Presence of varicella zoster virus in zosteriform leukaemia cutis

Summary

Leukaemia cutis is a relatively rare manifestation in chronic lymphocytic leukaemia, characterized by a diverse morphology of skin lesions. We report two patients who developed zosteriform skin symptoms; however, the histological analysis revealed leukaemia infiltration as the cause of their symptoms. Contrary to previous reports, varicella zoster virus DNA was detectable in the lesions. These findings suggest that varicella zoster virus plays an active role in the development of zosteriform leukaemia cutis.

http://bit.ly/2RjBY6O

Impact of smoking on imiquimod response in patients with vulval intraepithelial neoplasia

Summary

Background

Vulval intraepithelial neoplasia (VIN) is a precancerous condition that may progress to invasive malignancy. VIN is associated with human papillomavirus (HPV) infection in most cases, and with inflammatory skin disorders in a smaller proportion of patients. Treatment of VIN has traditionally been surgical excision; however, topical treatments, including imiquimod cream, are becoming increasingly used. Patient factors influencing response to imiquimod therapy, in particular smoking, have not yet been published.

Aim

To assess the impact of smoking and other patient characteristics that may influence the treatment response to topical imiquimod for VIN.

Methods

This was a retrospective cohort study of 46 women treated with topical imiquimod for VIN in a single centre dermatology unit from January 2011 to July 2017.

Results

Complete clinical resolution of VIN was observed in 28 of 46 patients (61%), but was significantly reduced in the smoking cohort.

Conclusions

Smoking may impair response to imiquimod for VIN, and should be considered when discussing VIN treatment options with patients.

http://bit.ly/2C8VmJ8

Two cases of perniosis in a free flap and a graft site of the hands

http://bit.ly/2H4koiq

Presence of varicella zoster virus in zosteriform leukaemia cutis

Summary

Leukaemia cutis is a relatively rare manifestation in chronic lymphocytic leukaemia, characterized by a diverse morphology of skin lesions. We report two patients who developed zosteriform skin symptoms; however, the histological analysis revealed leukaemia infiltration as the cause of their symptoms. Contrary to previous reports, varicella zoster virus DNA was detectable in the lesions. These findings suggest that varicella zoster virus plays an active role in the development of zosteriform leukaemia cutis.

http://bit.ly/2RjBY6O

Impact of smoking on imiquimod response in patients with vulval intraepithelial neoplasia

Summary

Background

Vulval intraepithelial neoplasia (VIN) is a precancerous condition that may progress to invasive malignancy. VIN is associated with human papillomavirus (HPV) infection in most cases, and with inflammatory skin disorders in a smaller proportion of patients. Treatment of VIN has traditionally been surgical excision; however, topical treatments, including imiquimod cream, are becoming increasingly used. Patient factors influencing response to imiquimod therapy, in particular smoking, have not yet been published.

Aim

To assess the impact of smoking and other patient characteristics that may influence the treatment response to topical imiquimod for VIN.

Methods

This was a retrospective cohort study of 46 women treated with topical imiquimod for VIN in a single centre dermatology unit from January 2011 to July 2017.

Results

Complete clinical resolution of VIN was observed in 28 of 46 patients (61%), but was significantly reduced in the smoking cohort.

Conclusions

Smoking may impair response to imiquimod for VIN, and should be considered when discussing VIN treatment options with patients.

http://bit.ly/2C8VmJ8

Two cases of perniosis in a free flap and a graft site of the hands

http://bit.ly/2H4koiq

Effects of a simulated system of straw phonation on the complete phonatory range of excised canine larynges

Abstract

Purpose

This study investigated the effects of straw phonation therapy on the aerodynamic and acoustic parameters of the vocal folds at different levels of elongation and subglottal pressure.

Methods

20 excised canine larynges were used in both experimental (straw phonation therapy simulation) and control conditions. Aerodynamic parameters, including phonation threshold pressure (PTP), phonation instability pressure (PIP), phonation pressure range (PPR), phonation threshold flow (PTF), phonation instability flow (PIF), phonation flow range (PFR), were obtained at different levels of vocal fold elongation (0%, 10%, 20%). Acoustic parameters, including fundamental frequency (F0), jitter, shimmer, signal noise ratio (SNR) were detected at different levels of vocal fold elongation (0%, 10%, 20%) and subglottal pressure (15 cmH₂O, 20 cmH₂O, 25 cmH₂O).

Results

Significant decreases in PTP and PTF and significant increases in PIP, PIF, PPR, and PFR occurred in experimental condition at all levels of elongation when compared with control condition. However, no significant changes of acoustic parameters were obtained between conditions at all levels.

Conclusion

At different levels of vocal fold elongation, straw phonation not only lowered the onset of normal voice, but also elevated the onset of chaotic voice, indicating a better voice economy and voice control. Moreover, the improved phonatory range demonstrated that straw phonation had the potential to prevent voice users who have high voice demand from voice fatigue and vocal damage.

http://bit.ly/2TIhscJ

Assessing climate change impacts on pearl millet under arid and semi-arid environments using CSM-CERES-Millet model

Abstract

Climate change adversely affects food security all over the world, especially in developing countries where the increasing population is confronting food insecurity and malnutrition. Crop models can assist stakeholders for assessment of climate change in current and future agricultural production systems. The aim of this study was to use of system analysis approach through CSM-CERES-Millet model to quantify climate change and its impact on pearl millet under arid and semi-arid climatic conditions of Punjab, Pakistan. Calibration and evaluation of CERES-Millet were performed with the field observations for pearl millet hybrid 86M86. Mid-century (2040–2069) climate change scenarios for representative concentration pathway (RCP) 4.5 and RCP 8.5 were generated based on an ensemble of selected five general circulation models (GCMs). The model was calibrated with optimum treatment (15-cm plant spacing and 200 kg N ha⁻¹) using field observations on phenology, growth and grain yield. Thereafter, pearl millet cultivar was evaluated with remaining treatments of plant spacing and nitrogen during 2015 and 2016 in Faisalabad and Layyah. The CERES-Millet model was calibrated very well and predicted the grain yield with 1.14% error. Model valuation results showed that there was a close agreement between the observed and simulated values of grain yield with RMSE ranging from 172 to 193 kg ha⁻¹. The results of future climate scenarios revealed that there would be an increase in T_min (2.8 °C and 2.9 °C, respectively, for the semi-arid and arid environment) and T_max (2.5 °C and 2.7 °C, respectively, for the semi-arid and arid environment) under RCP4.5. For RCP8.5, there would be an increase of 4 °C in T_min for the semi-arid and arid environment and an increase of 3.7 °C and 3.9 °C in T_max, respectively, for the semi-arid and arid environment. The impacts of climate changes showed that pearl millet yield would be reduced by 7 to 10% under RCPs 4.5 and 8.5 in Faisalabad and 10 to 13% in Layyah under RCP 4.5 and 8.5 for mid-century. So, CSM-CERES-Millet is a useful tool in assessing the climate change impacts.

http://bit.ly/2Cf06Nt

The effect of various primers improving adhesiveness of gel polish hybrids on pH, TOWL and overall nail plates condition

Summary

Background

Hybrid manicure is now a popular method of nail care and nail art, which is associated with its durability. Unfortunately, it has an adverse effect on pH, TOWL and overall nail plates condition and has not been investigated in detail so far.

Aims

The aim of this study was to compare the pH and TOWL of the hand nails after using different primers. The effect of application time, breaks between applications and the method of curing and removal on those parameters and overall nail plates condition were evaluated.

Patients/Methods

An evaluation survey was conducted among 116 women. pH and TOWL measurements of the nail plate in 35 women were taken using the Courage & Khazaka. Clinical photos were made using the Fotomedicus system.

Results

The measured pH values of the nail plate in the test group with gel polish hybrid on the nails were from 5.50 to 6.65, while after removal of the gel polish hybrid, the values ranged from 5.63 to 6.68. TOWL of the nail plate covered with gel polish hybrid ranged from 2.9 to 33.2 g/m²/h, whereas after removal of hybrids—from 1.9 to 45.7 g/m²/h.

Conclusion

Different forms of acid‐free primers maintain a lower pH of the nail plate covered with a gel polish hybrid, while the acidic primer maintains higher values of the nail plate pH. The significant decrease in the nail plate TOWL following the application of gel polish hybrid indicates a reduced loss of water from the surface of the nail to the atmosphere.

http://bit.ly/2FnnRWD

The effect of various primers improving adhesiveness of gel polish hybrids on pH, TOWL and overall nail plates condition

Summary

Background

Hybrid manicure is now a popular method of nail care and nail art, which is associated with its durability. Unfortunately, it has an adverse effect on pH, TOWL and overall nail plates condition and has not been investigated in detail so far.

Aims

The aim of this study was to compare the pH and TOWL of the hand nails after using different primers. The effect of application time, breaks between applications and the method of curing and removal on those parameters and overall nail plates condition were evaluated.

Patients/Methods

An evaluation survey was conducted among 116 women. pH and TOWL measurements of the nail plate in 35 women were taken using the Courage & Khazaka. Clinical photos were made using the Fotomedicus system.

Results

The measured pH values of the nail plate in the test group with gel polish hybrid on the nails were from 5.50 to 6.65, while after removal of the gel polish hybrid, the values ranged from 5.63 to 6.68. TOWL of the nail plate covered with gel polish hybrid ranged from 2.9 to 33.2 g/m²/h, whereas after removal of hybrids—from 1.9 to 45.7 g/m²/h.

