hearing usually predicts long-term hearing. Recent data on stereotactic radiation suggest long-term deterioration of hearing following definitive therapy.
    Conclusion: In patients under the age of 65 years with small vestibular schwannomas, microsurgery via the middle fossa approach offers durable preservation of hearing.
  • Reversible hearing loss following cryptococcal meningitis: case study2016-06-22 15:47:59 PM

    Clinical Record

    Reversible hearing loss following cryptococcal meningitis: case study

    W L Neoa1 c1, N Durisalaa2 and E C Hoa1

    a1 Department of Otolaryngology, Tan Tock Seng Hospital, Singapore
    a2 Department of Audiology, Tan Tock Seng Hospital, Singapore
    Abstract
    Background: Sensorineural hearing loss is a recognised complication of cryptococcal meningitis. The mechanism of hearing loss in patients with cryptococcal meningitis is different from that in bacterial meningitis.
    Case report: An immune-competent man with cryptococcal meningitis presented with sudden onset, bilateral, severe to profound sensorineural hearing loss and vestibular dysfunction. He was initially evaluated for cochlear implantation. However, he had a significant recovery; he no longer required surgery and was able to cope without a hearing aid.
    Conclusion: Typically, cochlear implantation is performed with some urgency in patients with hearing loss post-bacterial meningitis, because of the risk of labyrinthitis ossificans. However, this process has not been described in patients with cryptococcal meningitis. Furthermore, patients with hearing loss associated with cryptococcal meningitis have shown varying degrees of reversibility. In this case report, hearing loss from cryptococcal meningitis is compared with that from bacterial meningitis, and the need for cochlear implantation in patients with cryptococcal meningitis is discussed.
  • Does topical use of autologous serum help to reduce post-tonsillectomy morbidity? A prospective, controlled preliminary study2016-06-22 15:47:55 PM

    Main Articles

    Does topical use of autologous serum help to reduce post-tonsillectomy morbidity? A prospective, controlled preliminary study

    M Karaa1 c1, H Erdoğana1, H B Altinişika2, H Aylança3, O Güçlüa1 and F S Dereköya1

    a1 Department of Otorhinolaryngology, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
    a2 Department of Anesthesiology and Reanimation, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
    a3 Department of Pediatry, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey
    Abstract
    Background: To evaluate the effects of autologous serum usage on throat pain, haemorrhage and tonsillar fossa epithelisation in patients after tonsillectomy.
    Methods: Thirty-two patients (aged 4–15 years) were included in the study. Tonsillectomy was performed and autologous serum was administered topically to the right tonsillar fossa during the operation, and at 8 and 24 hours post-operatively. The left side served as the control. A visual analogue scale was used to record the patient's pain every day. Each patient's oropharynx was observed on the 5th and 10th post-operative days to examine bleeding and epithelisation.
    Results: The pain scores for the side administered autologous serum were significantly lower than those for the control side, on the night following the operation and on the 1st, 2nd, 5th and 6th post-operative days. Tonsillar fossa epithelisation was significantly accelerated on the study side compared with the control side on the 5th and 10th post-operative days.
    Conclusion: In tonsillectomy patients, topically administered autologous serum contributed to throat pain relief and tonsillar fossa epithelisation during the post-operative period.
  • Age of onset of Ménière's disease in the Netherlands: data from a specialised dizziness clinic2016-06-22 15:47:43 PM

    Main Articles

    Age of onset of Ménière's disease in the Netherlands: data from a specialised dizziness clinic

    B F Van Escha1 c1, P P G Van Benthema1, H J Van Der Zaag-Loonena1 and TJ D Bruintjesa1

