Cutaneous larva migrans is a neglected zoonotic helminthic disease which is paradoxically underreported in low-income and middle-income countries from where a majority of the cases emanate. It presents as migr...
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Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Τετάρτη 19 Σεπτεμβρίου 2018
An unusual case of extensive truncal cutaneous larva migrans in a Cameroonian baby: a case report
Giant craniopharyngioma in an adult presenting with new onset seizure
Description
A 43-year-old man presented to the emergency department after experiencing a first episode seizure. No further information was available at presentation as the patient was confused on his arrival. On physical examination, vital signs were normal. The patient was confused, and his Glasgow Coma Score was 12(E3V4M5). Initial workup included complete blood count, electrolytes and ECG were normal. Thyroid function tests, insulin growth factor-1 and plasma random cortisol level were within the normal range. Testosterone levels were low, and luteinising hormone was inappropriately normal. CT demonstrated a cystic mass with peripheral calcification measuring 6.0x4.5x3.9 cm. The lesion originated from the pituitary fossa and expanded superiorly distorting the third ventricle and the left lateral ventricle causing hydrocephalus (figure 1). A pituitary MRI confirmed these findings (figure 2). The patient underwent a craniotomy with mass resection. The procedure was uneventful. Pathology demonstrated nodular whorls and...
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Partial mid-portion Achilles tear resulting in substantial improvement in pain and function in an amateur long-distance runner
This case presents symptom resolution for a long-distance runner with chronic Achilles tendinopathy (AT), following a partial tear of his Achilles tendon. The patient reported a sudden pain during a morning run, with preserved function. Three hours postinjury, he was reviewed in a musculoskeletal clinic. An ultrasound scan confirmed a partial Achilles tear, associated with significant Doppler activity. His index of AT severity The Victorian Institute of Sports Assessment - Achilles Questionnaire (VISA-A) 4 hours postinjury was markedly higher compared with 2 weeks preinjury, indicating reduced symptom severity. A follow-up scan 4 weeks postinjury showed minimal mid-portion swelling and no signs of the tear. His VISA-A score showed continued symptom improvement. This case represents resolution of tendinopathic symptomatology post partial Achilles tear. While the natural histories of AT and Achilles tears remain unknown, this case may indicate that alongside the known role of loading, inflammation may be a secondary mediator central to the successful resolution of AT pain.
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87-year-old woman with improved pulmonary function following accidental long-term inhalation therapy with dabigatran
Accidental long-term dabigatran etexilate inhalation was associated with subtherapeutic dabigatran serum concentrations in an elderly female patient with restrictive lung disease. A significant improvement in her pulmonary function was noted without other therapy directed towards her bronchopulmonary disease.
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Unusual case of levamisole-induced dual-positive ANCA vasculitis and crescentic glomerulonephritis
Cocaine adulterated levamisole is an increasingly reported cause of skin necrosis, arthralgia and systemic vasculitis, but renal involvement is uncommon. We present a case of a 40-year-old Hispanic man with a history of cocaine abuse who presented with acute kidney injury to the rheumatology clinic where he was being treated for chronic inflammatory arthritis. He was found to have a serum creatinine of 2.5 mg/dL, microscopic haematuria and subnephrotic proteinuria, along with positive proteinase 3, myeloperoxidase, anticardiolipin antibodies and an elevated antinuclear antibody titre. The renal pathology revealed focal necrotising glomerulonephritis with crescentic features and mild immune type deposition. The patient was treated with cocaine abstinence, pulse dose steroids followed by maintenance prednisone, rituximab and cyclophosphamide. His renal function subsequently improved but did not normalise. We believe that his incomplete improvement was due to the degree of kidney injury on presentation as well as recidivism with cocaine use.
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Microangiopathic haemolytic anaemia with thrombocytopenia induced by vitamin B12 deficiency long term after gastrectomy
Microangiopathic haemolytic anaemia with thrombocytopenia, called pseudo-thrombotic microangiopathy (TMA), is a clinically important complication in patients with vitamin B12 deficiency. We herein present a case of an 80-year-old woman with pseudo-TMA after gastrectomy. She was initially suspected with thrombotic thrombocytopenic purpura based on rapid progression of anaemia with schistocytes and thrombocytopenia; however, her anaemia and thrombocytopenia were improved by vitamin B12 supplementation alone, with a single session of plasma exchange. Vitamin B12 deficiency was finally confirmed by low vitamin B12 levels from the patient's initial blood sample. In addition, normal ADAMTS13 activity was proven, lowering the likelihood of thrombotic thrombocytopenic purpura. Therefore, this patient was diagnosed with pseudo-TMA caused by vitamin B12 deficiency. Pseudo-TMA can occur in patients with vitamin B12 deficiency post-gastrectomy.