Conclusion

Different forms of acid‐free primers maintain a lower pH of the nail plate covered with a gel polish hybrid, while the acidic primer maintains higher values of the nail plate pH. The significant decrease in the nail plate TOWL following the application of gel polish hybrid indicates a reduced loss of water from the surface of the nail to the atmosphere.

http://bit.ly/2FnnRWD

Combined influence of external nitrogen and soil contact on plant residue decomposition and indications from stable isotope signatures

Abstract

External nitrogen (N) supply has been testified to exert important impacts on plant residue decomposition. The influence of N may be interactive with soil contact in terrestrial ecosystems. However, the joint mechanisms of decomposition of plant residues driven by soil contact and N addition remain incomplete. Using contrasting residues, including needles of Chinese fir (Cuninghamia lanceolata) (Cl) (relatively hard to degrade) vs. leaves of eucalyptus (Eucalyptus urophylla) (Eu) (relatively easy to degrade), a full factorial experiment was conducted by 360-day experiment to investigate the combined effect of N addition and soil contact on residue decay. As the microbe-manipulated decomposition could leave an imprint on the residue carbon (C) and N stable isotope, variations of the two signatures (δ¹³C and δ¹⁵N) were synchronously monitored. Our results firstly showed that added N sped up initial decomposition, while it played an opposite role in subsequent stage, and soil contact always stimulated decay. Under soil contact condition, we found a markedly more accelerating effect of N addition on decay of Cl than without soil contact. Linking with residue N dynamics, we thought that although N immobilized from soil could not completely meet microbial needs for decay of Cl, this N limitation was just relieved by added N, leading to this synergistic effect. At late decay stage, the N inhibiting influence was partly offset under soil contact condition, and this phenomenon was more dramatic for Eu. Our results lastly revealed that the ¹³C and ¹⁵N signatures mirrored and explained the underlying mechanisms of the above interactions. Overall, we concluded that external N and soil contact could interactively affect decay, depending on plant residue decomposability. These results would be used to accurately predict C sequestration for terrestrial ecosystems under heightened N scenario in the future.

http://bit.ly/2QAwaQW

Glycolytic Inhibitor 2-Deoxy-D-Glucose at Chronic Low Dose Mimics Calorie Restriction in Rats Through Mitohormetic Induction of Reactive Oxygen Species

Rejuvenation Research, Ahead of Print.


http://bit.ly/2RjlU50

A Novel Mutation in the Adult-Onset Alexander’s Disease GFAP Gene

The case describes a 25-year-old Caucasian female diagnosed with Alexander's disease (AxD) as an outpatient after extensive inpatient workup. Her presenting complaints included incontinence, clumsiness, seizures, dysphagia, and dysarthria. She was also found to have pancytopenia and dysautonomia. A full neurologic and hematologic workup yielded very little results, until a thorough literature search of her presenting complaints and radiologic findings pointed to adult-onset Alexander's Disease. Alexander's disease is a rare genetic leukodystrophy with a broad variety of presentations. Despite its infrequency in adults and the difficulty in diagnosis, the prevalence of AxD has been increasing due to ease of genetic analysis and identification of key clinical and radiological findings. This case illustrates the necessity of vigilance and persistence in the face of unusual patient presentations; occasionally, the sound of hoofbeats is zebras.

http://bit.ly/2AE9z0N

A Big Thank You to Our Reviewers in The Past Year!

Exp Clin Endocrinol Diabetes 2019; 127: 5-7
DOI: 10.1055/a-0795-1114

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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http://bit.ly/2VGTIHG

Selenoprotein P in Patients with Nonalcoholic Fatty Liver Disease

Exp Clin Endocrinol Diabetes
DOI: 10.1055/a-0811-9136

Objective Main aim of this study was to evaluate circulating selenoprotein P (SEPP) levels in patients with simple steatosis (SS) and nonalcoholic steatohepatitis (NASH) compared with healthy controls. Methods Thirty-one patients with biopsy-proven NAFLD (15 with SS, 10 with borderline NASH, 6 with definite NASH) and 27 matched controls without NAFLD were enrolled. Serum SEPP levels and liver function tests plus biochemical parameters were measured with ELISA and standard methods, respectively. Homeostatic model of assessment - insulin resistance (HOMA-IR) was calculated. Results SEPP levels were statistically different between groups (p-value for trend=0.043). In pairwise comparisons, SEPP was lower in definite NASH compared with controls (p=0.029), but not SS (p=0.18) or borderline NASH (p=0.35). SEPP was not different between controls, SS and borderline NASH. The unadjusted trend between the controls, SS and NASH patients remained essentially unchanged after adjustment for age, sex, log(ALT) and waist circumference, but it marginally lost significance when log(HOMA-IR) entered into the model. SEPP levels were not different between groups of different severity of steatosis, fibrosis, hepatocellular ballooning, lobular and portal inflammation. Conclusions Lower SEPP levels were observed in patients with definite NASH compared with controls, a finding warranting larger studies.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

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http://bit.ly/2QBvZoD

Hauptsymptome und Elternerwartung bei Adenotomie und Adenotonsillotomie im Vorschulalter

Laryngo-Rhino-Otol
DOI: 10.1055/a-0816-5807

Hintergrund Um eine realistische Aufklärung vor Adeno(tonsillo)tomie zu leisten, wurden im Rahmen dieser Studie die kindliche Symptombelastung und die elterliche Erwartung an den Operationserfolg prospektiv erfasst. Material und Methoden Es wurden n = 111 Kinder (3–6 Jahre, ♂ 65 % ♀ 35 %) rekrutiert, welche an der HNO-Universitätsklinik Ulm eine Adenotomie (AT 66 %) oder Adenotonsillotomie (ATT 34 %) erhielten. In der fragebogenbasierten Befragung wurden die häufigsten Symptome und der Hauptgrund zur Operation aus Elternsicht erfasst (Operationstag, follow-up: 3,5 Mo.) und in Balkendiagrammen jeweils für Gesamtkollektiv und die Operationsgruppen AT und ATT visualisiert (Signifikanzniveau auf α = 5 %). Ergebnisse Am häufigsten wurden von den Eltern Zeichen einer Atemproblematik (Mundatmung 87 %, Nasenatmungsbehinderung 86 %, Schnarchen 78 %), Hörminderung (68 %) und vermehrter Infektneigung (66 %) beobachtet. Als Hauptgrund zur Operation wurden Nasenatmungsbehinderung (77,5 %) und Hörminderung (53,2 %) genannt. Bei reiner Rachenmandelhyperplasie dominierten Hörprobleme, während bei zusätzlich indizierter Tonsillotomie nächtlichen Apnoen als Operationsgrund am häufigsten genannt wurden. Bei allen abgefragten Symptomen konnte postoperativ eine wesentliche Verbesserung erzielt werden. Schlussfolgerungen Bei differenzierter Indikationsstellung ist es möglich, die Eltern über eine sehr gute und realistisch zu erwartende, effektive Symptomreduktion nach AT und ATT zu informieren.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

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http://bit.ly/2VzO4qG

Effects of dietary fluoranthene on nymphs of Blaptica dubia S. (Blattodea: Blaberidae)

Abstract

Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous environmental pollutants which exert detrimental effects on living beings. Considering the health risk associated with exposure to these pollutants, their presence in food increases efforts to establish early-warning indicators of pollution. We aimed to examine the effects of environmentally relevant concentrations of fluoranthene (0.2 ng and 18 ng/g dry weight of diet) on the activities of midgut antioxidant and detoxification enzymes in Blaptica dubia. Significant changes of superoxide dismutase and catalase activities, recorded at the higher fluoranthene concentration regardless of the exposure time, suggest that they may be used as biomarkers of PAH pollution. Increased GST activity and decreased total GSH content, detected upon acute exposure to the lower concentration, indicate processes of detoxification. Reorganization of B. dubia mechanisms of defense in response to oxidative stress caused by exposure to dietary PAH point to the necessity for further examination of fluoranthene actions.

http://bit.ly/2CYOiAj

Real-time monitoring and quantification of organic by-products and mechanism study of acetone decomposition in a dielectric barrier discharge reactor

Abstract

Non-thermal plasma (NTP) degradation of low-concentration acetone was investigated in a cylindrical dielectric barrier discharge reactor. The effects of oxygen content and flow rate on the removal efficiency at various discharge powers were examined in real-time. The acetone removal efficiency decreases drastically and then remains stable or increases gradually as the O₂ content increases from 0 to 25%, and further to 50%. The organic by-products were characterized and quantified using a real-time proton transfer reaction time-of-flight mass spectrometry (PTR-TOF-MS) instrument. The observed organic compounds, with concentrations about ppbv/ppmv by volume, were mainly formaldehyde, methanol, ketene, acetaldehyde, formic acid, acetone, and acetic acid. The discharge power was a critical factor affecting the concentration of the organic by-products and the selectivity toward CO₂. The mechanism study based on the by-product monitor in real-time showed that acetone firstly fragments into methyl radicals, acetyl radicals, and H; then, the methyl and acetyl radicals are oxidized by O or OH radicals into acetaldehyde, methanol, and other compounds. It seems that acetaldehyde could be an intermediate in acetone decomposition. Firstly, most of the acetone molecules were decomposed into acetaldehyde molecules; then, the acetaldehyde molecules continued to be decomposed and oxidized into other compounds, such as acetic acid and formaldehyde. These investigations not only proposed a detail decomposition mechanism for acetone in dielectric barrier discharge reactor, but also provided a potential way to analyze and evaluate the practicability of NTP removal of VOCs.

http://bit.ly/2TCa6Y7

Microsurgical Reconstruction of the Plantar Foot: Long-Term Functional Outcomes and Quality of Life

J reconstr Microsurg
DOI: 10.1055/s-0038-1677038

Background When faced with plantar defects, reconstruction of the weight-bearing areas presents unique surgical challenges. Several free flap modalities have been described in this respect, but there remains debate regarding the best-suited flap modality. Aim of this study was to compare free muscle and non-neurotized fasciocutaneous flaps for plantar reconstruction with respect to long-term functional outcomes. Methods Overall, 89 patients received 100 free flaps (anterolateral thigh [ALT] n = 46; gracilis n = 54) for plantar reconstruction. The data were screened for patients' demographics, as well as perioperative details. Postoperative complications were accounted for and the two groups compared accordingly. All patients were contacted for a long-term follow-up examination. Results There were no significant differences between the two groups regarding major (24 vs. 17%; p = 0.366) and minor surgical complications (61 vs. 70%; p = 0.318). However, the ALT group showed a significantly higher need for secondary surgeries (39 vs. 19%; p = 0.022). Sixty-eight patients (76%) returned for long-term follow-up evaluation (mean: 51.2 months, range: 13–71 months). The ALT group showed significantly less pain at the recipient (p = 0.0004) and donor (p = 0.010) sites, and scar assessment revealed significantly better results (p < 0.001). Additionally, the ALT group showed better depth (p = 0.017) and superficial (p = 0.007) sensation and enabled better shoe provision (p = 0.014). Conclusions Both the free ALT and gracilis flaps are well suited for plantar reconstruction, yielding overall similar functional outcomes. However, the ALT flap produces less scarring and pain, while showing better recovery of sensation and enabling better shoe provision. The ALT flap thus presents our preferred option.
[...]