    a1 Apeldoorn Dizziness Centre, Gelre Hospital, Apeldoorn, The Netherlands
    Abstract
    Objectives: To determine the age of onset of Ménière's disease in patients who visited a specialised dizziness clinic, and to verify whether the trend of a delayed onset age of Ménière's disease as reported for the Japanese population also occurs in the Netherlands.
    Method: A retrospective data analysis was performed of patients diagnosed with 'definite' Ménière's disease who visited our clinic between January 2000 and December 2013.
    Results: Mean onset age of Ménière's disease among the 296 patients was 53.0 ± 14.1 years; 209 patients (71 per cent) were diagnosed between the fifth and seventh decades of life. No trend towards a later onset of Ménière's disease was found (regression beta co-efficient for year of presentation was 0.03; 95 per cent confidence interval = −0.34–0.61; p = 0.58).
    Conclusion: Ménière's disease has a peak incidence between 40 and 69 years of age. No shift towards a later onset age of Ménière's disease was found.
  • The Pharmacokinetics of Atomized Lidocaine Administered via the Trachea2016-06-22 15:53:48 PM
    A Randomized Trial: imageBACKGROUND: Under emergent conditions, endotracheal drug administration may be an effective method of delivering emergency drugs. A common technique is to administer these drugs using a nonatomized spray. Atomized drug delivery may be an attractive alternative to nonatomized delivery because atomized particles are small, cover a large surface area, and may better adhere to endotracheal membrane resulting in more effective drug absorption. In this study, we compared the pharmacokinetic profile of lidocaine administered into the trachea using an atomized or a nonatomized technique.

    METHODS: Twenty patients were anesthetized using propofol and remifentanil. Ten minutes after rocuronium was administered, patients received 4% lidocaine (2 mg/kg) intratracheally over 2 seconds before tracheal intubation. Ten patients received atomized lidocaine using a mucosal atomization device, and the other 10 patients received nonatomized lidocaine using a traditional spray tube. Arterial lidocaine plasma concentrations were measured before; at 1, 3, 5, 7, 10, 15, 20, 30, 45, and 60 minutes; and then every 60 minutes after the administration of lidocaine until the end of the operation. We developed a pharmacokinetic model to examine whether bioavailability or absorption rate was different between atomized versus nonatomized lidocaine administration. The total body clearance was fixed at a published value to determine the bioavailability.

    RESULTS: Peak plasma concentrations were larger using the mucosal atomization device (median [range]: 1.9 [1.4−3.2] μg/mL) than the spray tube (1.1 [0.6−2.0] μg/mL; P = 0.0021). Our pharmacokinetic model estimated a difference of bioavailability between the atomized and the nonatomized lidocaine (0.801 and 0.559 respectively, P = 0.0005), whereas our model estimated no difference in the absorption rate constant (0.00688/min).

    CONCLUSIONS: Our results suggest that when using atomized delivery of lidocaine, less drug is required to achieve a near equivalent plasma lidocaine concentration. Atomized drug administration may be a more efficient method for endotracheal drug administration.


  • A Primer on Population Health Management and Its Perioperative Application2016-06-22 15:53:15 PM
    A Primer on Population Health Management and Its Perioperative Application: imageThe movement toward value-based payment models, driven by governmental policies, federal statutes, and market forces, is propelling the importance of effectively managing the health of populations to the forefront in the United States and other developed countries. However, for many anesthesiologists, population health management is a new or even foreign concept. A primer on population health management and its potential perioperative application is thus presented here. Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health. The Population Health Alliance has created a particularly cogent conceptual framework and interconnected and very useful population health process model, which together identify the key components of population health and its management. Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population. The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures. Population health management strategies are increasingly more important to leaders of health care systems as the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, robust outcomes data analysis, and continuous quality improvement. Anesthesiologists have an opportunity to help lead these efforts in concert with their surgical and nursing colleagues. The Triple Aim of Healthcare includes (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing per-capita costs of care. The Perioperative Surgical Home essentially seeks to transform perioperative care by achieving the Triple Aim, including improving the health of the surgical population. Many health care delivery systems and many clinicians (including anesthesiologists) are just beginning their population health management journeys. However, by doing so, they are preparing to navigate a much greater risk-sharing landscape, where these efforts can create greater financial stability by preventing major financial loss. Anesthesiologists can and should be leaders in this effort to add value by improving the comprehensive continuum of care of our patients.


  • Hemostatic Therapy Using Tranexamic Acid and Coagulation Factor Concentrates2016-06-22 15:52:55 PM
     in a Model of Traumatic Liver Injury: BACKGROUND: The potential clinical benefits of targeted therapy with coagulation factor concentrates (e.g., fibrinogen) and antifibrinolytic agents (e.g., tranexamic acid [TXA]) for the treatment of trauma-induced coagulopathy are increasingly recognized. We hypothesized that human fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC), administered as combined therapy with TXA, would provide additive effects for reducing blood loss in an animal trauma model.