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The Impact of Age on Perioperative Complications after Extremity Reconstruction with the Free Gracilis Flap: A Retrospective Cohort Study Involving 153 Patients

J reconstr Microsurg
DOI: 10.1055/s-0038-1677455

Background The need for plastic and reconstructive surgery on elderly patients has been on the rise due to an increase in life expectancy in the past decades. Therefore, a study was conducted on young and elderly patients following microsurgical extremity reconstructions with free gracilis muscle flaps with the primary aim to investigate the influence of age and the American Society of Anesthesiologists (ASA) score on the general outcome, as well as surgical and medical complications. Methods A retrospective analysis of 153 patients receiving free gracilis muscle flaps for extremity reconstructions between November 2009 and January 2018 was performed at two partner institutions specialized in microsurgical reconstructions. A logistic regression analysis was performed to correlate age and the ASA score with postoperative complication probability. Patients younger than 70 years were directly compared with elderly patients with respect to age, gender, ASA score, preexisting comorbidities, localization, and postoperative medical and surgical complications. Results Age turned out to be not significantly associated with major flap complications (p = 0.925) but with higher ASA scores (p = 0.016). However, an age-related significant increase in minor flap complications could be observed in the elderly (p = 0.008). A significant correlation between minor medical complications and age could be observed (p = 0.001) in contrast to ASA score (p = 0.912). Conclusion An increased minor flap, as well as minor and major medical complications, must be expected in extremity reconstructions with free gracilis flaps in elderly patients. Higher ASA scores correlate with a higher incidence of major flap complications. Septuagenarians are more prone to develop perioperative major medical complications than patients younger than 70 years. Age and general medical condition, coupled with the performance of each patient, should be thoroughly assessed individually to facilitate a tailored reconstructive approach using risk assessment tools and established scoring systems.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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http://bit.ly/2SO41b2

Microvascular Anastomotic Coupler: An Unexpected Adverse Event

J reconstr Microsurg
DOI: 10.1055/s-0038-1677036

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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Cortical atrophic-hypometabolic dissociation in the transition from premanifest to early-stage Huntington’s disease

Abstract

Purpose

Huntington's disease (HD) is a fatal neurodegenerative disorder with no effective treatment currently available. Although the pathological hallmark of HD is massive striatal atrophy, it has been suggested that cortical deterioration may concomitantly occur and play a major role in the patient's functional independence. Our objective was to characterize cortical structural and metabolic neurodegeneration in the transition from premanifest to early-stage Huntington's disease (HD).

Methods

Using a surface-based neuroimaging approach, we compared cortical thickness and intracortical FDG-PET uptake in 19 early-symptomatic HD patients with respect to 21 premanifest HD individuals.

Results

Early-HD patients showed significant cortical atrophy and intracortical hypometabolism when compared to premanifest subjects (p < 0.05, corrected for multiple comparisons). However, whereas the atrophy pattern was restricted to precentral and parieto-occipital regions, a pronounced frontotemporal hypometabolism was observed. Importantly, structural changes correlated with motor and cognitive performance, and metabolic changes were associated with the presence and severity of apathy in this population, a core neuropsychiatric feature of this disorder.

Conclusion

Our findings reveal an asynchronous neuronal loss and metabolic compromise across the cerebral cortex in early HD. Hence, the use of structural and metabolic imaging indicators to characterize disease progression in this population should take into consideration the dissociation which occurs between cortical atrophy and hypometabolism.

http://bit.ly/2SO0KZi

Clinical Communication: Systemic Capillary Leak Syndrome Due to Mast Cell Activation?

Clinical Communication: Idiopathic Anaphylaxis Masquerading as Systemic Capillary Leak Syndrome

http://bit.ly/2M2inlr

Anaphylaxis to amoxicillin-clavulanate, differenitiating the components

Drug hypersensitivity skin testing (ST) has been standardized only when referring to penicillin. However, this method remains a common practice for other drugs and while being a practical tool, oral provocation tests (OPT) are the gold standard in diagnosis of drug hypersensitivity and should be used when available.1 β-lactams remain the most frequently reported cause of adverse drug reactions.2 Isolated adverse drug reactions to clavulanate, a β-lactamase inhibitor added to amoxicillin to form amoxicillin-clavulanate, remain rarer but have been reported.

http://bit.ly/2sjKH9V

The Microbiome and Allergic Diseases: A struggle between good and bad microbes

Disclosures:

http://bit.ly/2M1DjZX

IgE Testing Can Predict Food Allergy Status in Patients with Moderate-Severe Atopic Dermatitis

Atopic dermatitis (AD) is the most common chronic inflammatory disease of the skin in pediatric populations, affecting up to 20% of children in industrialized countries.1-4 AD is frequently associated with other atopic diseases.5, 6 Up to two-thirds of AD patients are sensitized to food antigens, and 15-40% have clinical food allergy.7-11 Children with severe and persistent AD are at highest risk for having coexistent food allergy.5, 12, 13

http://bit.ly/2slgPdw

Incidence of Pneumocystosis Among Patients Exposed to Immunosuppression

•This population analysis add to the limited data that guides dermatologists on need to administer prophylaxis against pneumocystosis with trimethoprim/sulfamethoxazole. Benefit of prophylaxis with trimethoprim/sulfamethoxazole appears to outweigh risk of severe drug reaction for patients receiving combination corticosteroid and immunosuppressant therapy.

http://bit.ly/2VDMbt6

Mohs micrographic surgery for eyelid sebaceous carcinoma: a multicenter cohort of 360 patients

Whether to perform Mohs micrographic surgery or wide local excision as the primary resection for eyelid sebaceous carcinoma remains controversial. Compared with wide local excision, Mohs micrographic surgery exhibited lower recurrence rate, but comparable chances of metastasis and tumor-related mortality. Patients with pagetoid invasion may require adjuvant measures.

http://bit.ly/2QAl8Lz

Management of Median and Paramedian Craniofacial Clefts

Median and paramedian craniofacial clefts are associated with hypertelorism, anterior encephalocele, positional abnormalities of the maxilla and nasal deformity. Cleft lip and palate, eyelid coloboma and widow's peak are frequently present.

http://bit.ly/2RC3mMG

Treatment of fingertip avulsion injuries using two periposition pedicled flaps

We described a treatment of fingertip avulsion injury by two periposition pedicled flaps, the reversed pedicle island flap of dorsal branch of proper digital artery and the cross-finger flap. From February 2009 to January 2017, 22 patients (22 fingers) with fingertip avulsion injury were treated with two periposition pedicled flaps, 14 male and 8 female, aged from 17 to 47 years (mean 32±9 years). All of the patients were followed up more than 6 months after operations (mean 9.6±2.6 months). All flaps survived completely.

http://bit.ly/2H3hkmz

“Surgical Outcomes of VRAM versus Gracilis Flaps for the Reconstruction of Pelvic Defects following Oncologic Resection”

Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone.2,3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection.

http://bit.ly/2RD0WNO

PART 2: CAN IMPROVEMENT IN OUTCOME MEASUREMENT IN PLASTIC SURGERY BE ACHIEVED IN TODAY'S HEALTH SYSTEMS?

Being able to accurately measure relevant constructs is particularly valuable in plastic surgery, where the objective of treatment may range across improving hand function, identifying satisfaction with breast reconstruction, or establishing quality of life changes from surgery. This matters in research applications such as clinical trials, and for quality assurance of surgery through routine data collection in clinical practice. The technical aspects of refining measurement to ensure that it is accurate and the process for selecting outcome measures have both been described in recent articles in this journal.

http://bit.ly/2H4ONwO

A Novel Modification of Keystone Flap for Superficial Defects Repair

In 2003, Behan1 was the first to report the Keystone Design Perforator Island Flap (KDPIF). The KDPIF has the advantages of simple design, convenient operation, certain perforator blood supply, adjacent tissue, good appearance and nearby texture. Therefore, it has been widely applied to repairing skin soft tissue defects caused by trauma, tumor resection, and scars.2,3 However, the KDPIF has certain issues such as excessive tension, constraint on the closure of the donor area,4,5 and skin contractures due to straight line scars across the joints in repairing large-size defects of the trunk, the joints or other moving areas.

http://bit.ly/2Ryb7Dl

Long-term pre- and postconditioning with low doses of erythropoietin protects critically perfused musculo-cutaneous tissue from necrosis

It has been shown that pre- and postconditioning of ischemically challenged tissue with erythropoietin (EPO) is able to reduce necrosis in a dose-dependent manner. The aim of this study was to determine the tissue-protective effects of different EPO dosages and administration regimes.Three groups of six C57Bl/6-mice each were analyzed. 1. Pre- and postconditioning with initial high doses of EPO (starting at 2500 I.U./kg bw i.p.) followed by low doses of EPO (125 I.U./kg bw i.p.) (EPO-high-dose); 2.

http://bit.ly/2GZUgoG

Relationship between the expression of PD-1/PD-L1 and 18 F-FDG uptake in bladder cancer

Abstract

Purpose

Immunotherapy aimed at inhibiting the PD-1/PD-L1 immune checkpoint has been approved and used successfully for the treatment of bladder cancer. The identification of markers predictive of response to immune checkpoint inhibitors is critical to advancing the success of this therapy. ¹⁸F-FDG PET/CT is a molecular imaging technique that can provide phenotypic information on malignant tumours. It is currently unknown whether there is a relationship between ¹⁸F-FDG uptake and expression of PD-1/PD-L1 in bladder cancer. In this study, we investigated whether PD-1/PD-L1 expression is associated with ¹⁸F-FDG uptake in bladder cancer, and whether ¹⁸F-FDG PET/CT imaging can be used to predict the PD-1/PD-L1 status of bladder cancer.

Methods

A retrospective analysis was performed in 63 patients with bladder cancer who had undergone ¹⁸F-FDG PET/CT before surgical resection. Maximum standardized uptake values (SUVmax) were determined.

Results

SUVmax was significantly higher in PD-1-positive patients than in PD-1-negative patients (33.0 ± 13.9 and 19.6 ± 14.2, respectively; P = 0.032), and in PD-L1-positive patients than in PD-L1-negative patients (29.1 ± 15.6 and 15.8 ± 11.4, respectively; P < 0.0001). In a multivariate analysis SUVmax was significantly associated with both PD-1 expression and PD-L1 expression (P = 0.021 and P = 0.003, respectively). Using a SUVmax cut-off value of 22.7, PD-1 status and PD-L1 status could be predicted with accuracies of 71.4% and 77.8%, respectively.

Conclusion

Higher ¹⁸F-FDG uptake by bladder cancer is associated with elevated PD-1/PD-L1 expression. ¹⁸F-FDG PET/CT may be useful for predicting the PD-1/PD-L1 status of bladder cancer and for determining the optimal therapeutic strategy.

http://bit.ly/2FokAGv

Supplementing Resident Education in Vasculitis and Autoimmune Connective Tissue Disease

This prospective study examines the influence of an online curriculum in residents' knowledge of cutaneous manifestations of vasculitis and autoimmune connective tissue diseases.

http://bit.ly/2siZTEn

Endemic Human Cutaneous Leishmaniasis Incidence in the United States

To the Editor The recently published article by McIlwee and colleagues provides valuable insight into a protozoal disease the transmission of which within the United States (predominantly Texas) has been largely underrecognized by the US medical community. We would like to commend the authors for publishing this work and briefly expand on some topics presented that we believe warrant clarification and further discussion.

http://bit.ly/2LZoszj

Bullous Pemphigoid and Dipeptidyl Peptidase-4 Inhibitors in Patients With Diabetes

This case-control study examines the association between the use of dipeptidyl peptidase 4 inhibitors and the risk of developing bullous pemphigoid in patients with diabetes.

http://bit.ly/2slBu0Z

Evaluation of Unresectable Primary Cutaneous Melanoma Response to Immunotherapy Using Reflectance Confocal Microscopy

This case report study describes 2 patients with locally advanced primary melanomas and the use of reflectance confocal microscopy for imaging of cutaneous involvement and disease monitoring.

http://bit.ly/2M1bZen

Assessment of Diagnostic Strategy for Pemphigoid

This study analyzes the direct immunofluorescence and serologic data from 1125 consecutive patients for diagnosing pemphigoid, a cutaneous autoimmune disease that primarily affects older people.

http://bit.ly/2sspOtv

Understanding Perceived Barriers of Minority Medical Students Pursuing a Career in Dermatology

This survey study evaluates the perceived barriers of minority medical students pursuing a career in dermatology.

http://bit.ly/2M7DumJ

Endemic Human Cutaneous Leishmaniasis Incidence in the United States—Reply

In Reply We appreciate the comments of Mr Kipp and Dr Hergert and thank them for their observations regarding our study. Specifically, when discussing endemic human cutaneous leishmaniasis in the United States, we concur with the importance of making a distinction between anthropophagic and non-anthropophagic sand flies.

http://bit.ly/2siiAba

Assessment of the Prevalence of Mucosal Involvement in Bullous Pemphigoid

This cohort study examines the prevalence and distribution of mucosal involvement among patients with bullous pemphigoid.

http://bit.ly/2LYWcgb

Diagnostic Criteria and Phenotypes of Pemphigoid and the Association With Gliptins

In this issue, there are 2 excellent large retrospective studies from single centers in Groningen, The Netherlands, and Haifa, Israel of patients referred for possible bullous pemphigoid (BP). In addition, there is a nationwide population-based study from Korea evaluating the risk of BP in patients with diabetes receiving dipeptidyl peptidase 4 inhibitors (gliptins).

http://bit.ly/2slYT25

A New Molecular Taxonomy to Predict Immune Checkpoint Inhibitor Sensitivity in Prostate Cancer

http://bit.ly/2FlacR1

Brain Metastases and Place of Antiangiogenic Therapies in Alveolar Soft Part Sarcoma: A Retrospective Analysis of the French Sarcoma Group

AbstractBackground.Alveolar soft part sarcoma (ASPS) is a rare sarcoma characterized by a slow evolution, brain metastasis (BM), and resistance to doxorubicin. Antiangiogenic therapies (AAT) have shown clinical activity, but little is known about the optimal therapeutic strategy, specifically considering BM.Subjects, Materials, and Methods.We performed a retrospective analysis of all patients with ASPS treated in three referral centers of the French Sarcoma Group. We aimed to describe factors associated with overall survival (OS) and the impact of BM on outcome of patients treated by AAT.Results.We identified 75 patients between 1971 and 2012 (median age = 23, range: 5–96 years). Median follow‐up was 74 months. Patients with localized (n = 44, 59%) and metastatic (n = 31, 41%) diseases had a 10‐year OS of 69% and 25%, respectively. Only surgical incomplete resection was associated with shorter OS in localized disease (hazard ratio [HR] = 5.2, 95% confidence interval [CI] 1.2–22.4, p = .02). Fifty‐two (69%) patients developed lung metastasis (LM; baseline: n = 31, [41%]; de novo: n = 21, [28%]). Thirteen patients developed BM, all occurring after LM. Tumor size ≥5 cm was associated with poorer BM‐free survival (HR = 8.4, 95% CI 2.1–33.9, p = .002). Median OS post‐BM was 17 months (95% CI 15 to not assessable). Overall, 12 patients were treated with AAT (sunitinib n = 10): 5 patients had BM and achieved poor outcomes compared with patients without, with median progression‐free‐survivals of 2 versus 11 months, respectively.Conclusion.Baseline larger tumors were associated with increased risk of brain metastasis in patients with ASPS. Patients with BM seem to have little benefit from AAT, suggesting the need to develop antineoplastic agents with high central nervous system penetrance in this setting.Implications for Practice.Alveolar soft part sarcoma (ASPS) is an extremely rare subtype of sarcoma that is particularly resistant to conventional therapies. Antiangiogenic therapies (AAT) have shown promising results. However, patients with ASPS still die of tumor evolution. This study highlights the prognostic shift induced by brain metastasis (BM), identifying this event as a major contributor to the death of patients with ASPS, and observes a striking lack of effectiveness of AAT in patients who had previously developed BM. This observation is of interest for the therapeutic development in ASPS, highlighting the need to develop strategies dedicated to BM, such as radiosurgery or high‐central nervous system penetrance tyrosine kinase inhibitors.

http://bit.ly/2FocfTd

Immediate Use of Continuous Positive Airway Pressure in Patients With Obstructive Sleep Apnea Following Transsphenoidal Pituitary Surgery: A Case Series

Background: Patients who undergo transsphenoidal pituitary resection have an elevated risk of obstructive sleep apnea (OSA) yet their outcomes and the safety of continuous positive airway pressure (CPAP) remains unclear. Our study objective was to determine the incidence of complications related to the use of early positive airway pressure following pituitary resection. Methods: We retrospectively identified all patients who underwent endoscopic transsphenoidal pituitary tumor resection between January 1, 2005 and March 24, 2016 at our institution, including those with diagnosed or suspected OSA. We compared characteristics and postoperative complications of OSA patients who did and did not receive CPAP postoperatively. Results: In total, 427 patients underwent transsphenoidal pituitary resection. Of these, 64 (15%) had OSA. Acromegaly was more common in patients with OSA (42% vs. 10%; P

http://bit.ly/2RkwF74

JNA Journal Club

No abstract available

http://bit.ly/2Cdd6D9

SNACC Is Moving and We Are Really Excited!

No abstract available

http://bit.ly/2RlvwMz

Improving Severe Traumatic Brain Injury Observational Research: Not All Questions Need an RCT

No abstract available

http://bit.ly/2Cg3FCS

JAMA Dermatology

Mission Statement: JAMA Dermatology publishes information concerning the skin, its diseases, and their treatment. Its mission is to explicate the structure and function of the skin and its diseases and the art of using this information to deliver optimal medical and surgical care to the patient. We attempt to enhance the understanding of cutaneous pathophysiology and improve the clinician's ability to diagnose and treat skin disorders. This journal has a particular interest in publishing clinical and laboratory studies that reveal new information pertinent to the interests and needs of the medical dermatologist, dermatologic surgeon, and all those concerned with state-of-the-art care of cutaneous disease. We believe that knowledge derived from well-designed clinical trials and studies of cost-effectiveness are especially important for improving the practice of dermatology. Studies that increase the understanding of the outcome of treatment or the means by which the burden of dermatologic disease can be measured and reduced to promote the health of patients with skin disease will receive special priority. The journal regularly publishes reports on clinical investigations, editorials, and reviews. It also features reports and discussions on clinicopathologic correlations; clinical disorders of unique didactic value; pharmacologic, medical and surgical therapeutics; and ethical, moral, socioeconomic, and political issues.

http://bit.ly/2M36ZFT

January 2019 Issue Highlights

http://bit.ly/2sk0CVQ

Cutaneous Sensitization to Peanut in Children With Atopic Dermatitis

This Viewpoint discusses recent findings associating atopic dermatitis in infants with increased sensitization to peanut protein and how those findings are informing new guidelines and efforts to prevent peanut allergy.

http://bit.ly/2M3baBy

Use of Combination Systemic-Intratumoral HPV Vaccine to Treat Cutaneous Basaloid Squamous Cell Carcinomas—Reply

In Reply We thank Dr Brunet-Possenti and her colleagues for their interest and thoughtful comments on our article. In that report, we described using a combination of systemic and intratumoral delivery of the 9-valent human papillomavirus (HPV) vaccine to treat a woman in her 90s with multiple cutaneous squamous cell carcinomas (SCCs). This novel approach was followed by complete regression of all tumors 11 months after the first intratumoral injection of the vaccine. This readily available vaccine was well tolerated, and at last follow-up, the patient remained free of tumors. To our knowledge, this is the first report suggesting that the HPV vaccine may have therapeutic utility for SCCs.

http://bit.ly/2sh2xKN

A Meta-analysis of Benefits and Harms of Omalizumab in Patients With Chronic Idiopathic Urticaria

This meta-analysis of 67 observational studies analyzes the effectiveness and adverse event rate of omalizumab therapy in patients with chronic idiopathic urticaria and compares these findings with those of randomized clinical trials conducted among similar patients.

http://bit.ly/2LZ76CF

Use of Combination Systemic-Intratumoral HPV Vaccine to Treat Cutaneous Basaloid Squamous Cell Carcinomas

To the Editor We read with great interest the article by Nichols et al regarding the use of combined systemic and intratumoral human papillomavirus (HPV) vaccine to treat a woman in her 90s with multiple cutaneous squamous cell carcinomas. This article drew our attention because of the difficulties encountered in the management of such lesions in elderly patients. In the reported case, it seems clear that neither surgery nor chemotherapy would have been suitable for the patient.

http://bit.ly/2sk0plw

Association Between Psoriasis and Sexual and Erectile Dysfunction in Epidemiologic Studies

This systematic review evaluates the main characteristics of the studies of psoriasis and sexual dysfunction (SD) or erectile dysfunction (ED), including level of evidence, tools used to assess SD or ED, and prevalence and incidence of SD or ED.

http://bit.ly/2LZJoWQ

Use of Big Data to Estimate Defective DNA Repair Variants in the US Population

This molecular epidemiologic study examinsd 3 large exome sequence databases totaling more than 200 000 alleles to correlate disease-associated allele frequencies with the expected and reported prevalence of clinical disease.

http://bit.ly/2sk0iGC

Use of Dapsone in the Treatment of Chronic Idiopathic and Autoimmune Urticaria

This medical record review evaluates the efficacy and safety of dapsone as second-line therapy in patients with chronic spontaneous urticaria.

http://bit.ly/2M7nfGh

Aggressive Squamous Cell Carcinoma in Organ Transplant Recipients

This case series describes the clinicopathologic features of and identifies factors associated with aggressive squamous cell carcinoma in solid organ transplant recipients.

http://bit.ly/2shJPT8

Reduced Itch Associated With Dupilumab Treatment In 4 Patients With Prurigo Nodularis

This case report describes itch reduction in 4 patients with prurigo nodularis following treatment with dupilumab.

http://bit.ly/2M1htFX

Comparison of Injuries From Sharps Among Residents Within Dermatology and Other Medical Specialties

This study assesses whether the nature of injuries from sharps among dermatology residents is demonstrably different compared with injuries from sharps among residents in other medical and surgical specialties.

http://bit.ly/2shcrw5

Clinical Features of Neutrophilic Dermatosis Variants Resembling Necrotizing Fasciitis

This case series examines 6 previously unreported patients and published reports of 48 patients with necrotizing neutrophilic dermatosis to identify the traits and infection-mimicking features of a new subset of necrotizing neutrophilic dermatosis.

http://bit.ly/2LYEZn5

Expert-Level Diagnosis of Nonpigmented Skin Cancer by Combined Convolutional Neural Networks

This study compares the accuracy of a convolutional neural network–based classifier with that of physicians with different levels of experience at classifying dermoscopic and close-up images of nonpigmented lesions.