    METHODS: Thirty-six pigs were subjected to 2 consecutive blunt liver injuries, resulting in severe hemorrhagic shock and coagulopathy. Intervention comprised saline (control group); TXA (15 mg kg−1, TXA group); TXA and FC (90 mg kg−1, TXA–FC); or TXA, FC, and PCC (20 U kg−1, TXA–FC–PCC). Blood loss, thromboelastometry (ROTEM), measures of thrombin generation, platelet activation, and global coagulation variables were monitored for 4 hours. Tissue sections were examined to determine the occurrence of thromboembolic events.

    RESULTS: Total blood loss was similar in the TXA–FC and TXA–FC–PCC groups (mean ± SD: 1012 ± 86 mL and 1037 ± 118 mL, respectively; P = 1.000). These values were both lower (P


  • The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves: A Study on Amputated Human Limbs2016-06-22 15:52:24 PM
    The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves: A Study on Amputated Human Limbs: BACKGROUND: Even as the use of peripheral nerve blockade in the perioperative setting is increasing, neural injury secondary to accidental intraneural injection remains a significant patient safety concern. Current modalities, including electrical stimulation and ultrasound imaging, still lack consistency and absolute reliability in both the detection and prevention of this complication. The measurement of electrical impedance (EI) could be an easy and valuable additional tool to detect intraneural needle placement. Our objectives in this study were to measure the change in EI with intraneural needle advancement in recently amputated human limbs.

    METHODS: The study was conducted within 45 minutes of amputation. The nerves that were studied were the sciatic nerve in the popliteal fossa in above-knee amputations or the tibial nerve below the calf in below-knee amputations. The amputated limb was placed on a tray and under ultrasound imaging guidance, an insulated peripheral block needle connected to a nerve stimulator was placed extraneurally and subsequently advanced intraneurally. The experiment was repeated on the same nerve after exposure by surgical dissection. The differences in impedance measurements between intraneural and extraneural needle placement were compared.

    RESULTS: In the below-knee amputated extremity (tibial nerve, n = 6) specimens based on the ultrasound methods, mean ± SD for ultrasound-guided intraneural impedance was 10 ± 2 kΩ compared with an extraneural impedance of 6 ± 1.6 kΩ (P = 0.005). The difference between intraneural and extraneural impedance after open dissection was also significant when we repeated the analysis based on the same specimens (P = 0.005). Similarly, in the above-the-knee amputated extremity (sciatic nerve, n = 5) specimens, mean intraneural impedance was 35.2 ± 7.9 kΩ compared with an extraneural impedance of 25.2 ± 5.3 kΩ (P = 0.037). The difference between intraneural and extraneural impedance obtained after open dissection was also significant when we repeated the analysis based on the same specimens (P = 0.0002). The impedance values were consistent and similar to those obtained after open dissection.

    CONCLUSIONS: There is no reliable "gold standard" to predict or prevent intraneural needle placement during peripheral nerve blockade. This small sample-sized study demonstrated that there is a change in EI with intraneural needle advancement. In clinical practice, measurement of the EI in conjunction with nerve stimulation may serve as another tool to use for identifying intraneural needle placement during peripheral nerve blockade.


  • Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study2016-06-22 15:52:00 PM
    Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study: BACKGROUND: Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients.

    METHODS: We approached 311 patients aged 65 years and older presenting for preoperative evaluation before elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible, and 63 declined. The remaining 200 were randomly assigned to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room, and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5.

    RESULTS: The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. There were no significant differences between patients randomly assigned to the Mini-Cog and CIB test in age, weight, gender, education, ASA physical status, or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P = 1.0 by χ2 analysis). Both tests had good interrater reliability (Krippendroff α = 0.86 [0.72–0.93] for Mini-Cog and 11 for CIB).

    CONCLUSIONS: Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.


  • The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor2016-06-22 15:51:35 PM
    The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor: BACKGROUND: Sleep disruption in critically ill adults can result in acute decrements in cognitive function, including delirium, but it is underdiagnosed in the setting of the intensive care unit (ICU). Although sleep stages can be assessed by polysomnography (PSG), acquisition and interpretation of PSG is costly, is labor intensive, is difficult to do over an extended period of time with critically ill patients (multiple days of continuous recording), and may interfere with patient care. In this pilot study, we investigated the feasibility and utility of monitoring sleep in the ICU setting using a portable electroencephalography (EEG) monitor, the SedLine® brain monitor.

    METHODS: We first performed a baseline comparison study of the SedLine brain monitor by comparing its recordings to PSG recorded in a sleep laboratory (n = 3). In a separate patient cohort, we enrolled patients in the ICU who were monitored continuously with the SedLine monitor for sleep disruption (n = 23). In all enrolled patients, we continuously monitored their EEG. The raw EEG was retrieved and sleep stages and arousals were analyzed by a board-certified technologist. Delirium was measured by a trained research nurse using the Confusion Assessment Method developed for the ICU.

    RESULTS: For all enrolled patients, we continuously monitored their EEGs and were able to retrieve the raw EEGs for analysis of sleep stages. Overall, the SedLine brain monitor was able to differentiate sleep stages, as well as capture arousals and transitions between sleep stages compared with the PSG performed in the sleep laboratory. The percentage agreement was 67% for the wake stage, 77% for the non-rapid eye movement (REM) stage (N1 = 29%, N2 = 88%, and N3 = 6%), and 89% for the REM stage. The overall agreement was measured with the use of weighted kappa, which was 0.61, 95% confidence interval, 0.58 to 0.64. In the ICU study, the mean recording time for the 23 enrolled patients was 19.10 hours. There were several signs indicative of poor-quality sleep, where sleep was distributed throughout the day, with reduced time spent in REM (1.38% ± 2.74% of total sleep time), and stage N3 (2.17% ± 5.53% of total sleep time) coupled with a high arousal index (34.63 ± 19.04 arousals per hour). The occurrence of ICU delirium was not significantly different between patients with and without sleep disruption.

    CONCLUSIONS: Our results suggest the utility of a portable EEG monitor to measure different sleep stages, transitions, and arousals; however, the accuracy in measuring different sleep stages by the SedLine monitor varies compared with PSG. Our results also support previous findings that sleep is fragmented in critically ill patients. Further research is necessary to develop portable EEG monitors that have higher agreement with PSG.


  • Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine2016-06-22 15:51:12 PM
    Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine: imageBACKGROUND: Histamine receptors are known to participate in spinal cord nociceptive transmission, and previous studies have suggested that histaminergic receptors are involved in the analgesic effects of morphine. Herein, we investigated the effect of intrathecal injection of histaminergic agonists and antagonists in a model of acute articular inflammation and their interaction with morphine.

    METHODS: After carrageenan injection in the right knee joint, articular incapacitation was measured hourly, for up to 6 hours, by the paw elevation time during 1-minute periods of stimulated walking. Inflammatory edema was also assessed hourly by determining an increase in articular diameter. Spinal treatments were administered 20 minutes before knee-joint carrageenan injection and were compared with the saline-treated control group.

    RESULTS: Intrathecally injected histamine increased incapacitation and articular edema, whereas the H1R antagonist, cetirizine, decreased both parameters. The H3R agonist, immepip, decreased both incapacitation and edema, but the H3R antagonist, thioperamide, increased both incapacitation and edema. Morphine inhibited both incapacitation and edema. Furthermore, combining a subeffective dose of morphine with cetirizine or immepip potentiated the analgesic and antiedematogenic effect.

    CONCLUSIONS: Histamine seems to act at the spinal level via H1 and H3 receptors to modulate acute arthritis in rats. An H1R antagonist and H3R agonist were found to potentiate the analgesic and antiedematogenic effects of morphine, suggesting that histaminergic and opioid spinal systems may be explored for means of improving analgesia, as well as peripheral anti-inflammatory effects.


  • Vermilion Reconstruction with Genital Mucosa2016-06-22 15:50:50 PM
    Vermilion Reconstruction with Genital Mucosa:

      imageSummary: Functional and aesthetical reconstruction, especially of the upper lip after ablative tumor surgery, can be very challenging. The skin of the lip might be sufficiently reconstructed by transpositional flaps from the nasolabial or facial area. Large defects of the lip mucosa, including the vestibule, are even more challenging due to the fact that flaps from the inner lining of the oral cavity often lead to functional impairments. We present a case of multiple vermilion and skin resections of the upper lip. At the last step, we had to resect even the whole vermilion mucosa, including parts of the oral mucosa of the vestibule, leaving a bare orbicularis oris muscle. To reconstruct the mucosal layer, we used a mucosal graft from the labia minora and placed it on the compromised lip and the former transpositional flaps for the reconstructed skin of the upper lip with very good functional and aesthetic results.