http://bit.ly/2sjiP5N

A Child With Multiple Hypopigmented Macules on the Abdomen

A child presented with multiple, asymptomatic, scattered white macules on the lower abdomen and pubic area, which were present at birth and had gradually increased in size and number; there was no history of any systemic disorder and no family history of similar lesions. What is your diagnosis?

http://bit.ly/2RDmpWM

Creating a Partnership Between Dermatologists and Geriatricians—Reply

In Reply We thank Drs Mundluru and Lee for their thoughtful response to our Viewpoint titled "Geriatric Dermatology—A Framework for Caring for Older Patients With Skin Disease." We agree that we need to create practical collaborations that simultaneously support increased knowledge of dermatology in the field of geriatrics while also broadening the knowledge and application of geriatrics in the field of dermatology. We share a common goal—to improve the care of older adults with skin disease. Collaboration is essential. We support the proposed approach to improving the content of dermatology in geriatrics fellowships.

http://bit.ly/2HcvIJs

Pricing a Year of Progression-Free Survival

What is a reasonable price for society to pay to give a patient with cancer 1 extra year of life without tumor growth?

http://bit.ly/2RCFBUI

Patch Testing and Allergen-Specific Inhibition in a Patient Taking Dupilumab

This case report describes changes in repeated patch test results in a patient receiving dupilumab therapy.

http://bit.ly/2H30aW5

Factors Associated With Persistent Atopic Dermatitis in Children

This clinical birth cohort study evaluates the association of genetic, environmental, clinical, and social factors with the persistence of atopic dermatitis at age 13 years among children born to parents with asthma.

http://bit.ly/2RGCM4O

Creating a Partnership Between Dermatologists and Geriatricians

To the Editor We read with great interest and enthusiasm the recent Viewpoint by Linos et al about the need to create a coherent framework to address geriatric dermatologic issues. We agree that older adults are a rapidly expanding and vulnerable segment of the population who require special attention by dermatologists.

http://bit.ly/2H3RPSa

Lack of consensus on the peri-operative management of patients with diabetes mellitus

No abstract available

http://bit.ly/2FlnWtW

Thromboprophylaxis in the obese surgical patient

No abstract available

http://bit.ly/2FhRv0e

Postoperative pneumonia: Can this important complication be predicted and anticipated?

No abstract available

http://bit.ly/2FiaRCu

Peri-operative endothelial dysfunction in patients undergoing minor abdominal surgery: An observational study

BACKGROUND Myocardial injury after noncardiac surgery is common and associated with major adverse cardiac events. Surgery induces acute endothelial dysfunction, which might be central in the pathophysiology of myocardial injury; however, the relationship between surgical stress and endothelial function remains incompletely understood. OBJECTIVES This study aimed to assess the acute peri-operative changes in endothelial function after minor elective abdominal surgery. DESIGN A prospective, observational, single-centre study. SETTING A university hospital from February 2016 to January 2017. PATIENTS Sixty patients undergoing elective minor abdominal surgery. MAIN OUTCOME MEASURES The change in endothelial function, expressed as the reactive hyperaemia index (RHI), was assessed by non-invasive digital pulse tonometry. RHI, biomarkers of nitric oxide bioavailability and oxidative stress were assessed prior to and 4 h after surgery. RESULTS RHI decreased significantly from 1.93 [95% confidence interval (95% CI 1.78 to 2.09)] before surgery to 1.76 (95% CI 1.64 to 1.90), P = 0.03, after surgery. The nitric oxide production, L-arginine/asymmetric dimethylarginine, decreased significantly from a ratio of 213.39 (95% CI 188.76 to 241.2) to a ratio of 193.3 (95% CI 171.82 to 217.54), P = 0.03. Plasma biopterins increased significantly after surgery, while the ratio between tetrahydrobiopterin and dihydrobiopterin was unchanged. Total ascorbic acid decreased significantly after surgery (P 

http://bit.ly/2FllVOq

Intra-operative heart rate and postoperative outcomes – rowing against the tide?

No abstract available

http://bit.ly/2FnNfvl

Noninvasive continuous arterial pressure monitoring with Clearsight during awake carotid endarterectomy: A prospective observational study

BACKGROUND Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a less invasive alternative compared with invasive intra-arterial monitoring for awake patients during carotid endarterectomy (CEA) under regional anaesthesia. OBJECTIVE We investigated the agreement of blood pressure (BP) recorded with invasive and CNBP methods during awake CEA. DESIGN A prospective observational study for assessing agreement with Bland–Altman plots, agreement-tolerability indices (ATI), concordance and interchangeability. SETTING Azienda Ospedaliera Universitaria G. Martino, Messina, a University tertiary referral centre in Italy. PATIENTS In 30 consecutive patients, we recorded continuously ipsilateral invasive and noninvasive BPs, from 3 min before carotid cross-clamping to 5 min after unclamping. MAIN OUTCOME MEASURES Primary outcome was bias, 95% limits of agreement, ATI, concordance and interchangeability for mean arterial pressure (MAP). Secondary outcomes were agreements for systolic arterial pressure and diastolic arterial pressure. Tracking of changes was assessed with four-quadrant polar plots and the trend interchangeability method. Optimal bias was defined as 5 mmHg or less. RESULTS A total of 2672 invasive and CNBP paired measurements (93% of overall data) were analysed, with a median of 92 readings per patient [IQR 76 to 100]. Mean (SD) bias for MAP, systolic arterial pressure and DAP were −6.8 (6.7), −3.0 (9.7) and −9.0 (5.4) mmHg, respectively. The ATIs were 0.88, 0.95 and 0.71, respectively, where ATI of 1.0 or less and at least 2.0 defined acceptable, marginal and unacceptable agreements. The four-quadrant plot analysis for beat-to-beat differences showed concordance rates of 97.3%, 99.98% and 96.4%, respectively. Polar plot analysis showed 95% limits of agreement of −3 to 3, −2 to 2 and −2 to 2 mmHg respectively. Trend interchangeability method showed an interchangeability rate of 95% for MAP. CONCLUSION During CEA performed under regional anaesthesia, CNBP offers a less invasive approach for BP monitoring. We found acceptable agreement for MAP defined by an ATI of 0.88 and an excellent 95% global interchangeability rate. A suboptimal bias of 7 mmHg was found with CNBP for MAP.

http://bit.ly/2Fib7Bs

Development of a prediction model for postoperative pneumonia: A multicentre prospective observational study

BACKGROUND Postoperative pneumonia is associated with increased morbidity, mortality and costs. Prediction models of pneumonia that are currently available are based on retrospectively collected data and administrative coding systems. OBJECTIVE To identify independent variables associated with the occurrence of postoperative pneumonia. DESIGN A prospective observational study of a multicentre cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe database). SETTING Sixty-three hospitals in Europe. PATIENTS Patients undergoing surgery under general and/or regional anaesthesia during a 7-day recruitment period. MAIN OUTCOME MEASURE The primary outcome was postoperative pneumonia. Definition: the need for treatment with antibiotics for a respiratory infection and at least one of the following criteria: new or changed sputum; new or changed lung opacities on a clinically indicated chest radiograph; temperature more than 38.3 °C; leucocyte count more than 12 000 μl−1. RESULTS Postoperative pneumonia occurred in 120 out of 5094 patients (2.4%). Eighty-two of the 120 (68.3%) patients with pneumonia required ICU admission, compared with 399 of the 4974 (8.0%) without pneumonia (P 

http://bit.ly/2FmgCOU

Six-minute walk test in pre-operative evaluation of patients for upper abdominal surgery

No abstract available

http://bit.ly/2FhZ9rt

Intra-operative tachycardia is not associated with a composite of myocardial injury and mortality after noncardiac surgery: A retrospective cohort analysis

BACKGROUND Myocardial injury after noncardiac surgery (MINS) is a major contributor to peri-operative morbidity and mortality with a reported incidence of about 8%. Tachycardia increases myocardial oxygen demand, and decreases oxygen supply, and is therefore a potential cause of MINS. OBJECTIVE We tested the hypothesis that there is an association between intra-operative area above a heart rate (HR) of 90 bpm and a composite of MINS and in-hospital all-cause mortality. DESIGN Retrospective analyses. SETTING Major tertiary care hospital, Cleveland, USA. PATIENTS Adults having elective or nonelective noncardiac surgery and scheduled troponin monitoring during the first 3 postoperative days between 2010 and 2015. MAIN OUTCOME MEASURES All-or-none composite of myocardial injury (MINS), defined by a peak postoperative generation 4 troponin T concentration at least 0.03 ng ml−1, and in-hospital all-cause mortality. RESULTS Among 2652 eligible patients, 123 (4.6%) experienced MINS within 7 days after surgery and 6 (0.2%) died before discharge. Intra-operative area above HR more than 90 bpm was not associated with the all-or-none composite of MINS and in-hospital mortality, with an estimated odds ratio (95% confidence interval) of 0.99 (0.97 to 1.01) per 1 h bpm increase in area above HR more than 90 bpm. Secondary outcomes were also unrelated to the composite, with estimated odds ratios (98.3% confidence interval) of 0.99 (0.98 to 1.00) for area above HR more than 80, 0.98 (0.92 to 1.04) for area above HR more than 100 bpm, and 0.96 (0.88 to 1.05) for maximum HR. CONCLUSION There was no apparent association between various measures of tachycardia and a composite of MINS and death, a result that contradicts previously reported associations between other measures of intra-operative tachycardia and MINS/mortality.

http://bit.ly/2FjGr21

Relevance of peripheral cholinesterase activity on postoperative delirium in adult surgical patients (CESARO): A prospective observational cohort study

BACKGROUND The cholinergic system is considered to play a key role in the development of postoperative delirium (POD), which is a common complication after surgery. OBJECTIVES To determine whether peri-operative acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) activities are associated with the development of POD in in-hospital surgical patients, and raise hypotheses on cholinergic regulatory mechanisms in POD. DESIGN A prospective multicentre observational study by the Peripheral Cholinesterase-activity on Neurocognitive Dysfunctions in Surgical Patients (CESARO) study group. SETTING Nine German hospitals. PATIENTS Patients of at least 18 years of age scheduled for inpatient elective surgery for a variety of surgical procedures. A total of 650 patients (mean age 61.5 years, 52.8% male) were included. METHODS Clinical variables, and peripheral AChE and BuChE activities, were assessed throughout the peri-operative period using bedside point-of-care measurements (one pre-operative and two postoperative measurements). POD screening was conducted postoperatively for at least 24 h and up to the third postoperative day using a validated screening tool (nursing delirium screening scale). RESULTS In all, 179 patients (27.5%) developed POD within the early postoperative phase. There was a lower BuChE activity in patients with delirium compared with patients without delirium pre-operatively (Cohen's r = 0.07, P = 0.091), on postoperative day 1 (Cohen's r = 0.12, P = 0.003) and on postoperative day 2 (Cohen's r = 0.12, P = 0.002). In contrast, there was a significantly higher AChE activity in patients with delirium compared with patients without delirium pre-operatively (Cohen's r = 0.10, P = 0.012), on postoperative day 1 (Cohen's r = 0.11, P = 0.004) and on postoperative day 2 (Cohen's r = 0.13, P = 0.002). After adjusting for covariates in multiple logistic regression, a significant association between both BuChE and AChE activities and POD was not found. However, in the multivariable analysis using the Generalized Estimating Equation, cholinesterase activities showed that a decrease of BuChE activity by 100 U L−1 increased the risk of a delirium by approximately 2.1% (95% CI 1.6 to 2.8%) and for each 1 U g−1 of haemoglobin increase in AChE activity, there was a 1.4% (95% CI 0.6 to 2.2%) increased risk of POD. CONCLUSION Peri-operative peripheral cholinesterase activities may be related to the development of POD, but the clinical implications remain unclear. Further studies, in homogeneous patient groups with a strict protocol for measurement time points, are needed to investigate the relationship between cholinesterase activities and POD. TRIAL REGISTRATION www.clinicaltrials.gov. Identifier NCT01964274.