  • Three-dimensional autologous cartilage framework fabrication assisted by new additive manufactured ear-shaped templates for microtia reconstruction2016-06-22 15:50:06 PM
    Three-dimensional autologous cartilage framework fabrication assisted by new additive manufactured ear-shaped templates for microtia reconstruction: During microtia reconstruction, the intra-operative design of the cartilage framework is important for the appearance and symmetry of the bilateral auricles. Templates (traditionally, the x-ray film template) are usually utilized to complete the task, which can provide cues regarding size, cranioauricular angle and positioning to the surgeons. With a combination of three-dimensional (3D) scanning and additive manufacturing (AM) techniques, we utilized two different ear-shaped templates (sheet moulding and three-dimensional templates) during the fabrication of 3D customized autologous cartilage frameworks for auricle reconstruction.


  • A method to switch from oral dopamine agonists to rotigotine in patients with restless legs syndrome and mild augmentation2016-06-22 15:49:45 PM

    Article in Press

    Highlights

    • Augmentation of RLS symptoms with oral dopamine agonists is common.
    • Optimal management of augmentation in such cases is controversial.
    • Cross-titration to rotigotine was successful in 70% of patients with mild augmentation at 5 weeks.
    • However, at 1 year, 50% had discontinued rotigotine due to lack of continued efficacy or side effects.

    Abstract

    Background

    We examined the short- and long-term efficacy and tolerability of a cross-titration algorithm from oral dopamine agonists to the rotigotine transdermal patch in patients dissatisfied with their RLS treatment, predominantly with mild augmentation.

    Methods

    Patients with RLS (n=20) were recruited at a single site. The cross-titration consisted of decreasing oral dopaminergic agents (ropinirole by 1 mg or pramipexole by 0.25 mg) and increasing rotigotine by 1 mg every two days. Efficacy and AEs were assessed at 1, 3, 6 and 12 months after the switch.

    Results

    Patients had moderate-severe RLS symptoms at baseline (mean IRLS score 19.4 ± 5.5); 85% had augmentation and 45% reported afternoon RLS symptoms. Baseline mean pramipexole equivalent dose was 0.6 ± 0.3 mg. At Week 5, 85% (17/20) had successfully switched from their oral dopamine agonist to rotigotine (mean dose 2.5 ± 0.6 mg; change in IRLS score: -6.7 ± 8.4, p=0.002); 14 patients were CGI-I responders (much or very much improved). Three patients withdrew due to lack of efficacy. Twelve months after cross-titration, 10 patients continued on rotigotine, of whom 4 required either higher doses of rotigotine or supplemental RLS medication compared to their optimal Week 5 dose; five patients withdrew due to AEs and 2 due to lack of efficacy.

    Conclusion

    A cross-titration to rotigotine was efficacious after 5 weeks in 70% of patients dissatisfied with RLS treatment, most of whom had mild augmentation. At 1 year following the medication switch 50% had discontinued rotigotine due to lack of continued efficacy or side effects.
  • Sleep disordered breathing and nocturnal hypoxemia in young adults with sickle cell disease2016-06-22 15:49:00 PM

      Highlights

      • An AHI > 5 was seen in 10 of 20 subjects attending a sickle cell disease clinic.
      • Elevated AHI correlated with systolic BP, mitral valve E/A ratio, and QoL scores.
      • Hypoxemia occurred in some subjects independently from sleep apnea events.
      • Results suggest further study with larger subject numbers is warranted.