http://bit.ly/2FmpKmy

Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial

BACKGROUND Goal-directed therapy (GDT) is expected to be of highest benefit in high-risk surgery. Therefore, GDT is recommended during oesophageal resection, which carries a high risk of postoperative complications. OBJECTIVES The aim of this study was to confirm the hypothesis that GDT during oesophageal resection improves outcome compared with standard care. DESIGN A randomised controlled study. SETTING Two Swedish university hospitals, between October 2011 and October 2015. PATIENTS Sixty-four patients scheduled for elective transthoracic oesophageal resection were randomised. Exclusion criteria included colonic interposition and significant aortic or mitral valve insufficiency. INTERVENTION A three-step GDT protocol included stroke volume optimisation using colloid boluses as assessed by pulse-contour analysis, dobutamine infusion if cardiac index was below 2.5 l min−1 m−2 and norepinephrine infusion if mean arterial blood pressure was below 65 mmHg. MAIN OUTCOME MEASURE The incidence of complications per patient at 5 and 30 days postoperatively as assessed using a predefined list. RESULTS Fifty-nine patients were available for analysis. Patients in the intervention group received more colloid fluid (2190 ± 875 vs. 1596 ± 759 ml, P 

http://bit.ly/2Fhax73

Orthostatic intolerance following hip arthroplasty: incidence, risk factors and effect on length of stay: A prospective cohort study

BACKGROUND Early postoperative mobilisation is important for enhanced recovery, but can be hindered by orthostatic intolerance, characterised by dizziness, nausea, vomiting, feeling of heat, blurred vision and ultimately syncope. Although the incidence of orthostatic intolerance following total hip arthroplasty has been identified, few studies have yet investigated potential risk factors for developing orthostatic intolerance after hip arthroplasty. OBJECTIVES The aim of this study was to assess the incidence of orthostatic intolerance on the first postoperative day after total hip arthroplasty, potential predisposing risk factors for developing orthostatic intolerance and its effect on length of stay. DESIGN A prospective observational study. SETTING Tertiary hospital, Auckland, New Zealand, May to September 2015. PATIENTS One hundred and seventeen consecutive patients undergoing unilateral total hip arthroplasty. Patients were excluded if they had revision surgery. MAIN OUTCOME MEASURES Incidence of orthostatic intolerance during mobilisation on the first postoperative day. Significant peri-operative risk factors for developing orthostatic intolerance were identified using logistic regression. Length of stay was compared between orthostatic intolerant and orthostatic tolerant patients using the Mann–Whitney U-test. RESULTS On the first postoperative day, 22% of patients failed mobilisation due to orthostatic intolerance. Factors independently associated with orthostatic intolerance were female sex; OR (95% CI), 3.11 (1.01 to 9.57), postoperative use of gabapentin; OR 3.55 (1.24 to 10.15) and high peak pain levels (≥5/10) during mobilisation; OR 4.05 (1.30 to 12.61). Overall, 78% of patients were correctly identified. The model was more accurate at predicting those who would not get orthostatic intolerance (89% correct), compared with those who did have orthostatic intolerance (39% correct). Length of stay was longer in patients with orthostatic intolerance (P = 0.019). CONCLUSION Orthostatic intolerance is common after total hip arthroplasty. Optimising pain control prior to mobilisation and limiting gabapentin use may modify the risk of developing postoperative orthostatic intolerance. Although personalised recovery pathways appear attractive, at present, the ability to predict at-risk individuals is still limited.

http://bit.ly/2FmpJPw

Reply to: thromboprophylaxis in the obese surgical patient

No abstract available

http://bit.ly/2FhZ8DV

Anaesthesiology residents have no significant effect on anaesthesia or procedure times

No abstract available

http://bit.ly/2Fhayb7

Monitoring haemodynamic response to fluid-challenge in ICU: comparison of pressure recording analytical method and oesophageal Doppler: A prospective observational study

BACKGROUND The ability of the pressure recording analytical method (PRAM) in tracking change in cardiac output (ΔCO) after a fluid challenge in ICU needs to be evaluated with the most contemporary comparison methods recommended by experts. OBJECTIVE Our objective was to report the trending ability of PRAM in tracking ΔCO after a fluid challenge in ICU and to compare this with oesophageal Doppler monitoring (ODM). DESIGN Prospective, observational study. SETTING Hôpital Lariboisière and Hôpital Européen George Pompidou, Paris, France, from April 2016 to December 2017. PATIENTS Critically ill patients admitted to ICU with monitoring of CO monitored by ODM and invasive arterial pressure. INTERVENTION ΔCO after fluid challenge was simultaneously registered with ODM and PRAM connected to the arterial line. MAIN OUTCOME MEASURE Polar statistics (mean angular bias, radial limits of agreement and polar concordance rate) and clinical concordance evaluation (error grid and clinical concordance rate). Predictors of bias were determined. RESULTS Sixty-eight fluid challenge were administered in 49 patients. At the time of fluid challenge, almost all were mechanically ventilated (99%), with 85% receiving norepinephrine. Admission diagnosis was septic shock in 70% of patients. Patients had a Sequential Organ Failure Assessment score of 10 [7 to 12] and a median Simplified Acute Physiology Score II of 61 [49 to 69]. Relative ΔCO bias was 7.8° (6.3°) with radial limits of agreement of ±41.7°, polar concordance rate 80% and clinical concordance rate 74%. ΔCO bias was associated with baseline bias (P = 0.007). Baseline bias was associated with radial location of the arterial line (P = 0.03). CONCLUSION When compared with ODM, PRAM has insufficient performance to track ΔCO induced by fluid challenge in ICU patients. Baseline bias is an independent predictor of trending bias. TRIAL REGISTRATION IRB 00010254-2016-033.

http://bit.ly/2Flbz0Z

European paediatric anaesthesia e-learning platform pearls and challenges

No abstract available

http://bit.ly/2Fj3sCO

Lack of consensus on the peri-operative management of patients with diabetes mellitus

No abstract available

http://bit.ly/2FlnWtW

Thromboprophylaxis in the obese surgical patient

No abstract available

http://bit.ly/2FhRv0e

Intra-operative heart rate and postoperative outcomes – rowing against the tide?

No abstract available

http://bit.ly/2FnNfvl

Noninvasive continuous arterial pressure monitoring with Clearsight during awake carotid endarterectomy: A prospective observational study

BACKGROUND Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a less invasive alternative compared with invasive intra-arterial monitoring for awake patients during carotid endarterectomy (CEA) under regional anaesthesia. OBJECTIVE We investigated the agreement of blood pressure (BP) recorded with invasive and CNBP methods during awake CEA. DESIGN A prospective observational study for assessing agreement with Bland–Altman plots, agreement-tolerability indices (ATI), concordance and interchangeability. SETTING Azienda Ospedaliera Universitaria G. Martino, Messina, a University tertiary referral centre in Italy. PATIENTS In 30 consecutive patients, we recorded continuously ipsilateral invasive and noninvasive BPs, from 3 min before carotid cross-clamping to 5 min after unclamping. MAIN OUTCOME MEASURES Primary outcome was bias, 95% limits of agreement, ATI, concordance and interchangeability for mean arterial pressure (MAP). Secondary outcomes were agreements for systolic arterial pressure and diastolic arterial pressure. Tracking of changes was assessed with four-quadrant polar plots and the trend interchangeability method. Optimal bias was defined as 5 mmHg or less. RESULTS A total of 2672 invasive and CNBP paired measurements (93% of overall data) were analysed, with a median of 92 readings per patient [IQR 76 to 100]. Mean (SD) bias for MAP, systolic arterial pressure and DAP were −6.8 (6.7), −3.0 (9.7) and −9.0 (5.4) mmHg, respectively. The ATIs were 0.88, 0.95 and 0.71, respectively, where ATI of 1.0 or less and at least 2.0 defined acceptable, marginal and unacceptable agreements. The four-quadrant plot analysis for beat-to-beat differences showed concordance rates of 97.3%, 99.98% and 96.4%, respectively. Polar plot analysis showed 95% limits of agreement of −3 to 3, −2 to 2 and −2 to 2 mmHg respectively. Trend interchangeability method showed an interchangeability rate of 95% for MAP. CONCLUSION During CEA performed under regional anaesthesia, CNBP offers a less invasive approach for BP monitoring. We found acceptable agreement for MAP defined by an ATI of 0.88 and an excellent 95% global interchangeability rate. A suboptimal bias of 7 mmHg was found with CNBP for MAP.

http://bit.ly/2Fib7Bs

Development of a prediction model for postoperative pneumonia: A multicentre prospective observational study

BACKGROUND Postoperative pneumonia is associated with increased morbidity, mortality and costs. Prediction models of pneumonia that are currently available are based on retrospectively collected data and administrative coding systems. OBJECTIVE To identify independent variables associated with the occurrence of postoperative pneumonia. DESIGN A prospective observational study of a multicentre cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe database). SETTING Sixty-three hospitals in Europe. PATIENTS Patients undergoing surgery under general and/or regional anaesthesia during a 7-day recruitment period. MAIN OUTCOME MEASURE The primary outcome was postoperative pneumonia. Definition: the need for treatment with antibiotics for a respiratory infection and at least one of the following criteria: new or changed sputum; new or changed lung opacities on a clinically indicated chest radiograph; temperature more than 38.3 °C; leucocyte count more than 12 000 μl−1. RESULTS Postoperative pneumonia occurred in 120 out of 5094 patients (2.4%). Eighty-two of the 120 (68.3%) patients with pneumonia required ICU admission, compared with 399 of the 4974 (8.0%) without pneumonia (P 

http://bit.ly/2FmgCOU

Six-minute walk test in pre-operative evaluation of patients for upper abdominal surgery

No abstract available

http://bit.ly/2FhZ9rt

Intra-operative tachycardia is not associated with a composite of myocardial injury and mortality after noncardiac surgery: A retrospective cohort analysis