      Abstract

      Sleep disordered breathing (SDB) is reported in up to 69% of adolescents and children with sickle cell disease (SCD) [1], but data regarding the prevalence of SDB in adults with SCD are limited. To obtain a preliminary assessment of the frequency and degree of sleep-related hypoxemia and potential associations with cardiovascular function in adults with SCD, we performed overnight sleep studies, 6-minute walk tests, echocardiograms, hematologic and chemistry panels, and administered the Pittsburgh Sleep Quality Index (PSQI), fatigue and health related quality of life measurement in 20 young adults with SCD attending a sickle cell clinic for routine care. Sleep apnea, defined as an apnea-hypopnea index (AHI) >5 events/hour, was found in 50% of subjects. Traditional clinical indicators such as obesity, the presence of snoring, and reported sleep complaints did not reliably differentiate these subjects. Subjects with an AHI>5 had higher mean systolic blood pressure (p =.03), evidence of impaired left ventricular diastolic function (i.e. increased mitral valve E/A ratio, p =.05), a trend toward greater reduction in 6 minute walk distances (p =.06), and lower Health-related Quality of Life scores (p <=.01). Three of nine subjects with more severe anemia (total Hb < 9.0) demonstrated nocturnal hypoxemia in the absence of sleep apnea. As prolonged and frequent hypoxemic episodes likely increase risks for vaso-occlusive, cardiovascular, and neurologic complications of SCD, these results suggest that the prevalence and severity of SDB should be investigated further in studies of larger patient populations. If confirmed, these findings could identify opportunities to prevent or reduce nocturnal hypoxia and improve outcomes.
    • Free Tissue Transfer to Head and Neck2016-06-22 15:47:51 PM

      Publication date: Available online 22 June 2016
      Source:Clinics in Plastic Surgery
      Author(s): Thomas H. Nagel, Richard E. Hayden

      Teaser

      Free tissue transfer to the head and neck in the modern era has a high success rate. To maximize success with reconstructive surgery in the head and neck region, it helps to understand those factors that present unique challenges. These factors include contamination by the upper aerodigestive tract, tissue mobility, and a high percentage of patients receiving radiotherapy for oncologic treatment. This article reviews the authors' experience in the head and neck, specifically how addressing these factors can best lead to successful functional and aesthetic outcomes. The authors share surgical techniques and lessons learned from their successes and failures.
    • Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology2016-06-22 15:42:15 PM
      Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology: Objective

      Nonthyroid metastases to the thyroid gland can cause morbidity, including dysphagia, dysphonia, and airway compromise. Because metastatic malignancies portend a poor prognosis, obtaining equipoise between treatment morbidity and local disease progression is paramount. We reviewed cases of nonthyroid metastases to determine treatment and prognostic recommendations.

      Study Design

      Case series with chart review.

      Setting

      Tertiary care hospital.

      Subjects and Methods

      We searched PubMed for reported cases between 1994 and September 2013 using search terms as follows: any combination of primary tumor locations and thyroid, as well as the terms thyroid and metastasis. Only unique cases of nonthyroid metastases were included. Combined with 17 additional tumors at our own institution, we found 818 unique nonthyroid metastases, of which 384 had management and survival data available.

      Results

      Renal cell carcinoma was most common, presenting in 293 (35.8%) patients, followed by lung and gastrointestinal malignancies. Patients were treated with total thyroidectomy (34.0%), subtotal thyroidectomy including lobectomy (32.6%), and no surgery (33.5%). Surgical management was associated with improved survival duration (P < .01). Locoregional recurrence was less likely in patients treated with total versus partial thyroidectomy (4.8% vs 13%). Extent of surgical management did not have a significant effect on patient survival. Delayed presentation was associated with improved survival duration (P = .01).

      Conclusions

      Nonthyroid metastases to the thyroid gland are unusual tumors. Surgical intervention is associated with improved survival, but expected morbidity of untreated tumors is difficult to assess. Site of origin, time to diagnosis, and surgical approach are related to survival and recurrence rates.

    • ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?2016-06-22 15:42:00 PM
      ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?:

      The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator is meant to provide an estimation of perioperative risk. Our goal was to determine the clinical applicability of the calculator in major head and neck surgery. A retrospective chart review was completed for major head and neck operations performed at 1 institution from 2013 to 2014. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. Overall, the ACS NSQIP calculator had little predictive value for pneumonia, surgical site infection, 30-day return to operating room, or length of stay within this cohort (P > .05). The calculator appears to have some value predicting total numbers of complications but has poor performance predicting an individual's risk of suffering a perioperative complication. In conclusion, in our small cohort of patients, the ACS NSQIP calculator was a poor predictor of perioperative complications following major head and neck operations.

    • Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care2016-06-22 15:41:51 PM
      Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care: Objectives

      (1) Measure patients' experiences with surgical care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey. (2) Use lean thinking to analyze and improve quality of patient care.

      Study Design

      A prospective quality improvement study.

      Setting

      Hospital-based otolaryngology clinic.

      Subjects and Methods

      The CAHPS Surgical Care Survey was distributed to 17 surgical patients to determine their perception of the current state of care. Survey results were analyzed with lean thinking, and changes were made to improve critical areas. A second set of surveys was distributed to 10 patients to assess the success of the interventions immediately and 2 months later. The data were analyzed with the Mann-Whitney U test.

      Results

      Seventeen patients completed the CAHPS Surgical Care Survey to determine the initial state. A3 Thinking was used to analyze the results and design an improvement. Overall positive patient experience was 57% at the postoperative visit with 3 key aspects of care: time spent during visit, encouragement to ask questions, show of respect to the patient. Two causes were postulated; then, solution approaches were developed and tested in a series of rapid experiments. Two groups of 10 patients completed the CAHPS Surgical Care Survey to determine the postintervention state. Overall positive patient experience significantly improved to 93% (U = 474, P < .001) and 83% (U = 546, P = .009) immediately and 2 months later, respectively.

      Conclusion

      Lean thinking helps to eliminate defects by breaking down complex problem solving into a scientific process. When combined with the CAHPS Surgical Care Survey, it can be successfully used to improve patients' surgical experiences.

    • Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy2016-06-22 15:41:41 PM
      Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy: Objective

      To determine if decisional regret (DR) in parents following tonsillectomy/adenotonsillectomy (TA) in their children is related to preoperative decisional conflict, perceived outcome of surgery, complications of surgery, or other factors.

      Study Design

      Observational analytic cohort study.

      Setting

      Tertiary care children's hospital.

      Subjects and Methods

      Preoperative decisional conflict (DC) and SURE tests were administered to a parent of a child scheduled for TA between July 2014 and July 2015. The DR tests were given 1 to 3 months postoperatively. Data were collected on patient age, sex, perceived outcome of surgery, complications (including bleeding), emergency room visits, and clinic phone calls.

      Results

      A total of 102 families were studied, including 48 female and 54 male patients with an average age of 6.29 years. Parental respondents included 83 mothers, 14 fathers, and 5 grandmothers. Overall, DC and DR were both low in this group, with a median of 0 for each (means: 7.74 for DC and 8.78 for DR). DC was higher in parents who canceled surgery or failed to keep follow-up appointments (27.19) versus parents who brought their children for surgery (6.78; P < .05). DR was significantly higher in parents with DC (20.00 vs 7.59; P < .05). It was not related to age of the patient, sex, parental perception of resolution of preoperative complaints, complications (including bleeding or dehydration), emergency department visits, or parental phone calls to the otolaryngology clinic. SURE tests indicated that every parent was confident of his or her decision on the day of surgery.

      Conclusion

      Preoperative DC is likely the most important factor in determining parental DR after the child undergoes TA.

    • Clinical Practice Guidelines: Whose Practice Are We Guiding?2016-06-22 15:41:27 PM
      Clinical Practice Guidelines: Whose Practice Are We Guiding?:

      The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has just released an update to the clinical practice guideline (CPG) on otitis media with effusion. This common condition is frequently managed by primary care providers; however, their awareness and utilization of the AAO-HNSF CPGs are unknown. We performed a cross-sectional survey to assess familiarity with otologic diagnoses, evaluation skills, and guidelines. Only 38.5% of respondents use pneumatic otoscopy, and roughly 50% utilize a CPG for management of otitis media or for referral for tympanostomy tube insertion. Providers predominantly use the acute otitis media guideline from the American Academy of Pediatrics. In this single-institution study, providers are largely unaware of the AAO-HNSF CPGs and could benefit from additional training, including workshops taught by otolaryngologists within individual health care systems or development of a national otolaryngology medical student curriculum. A more immediate option includes referencing our CPGs on specialty societies' websites or newsletters.

    • Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends2016-06-22 15:41:15 PM
      Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends:

      Four-dimensional computed tomography (4D-CT) is a new modality for preoperative localization of parathyroid adenomas. We performed a survey study to describe the role and trends in the utilization of 4D-CT. Of 361 radiologists, 200 (55%) reported that 4D-CT was used in their practices. Nineteen (10%) used 4D-CT as the first-line imaging study; 155 (76%) reported that 4D-CT played a secondary role; and 26 (13%) reported that it is performed routinely in combination with ultrasound and scintigraphy. Early adopters of 4D-CT (use for >3 years) were 3 times more likely to use 4D-CT in a first-line role (18%) when compared with radiologists who used 4D-CT for ≤3 years (6%; P < .05). In conclusion, more than half of radiologists perform 4D-CT, and a majority reported that 4D-CT plays a secondary role. However, this role may change, as utilization is increasing and radiologists may follow early adopters, who are more likely to use it as a first-line study.

    • Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes2016-06-22 15:41:06 PM
      Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes: Objectives

      to determine national benchmarks for established quality indicators in head and neck cancer (HNCA) surgery, focusing on differences between academic and nonacademic institutions.

      Study Design

      Cross-sectional analysis of national database.

      Subjects and Methods

      HNCA surgery admissions from the 2009-2011 Nationwide Inpatient Sample were analyzed for preoperative characteristics and postoperative outcomes. Multivariate analyses were used to identify factors influencing quality indicators after HNCA surgery. Quality metrics—including length of stay (LOS), inpatient death, return to the operating room (OR), wound infection, and transfusion—were compared for academic versus nonacademic institutions.

      Results

      A total of 38,379 HNCA surgery inpatient admissions (mean age, 56.5 years; 52.4% male) were analyzed (28,288 teaching vs 10,091 nonteaching). Nationally representative quality metrics for HNCA surgery were as follows: mean LOS, 4.26 ± 0.12 days; return to OR, 3.3% ± 0.2%; inpatient mortality, 0.7% ± 0.1%; wound infection rate, 0.9% ± 0.1%; wound complication rate, 4.3% ± 0.2%; and transfusion rate, 4.3% ± 0.3%. HNCA surgery patients at teaching hospitals had a greater proportion of males, radiation history, and high-acuity procedures and greater comorbidity scores (all P < .001). Multivariate analyses adjusting for age, sex, income, payer, prior radiation, comorbidity scores, and procedural acuity demonstrated that teaching hospitals had a slightly increased LOS (+0.30 days; P = .009) and odds ratio for wound infection (1.54; 95% CI: 1.22-1.94) versus nonteaching hospitals. There were no significant differences in return to OR (P = .271), inpatient mortality (P = .686), or transfusion rate (P = .960).

      Conclusion

      Despite caring for substantially more complex HNCA surgery patients with greater comorbidities, teaching hospitals demonstrate only a marginally increased LOS and wound complication rate versus nonteaching hospitals, while other established quality metrics are similar.

    • Are Online Zenkers Diverticulum Materials Readable and Understandable?2016-06-22 15:40:55 PM
      Are Online Zenkers Diverticulum Materials Readable and Understandable?: Objective

      Patients use a multitude of resources to learn about Zenker's diverticulum (ZD). The objectives of this study were to assess the readability and understandability of online materials on ZD, evaluate them against the existing criteria, and investigate the relationship between readability and understandability.

      Methods

      The first 50 webpages from an online search for ZD were analyzed. Twenty-one webpages had materials intended for patients and were included in the study. The patient education materials (PEMs) were analyzed using 6 readability tools. Four individuals used the Patient Education Materials Evaluation Tool (PEMAT) to assess the understandability. Fleiss interrater reliability analysis determined consistency among the raters. Finally, Pearson correlation coefficient analyzed the relationship between readability and understandability.

      Results

      The reading grade level of the materials reviewed ranged from 10th to 16th grade while the understandability ranged from 31% to 74%. Correlation analysis demonstrated a strong negative correlation between readability and understandability (r = –0.62, P < .05). Fleiss' interrater reliability for the raters demonstrated substantial agreement between the 4 raters ( = 0.64).

      Conclusion

      Online PEMs pertaining to ZD are written well above the recommended reading level. Materials written at a lower reading level are more understandable. A wide range of understandability exists among materials with identical reading grade levels.

      Implications for Practice

      Health care providers need to create new PEMs for ZD that are available online that are both readable and understandable. The PEMAT and readability formulas can provide a framework for authors to create these materials.




    from #Med Blogs by Alexandros G.Sfakianakis via Alexandros G.Sfakianakis on Inoreader http://ift.tt/28NdGvD
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