BACKGROUND Myocardial injury after noncardiac surgery (MINS) is a major contributor to peri-operative morbidity and mortality with a reported incidence of about 8%. Tachycardia increases myocardial oxygen demand, and decreases oxygen supply, and is therefore a potential cause of MINS. OBJECTIVE We tested the hypothesis that there is an association between intra-operative area above a heart rate (HR) of 90 bpm and a composite of MINS and in-hospital all-cause mortality. DESIGN Retrospective analyses. SETTING Major tertiary care hospital, Cleveland, USA. PATIENTS Adults having elective or nonelective noncardiac surgery and scheduled troponin monitoring during the first 3 postoperative days between 2010 and 2015. MAIN OUTCOME MEASURES All-or-none composite of myocardial injury (MINS), defined by a peak postoperative generation 4 troponin T concentration at least 0.03 ng ml−1, and in-hospital all-cause mortality. RESULTS Among 2652 eligible patients, 123 (4.6%) experienced MINS within 7 days after surgery and 6 (0.2%) died before discharge. Intra-operative area above HR more than 90 bpm was not associated with the all-or-none composite of MINS and in-hospital mortality, with an estimated odds ratio (95% confidence interval) of 0.99 (0.97 to 1.01) per 1 h bpm increase in area above HR more than 90 bpm. Secondary outcomes were also unrelated to the composite, with estimated odds ratios (98.3% confidence interval) of 0.99 (0.98 to 1.00) for area above HR more than 80, 0.98 (0.92 to 1.04) for area above HR more than 100 bpm, and 0.96 (0.88 to 1.05) for maximum HR. CONCLUSION There was no apparent association between various measures of tachycardia and a composite of MINS and death, a result that contradicts previously reported associations between other measures of intra-operative tachycardia and MINS/mortality.

http://bit.ly/2FjGr21

Postoperative pneumonia: Can this important complication be predicted and anticipated?

No abstract available

http://bit.ly/2FiaRCu

Relevance of peripheral cholinesterase activity on postoperative delirium in adult surgical patients (CESARO): A prospective observational cohort study

BACKGROUND The cholinergic system is considered to play a key role in the development of postoperative delirium (POD), which is a common complication after surgery. OBJECTIVES To determine whether peri-operative acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) activities are associated with the development of POD in in-hospital surgical patients, and raise hypotheses on cholinergic regulatory mechanisms in POD. DESIGN A prospective multicentre observational study by the Peripheral Cholinesterase-activity on Neurocognitive Dysfunctions in Surgical Patients (CESARO) study group. SETTING Nine German hospitals. PATIENTS Patients of at least 18 years of age scheduled for inpatient elective surgery for a variety of surgical procedures. A total of 650 patients (mean age 61.5 years, 52.8% male) were included. METHODS Clinical variables, and peripheral AChE and BuChE activities, were assessed throughout the peri-operative period using bedside point-of-care measurements (one pre-operative and two postoperative measurements). POD screening was conducted postoperatively for at least 24 h and up to the third postoperative day using a validated screening tool (nursing delirium screening scale). RESULTS In all, 179 patients (27.5%) developed POD within the early postoperative phase. There was a lower BuChE activity in patients with delirium compared with patients without delirium pre-operatively (Cohen's r = 0.07, P = 0.091), on postoperative day 1 (Cohen's r = 0.12, P = 0.003) and on postoperative day 2 (Cohen's r = 0.12, P = 0.002). In contrast, there was a significantly higher AChE activity in patients with delirium compared with patients without delirium pre-operatively (Cohen's r = 0.10, P = 0.012), on postoperative day 1 (Cohen's r = 0.11, P = 0.004) and on postoperative day 2 (Cohen's r = 0.13, P = 0.002). After adjusting for covariates in multiple logistic regression, a significant association between both BuChE and AChE activities and POD was not found. However, in the multivariable analysis using the Generalized Estimating Equation, cholinesterase activities showed that a decrease of BuChE activity by 100 U L−1 increased the risk of a delirium by approximately 2.1% (95% CI 1.6 to 2.8%) and for each 1 U g−1 of haemoglobin increase in AChE activity, there was a 1.4% (95% CI 0.6 to 2.2%) increased risk of POD. CONCLUSION Peri-operative peripheral cholinesterase activities may be related to the development of POD, but the clinical implications remain unclear. Further studies, in homogeneous patient groups with a strict protocol for measurement time points, are needed to investigate the relationship between cholinesterase activities and POD. TRIAL REGISTRATION www.clinicaltrials.gov. Identifier NCT01964274.

http://bit.ly/2FmpKmy

Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial

BACKGROUND Goal-directed therapy (GDT) is expected to be of highest benefit in high-risk surgery. Therefore, GDT is recommended during oesophageal resection, which carries a high risk of postoperative complications. OBJECTIVES The aim of this study was to confirm the hypothesis that GDT during oesophageal resection improves outcome compared with standard care. DESIGN A randomised controlled study. SETTING Two Swedish university hospitals, between October 2011 and October 2015. PATIENTS Sixty-four patients scheduled for elective transthoracic oesophageal resection were randomised. Exclusion criteria included colonic interposition and significant aortic or mitral valve insufficiency. INTERVENTION A three-step GDT protocol included stroke volume optimisation using colloid boluses as assessed by pulse-contour analysis, dobutamine infusion if cardiac index was below 2.5 l min−1 m−2 and norepinephrine infusion if mean arterial blood pressure was below 65 mmHg. MAIN OUTCOME MEASURE The incidence of complications per patient at 5 and 30 days postoperatively as assessed using a predefined list. RESULTS Fifty-nine patients were available for analysis. Patients in the intervention group received more colloid fluid (2190 ± 875 vs. 1596 ± 759 ml, P 

http://bit.ly/2Fhax73

Orthostatic intolerance following hip arthroplasty: incidence, risk factors and effect on length of stay: A prospective cohort study

BACKGROUND Early postoperative mobilisation is important for enhanced recovery, but can be hindered by orthostatic intolerance, characterised by dizziness, nausea, vomiting, feeling of heat, blurred vision and ultimately syncope. Although the incidence of orthostatic intolerance following total hip arthroplasty has been identified, few studies have yet investigated potential risk factors for developing orthostatic intolerance after hip arthroplasty. OBJECTIVES The aim of this study was to assess the incidence of orthostatic intolerance on the first postoperative day after total hip arthroplasty, potential predisposing risk factors for developing orthostatic intolerance and its effect on length of stay. DESIGN A prospective observational study. SETTING Tertiary hospital, Auckland, New Zealand, May to September 2015. PATIENTS One hundred and seventeen consecutive patients undergoing unilateral total hip arthroplasty. Patients were excluded if they had revision surgery. MAIN OUTCOME MEASURES Incidence of orthostatic intolerance during mobilisation on the first postoperative day. Significant peri-operative risk factors for developing orthostatic intolerance were identified using logistic regression. Length of stay was compared between orthostatic intolerant and orthostatic tolerant patients using the Mann–Whitney U-test. RESULTS On the first postoperative day, 22% of patients failed mobilisation due to orthostatic intolerance. Factors independently associated with orthostatic intolerance were female sex; OR (95% CI), 3.11 (1.01 to 9.57), postoperative use of gabapentin; OR 3.55 (1.24 to 10.15) and high peak pain levels (≥5/10) during mobilisation; OR 4.05 (1.30 to 12.61). Overall, 78% of patients were correctly identified. The model was more accurate at predicting those who would not get orthostatic intolerance (89% correct), compared with those who did have orthostatic intolerance (39% correct). Length of stay was longer in patients with orthostatic intolerance (P = 0.019). CONCLUSION Orthostatic intolerance is common after total hip arthroplasty. Optimising pain control prior to mobilisation and limiting gabapentin use may modify the risk of developing postoperative orthostatic intolerance. Although personalised recovery pathways appear attractive, at present, the ability to predict at-risk individuals is still limited.

http://bit.ly/2FmpJPw

Reply to: thromboprophylaxis in the obese surgical patient

No abstract available

http://bit.ly/2FhZ8DV

Peri-operative endothelial dysfunction in patients undergoing minor abdominal surgery: An observational study

BACKGROUND Myocardial injury after noncardiac surgery is common and associated with major adverse cardiac events. Surgery induces acute endothelial dysfunction, which might be central in the pathophysiology of myocardial injury; however, the relationship between surgical stress and endothelial function remains incompletely understood. OBJECTIVES This study aimed to assess the acute peri-operative changes in endothelial function after minor elective abdominal surgery. DESIGN A prospective, observational, single-centre study. SETTING A university hospital from February 2016 to January 2017. PATIENTS Sixty patients undergoing elective minor abdominal surgery. MAIN OUTCOME MEASURES The change in endothelial function, expressed as the reactive hyperaemia index (RHI), was assessed by non-invasive digital pulse tonometry. RHI, biomarkers of nitric oxide bioavailability and oxidative stress were assessed prior to and 4 h after surgery. RESULTS RHI decreased significantly from 1.93 [95% confidence interval (95% CI 1.78 to 2.09)] before surgery to 1.76 (95% CI 1.64 to 1.90), P = 0.03, after surgery. The nitric oxide production, L-arginine/asymmetric dimethylarginine, decreased significantly from a ratio of 213.39 (95% CI 188.76 to 241.2) to a ratio of 193.3 (95% CI 171.82 to 217.54), P = 0.03. Plasma biopterins increased significantly after surgery, while the ratio between tetrahydrobiopterin and dihydrobiopterin was unchanged. Total ascorbic acid decreased significantly after surgery (P 

http://bit.ly/2FllVOq

Anaesthesiology residents have no significant effect on anaesthesia or procedure times

No abstract available

http://bit.ly/2Fhayb7

Monitoring haemodynamic response to fluid-challenge in ICU: comparison of pressure recording analytical method and oesophageal Doppler: A prospective observational study

BACKGROUND The ability of the pressure recording analytical method (PRAM) in tracking change in cardiac output (ΔCO) after a fluid challenge in ICU needs to be evaluated with the most contemporary comparison methods recommended by experts. OBJECTIVE Our objective was to report the trending ability of PRAM in tracking ΔCO after a fluid challenge in ICU and to compare this with oesophageal Doppler monitoring (ODM). DESIGN Prospective, observational study. SETTING Hôpital Lariboisière and Hôpital Européen George Pompidou, Paris, France, from April 2016 to December 2017. PATIENTS Critically ill patients admitted to ICU with monitoring of CO monitored by ODM and invasive arterial pressure. INTERVENTION ΔCO after fluid challenge was simultaneously registered with ODM and PRAM connected to the arterial line. MAIN OUTCOME MEASURE Polar statistics (mean angular bias, radial limits of agreement and polar concordance rate) and clinical concordance evaluation (error grid and clinical concordance rate). Predictors of bias were determined. RESULTS Sixty-eight fluid challenge were administered in 49 patients. At the time of fluid challenge, almost all were mechanically ventilated (99%), with 85% receiving norepinephrine. Admission diagnosis was septic shock in 70% of patients. Patients had a Sequential Organ Failure Assessment score of 10 [7 to 12] and a median Simplified Acute Physiology Score II of 61 [49 to 69]. Relative ΔCO bias was 7.8° (6.3°) with radial limits of agreement of ±41.7°, polar concordance rate 80% and clinical concordance rate 74%. ΔCO bias was associated with baseline bias (P = 0.007). Baseline bias was associated with radial location of the arterial line (P = 0.03). CONCLUSION When compared with ODM, PRAM has insufficient performance to track ΔCO induced by fluid challenge in ICU patients. Baseline bias is an independent predictor of trending bias. TRIAL REGISTRATION IRB 00010254-2016-033.

http://bit.ly/2Flbz0Z

European paediatric anaesthesia e-learning platform pearls and challenges

No abstract available

http://bit.ly/2Fj3sCO

Nasofacial Anthropometric Study Among Students of Shiraz University of Medical Sciences, Iran: A Population Based Study

Abstract

Anthropometry is a scientific study of linear dimensions and angles of living subjects. Knowing the details and anthropometric properties of nasofacial for each specific ethnic group is important for cosmetic operation as well as identifying individuals. In this study, facial and nasal anthropometric factors were studied in students of Shiraz University of Medical Sciences. In a cross-sectional study, 200 students of Shiraz University of Medical Sciences (100 male and 100 female and age range of 18–30 years) were selected. Nasal width (NW), nasal length (NL), nasal height (NH), face height (FH) and face width (FW) were measured in and the nasal (NI) and facial index (FI) were calculated for each case. Then, the data were analyzed using SPSS-22. The mean age was 21.84 ± 3.18 years. There were significant differences in the facial and nasal measurements including FH (P = 0.0001), FW (P = 0.0001), FI (P = 0.0001), NL (P = 0.002), NH (P = 0.001), NW (P = 0.0001) and NI (P = 0.0001) of sex groups. The most common types of face were mesoprosopic (36%) and hyperleptoprosopic (38%) types and and platyrrhine (63%) were mostly frequent. Based on the findings, all students of Shiraz University of Medical Sciences had mesoprosopic (36%) and hyperleptoprosopic (38%) types of face and platyrrhine type of nose. As well, a sexual dimorphism was recorded according to the nasofacial measurements in Iranian population that should be considered in the cosmetic operations. Sexual dimorphism and differences between different populations were recorded.

http://bit.ly/2ACbgM0

Nasofacial Anthropometric Study Among Students of Shiraz University of Medical Sciences, Iran: A Population Based Study

Abstract

Anthropometry is a scientific study of linear dimensions and angles of living subjects. Knowing the details and anthropometric properties of nasofacial for each specific ethnic group is important for cosmetic operation as well as identifying individuals. In this study, facial and nasal anthropometric factors were studied in students of Shiraz University of Medical Sciences. In a cross-sectional study, 200 students of Shiraz University of Medical Sciences (100 male and 100 female and age range of 18–30 years) were selected. Nasal width (NW), nasal length (NL), nasal height (NH), face height (FH) and face width (FW) were measured in and the nasal (NI) and facial index (FI) were calculated for each case. Then, the data were analyzed using SPSS-22. The mean age was 21.84 ± 3.18 years. There were significant differences in the facial and nasal measurements including FH (P = 0.0001), FW (P = 0.0001), FI (P = 0.0001), NL (P = 0.002), NH (P = 0.001), NW (P = 0.0001) and NI (P = 0.0001) of sex groups. The most common types of face were mesoprosopic (36%) and hyperleptoprosopic (38%) types and and platyrrhine (63%) were mostly frequent. Based on the findings, all students of Shiraz University of Medical Sciences had mesoprosopic (36%) and hyperleptoprosopic (38%) types of face and platyrrhine type of nose. As well, a sexual dimorphism was recorded according to the nasofacial measurements in Iranian population that should be considered in the cosmetic operations. Sexual dimorphism and differences between different populations were recorded.

http://bit.ly/2ACbgM0

Unilateral Thalamic Deep Brain Stimulation for Voice Tremor

Background: Voice tremor (VT) is the involuntary and rhythmical phonatory instability of the voice. Recent findings suggest that unilateral deep brain stimulation of the ventral intermediate nucleus (Vim-DBS) can sometimes be effective for VT. In this exploratory analysis, we investigated the effect of Vim-DBS on VT and tested the hypothesis that unilateral thalamic stimulation is effective for patients with VT. Methods: Seven patients with VT and previously implanted bilateral Vim-DBS were enrolled in the study. Each patient was randomized and recorded performing sustained phonation during the following conditions: left thalamic stimulation, right thalamic stimulation, bilateral thalamic stimulation (Bil-ON), and no stimulation (Bil-OFF). Perceptual VT ratings and an acoustic analysis to find the rate of variation of the fundamental frequency measured by the standard deviation of the pitch (f0SD) were performed in a blinded manner. For the purposes of this study, a "dominant" side was defined as one with more than twice as much reduction in VT following Vim-DBS compared to the contralateral side. The Wilcoxon signed-rank test was performed to compare the effect of the dominant side stimulation in the reduction of VT scores and f0SD. The volume of activated tissue (VAT) of the dominant stimulation side was modelled against the degree of improvement in VT to correlate the significant stimulation cluster with thalamic anatomy. Finally, tractography analysis was performed to analyze the connectivity of the significant stimulation cluster. Results: Unilateral stimulation was beneficial in all 7 patients. Five patients clearly had a "dominant" side with either benefit only seen following stimulation of one side or more than twice as much benefit from one side compared to the other. Two patients had similar benefit with unilateral stimulation from either side. The Wilcoxon paired test showed significant differences between unilateral dominant and unilateral nondominant stimulation for VT scores (p = 0.04), between unilateral dominant and Bil-OFF (p = 0.04), and between Bil-ON and unilateral nondominant stimulation (p = 0.04). No significant differences were found between Bil-ON and unilateral dominant condition (p = 0.27), or between Bil-OFF and unilateral nondominant (p = 0.23). The dominant VAT showed that the significant voxels associated with the best VT control were located in the most ventral and medial part of the Vim nucleus and the ventralis caudalis anterior internus nucleus. The connectivity analysis showed significant connectivity with the cortical areas of the speech circuit. Conclusions: Unilateral dominant-side thalamic stimulation and bilateral thalamic stimulation were equally effective in reducing VT. Nondominant unilateral stimulation alone did not significantly improve VT.
Stereotact Funct Neurosurg

http://bit.ly/2FgiGZn

BRCA Exchange aggregates data on thousands of BRCA variants to inform understanding of cancer risk

The BRCA Exchange, a global resource that includes data on thousands of inherited variants in the BRCA1/BRCA2 genes, is available to the public through a website and new smartphone app.

http://bit.ly/2FgO75W

Premaxillary–maxillary suture development in the first trimester

Abstract

Purpose

Our study was designed to investigate premaxillary–maxillary suture growth in fetuses from the first trimester of pregnancy using the B‑ultrasound technique in order to determine the suture fusion time.

Methods

We selected 169 healthy Han singleton pregnancies as subjects. All subjects received routine pregnancy tests and were divided into three groups based on the gestational age of the fetus: group 1, the 11th gestational week; group 2, the 12th gestational week; and group 3, the 13th gestational week. Fetal biometric measurements were recorded during consecutive prenatal ultrasonographic examinations. These measurements included nuchal translucency thickness, crown–rump length, and premaxillary–maxillary length. Intergroup comparisons were performed using analysis of variance (ANOVA).

Results

The premaxillary–maxillary suture grows gradually and its measured length at the 11th, 12th and 13th week was 0.54 cm, 0.65 cm, and 0.74 cm, respectively. We observed a significant linear correlation between the premaxillary–maxillary length and the week of gestation in the first trimester. The growth rate of the maxilla at the 11th, the 12th and the 13th week are significantly different with a descending order of growth rates being week 12, week 11 and week 13, with the 12th week rate being the most rapid.

Conclusion

The premaxillary and maxillary growth at 11 and 12 gestational weeks in the first trimester steadily accelerated, peaking at the 12th week. The rate of growth slows down after week 12 which may be associated with the fusion of the premaxillary–maxillary suture.

http://bit.ly/2TBJs1y

Photocatalytic degradation of pharmaceutical micro-pollutants using ZnO

Abstract

This research paper presents the results of an experimental investigation of the degradation of three different contaminants including progesterone (PGS), ibuprofen (IBU), and naproxen (NAP) using ZnO as the photocatalyst and ultraviolet (UV) light as a source for catalysts activation. Two operating parameters, namely, catalyst loading and initial concentration of contaminants, were tested in a batch photocatalytic reactor. To demonstrate the large-scale applications, experiments were also conducted in a submerged membrane photocatalytic reactor. It has proven that ZnO photocatalyst degraded the three contaminants very efficiently under almost all the studied experimental conditions, with efficiency rates of 92.3, 94.5, and 98.7 % for PSG, IBU, and NAP, respectively. The photodegradation kinetics study was performed to calculate the reaction rate constant, which is found to follow pseudo-first order kinetics. The membrane photocatalytic reactor was efficient to remove pollutants and it is observed that the degradation rate increases with increasing the membrane oscillation frequency approaching that of the stirred reactor.

http://bit.ly/2H5ettj

Bedeutung des follikulären Penetrationswegs für den Wirkstofftransport mittels Nanocarriern

Zusammenfassung

Hintergrund

Der Haarfollikel stellt einen bedeutenden Penetrationsweg für topisch applizierte Substanzen dar.

Fragestellung

Die perkutane Absorption von bestimmten Substanzen kann durch die Beteiligung der Haarfollikel deutlich gesteigert und beschleunigt werden. Ferner haben Nanopartikel die Eigenschaft, besonders tief und effektiv in die Haarfollikel hinein zu penetrieren.

Material und Methoden

Dies bietet die Möglichkeit, den Wirkstofftransport für topisch applizierte Substanzen zu optimieren, indem die Nanocarrier allein als Transporter für die Wirkstoffe in den Haarfollikel fungieren. Innerhalb des Haarfollikels muss nach erfolgter Penetration eine Freisetzung des Wirkstoffs vom Nanocarrier erfolgen. Dies kann durch verschiedene Mechanismen getriggert werden.

Ergebnisse

Die freigesetzten Nanocarrier können somit unabhängig vom Nanopartikel in das den Haarfollikel umgebende lebende Gewebe übergehen. Mithilfe dieser innovativen Strategie kann die Bioverfügbarkeit von topisch applizierten Substanzen deutlich verbessert werden.

Schlussfolgerung

Ein Transport von Wirkstoffen in die Haarfollikel mithilfe von Partikeln und die dortige Wirkstofffreisetzung stellen eine sehr effektive neue Methode dar, Wirkstoffe durch die Hautbarriere zu transportieren.

http://bit.ly/2C6FIhe