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Herpes simplex virus keratitis mimicking Acanthamoeba keratitis: a clinicopathological correlation
A 36-year-old male, soft contact lens wearer was referred by his primary ophthalmologist for corneal ulcer of the right eye (OD), which was persistent despite topical fluoroquinolone therapy for 1 month. A ring-shaped infiltrate typically seen in Acanthamoeba infection was noted, and topical therapy with chlorhexidine and polyhexamethylene biguanide was initiated. However, the patient's condition deteriorated over the next several weeks; thus, diagnostic and therapeutic penetrating keratoplasty was performed. The postoperative immunohistochemical analysis suggested a diagnosis of herpes simplex virus (HSV) keratitis. The patient ultimately improved after initiation of oral valacyclovir following penetrating keratoplasty. We report a case of a commonly encountered clinical entity, HSV keratitis, with an atypical clinical presentation, masquerading as Acanthamoeba keratitis.
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Acute testicular pain secondary to a leaking abdominal aortic aneurysm (AAA)
We present the case of a 56-year-old male smoker with a background of hypertension who presented with acute onset right testicular pain secondary to a leaking abdominal aortic aneurysm. Following urgent surgical repair and a complicated intensive care recovery, the patient was discharged with no residual disability. This case highlights an atypical presentation of what is a devastating illness.
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Isolated Fourniers gangrene of the penis with penile autoamputation
Description
A 65-year-old non-diabetic man presented to us with blackish discolouration of his penile shaft for 10 days (figures 1 and 2). He had undergone total thyroidectomy for follicular carcinoma of the thyroid gland 2 weeks previously. Intraoperatively, failed attempts were made to catheterise the patient. These attempts were traumatic, and a suprapubic catheter was hence placed. Following this, he developed inflammation and oedema on his penile shaft which then gradually started turning black for which he came to us. A diagnosis of isolated Fournier's gangrene of penis was made. Debridement was done, and the patient was advised regular dressings. During the initial debridement, the tunica albuginea and corpus cavernosa were not excised although the patient had slight gangrenous changes over the cavernosa. Later, gradually, a line of demarcation developed, and there was autoamputation of the involved shaft, 2 weeks after the initial debridement. The patient...
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Positron emission tomography and reframing vasculitis as a spectrum of disease when investigating a patient with a fever of unknown origin
A retired businessman presented to the infectious diseases department with a history of ongoing fevers and myalgia and raised inflammatory markers. This continued despite adequate antibiotic treatment of an epididymo-orchitis. Extensive investigations, including bone marrow and liver biopsies and a positron emission tomography, did not reveal a cause but showed reactive change in the bone marrow. Later, he developed a vasculitic rash and vision loss due to non-arteritic anterior ischaemic optic neuropathy. High-dose steroids were immediately initiated. A temporal artery biopsy was performed, which confirmed a healing large vessel vasculitis, possibly giant cell arteritis. He has responded very well to therapy. We must better appreciate the limitations of positron emission tomography in investigating a fever of unknown origin. The case also encourages awareness of autoimmune disorders as the leading category of causative diseases for this in older age groups.
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Rare cause of ovarian mass
Pelvic actinomycosis is a rare entity that occurs almost exclusively in women, the presentation of which is usually non-specific and variable. Pelvic actinomycosis is almost always associated with the use of an intrauterine contraceptive device (IUD). Pelvic actinomycosis unrelated to IUD use is almost always associated with previous surgical procedures. The symptoms, clinical signs and radiological findings are usually non-specific, mimicking an ovarian malignancy. So an awareness of this rare condition and a proper diagnosis can avoid unnecessary surgeries because these cases can be treated with a prolonged course of antibiotics. We present a case of pelvic actinomycosis which masqueraded as an ovarian malignancy.
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Making a difference providing equitable renal care globally
In their report, Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala, Moore et al describe a 42-year old indigenous Maya man who loses his job after being diagnosed with complicated diabetes. He later develops renal failure of unknown etiology. The patient originally presents to a non-profit clinic, then goes to a "higher-level laboratory in the regional capital," and finally to "The National Centre for Chronic Renal Disease (UNAERC)" The patient is given two options for renal replacement therapy, either twice-weekly haemodialysis or continuous ambulatory peritoneal dialysis (CAPD). Due to his limited mobility and finances, the patient chose CAPD as management of his renal failure.
Chronic Kidney Disease (CKD) is a common effect of many non-communicable disease processes, including hypertension, diabetes, and iatrogenic causes. The burden of this disease, "is significant and rising." CKD in general, and end-stage renal disease (ESRD) in particular are illnesses which have profound impact on the family, social, economic and psychological well-being of patients. As described by the authors, the patient's wife "cannot hold a regular job…as primary caregiver…. The patient and his family have subsided on donations…as well as meagre wages…. The patient… worries constantly about the future. His chronic diseases have caused him to feel distress, helplessness and shame." The patient is not alone in feeling this way. While studies in the developing world regarding quality of life on dialysis patients are lacking, those that do exist support the psychosocial detriment that dialysis is to many.[1] According to one patient, "In many ways… dialysis is the end of hope." [2] This reveals the importance of a multidisciplinary approach to renal replacement in the developing world, with a special emphasis on social work and mental health services.
CKD and ESRD also target vulnerable populations. The authors speak convincingly of a "sickness-poverty cycle… he became too sick to work, then too poor to pay for quality healthcare and medications and consequently he became even sicker." The inability of patients to access care and the inequity created by the care delivered can be devastating for patients who do not possess social capital to protect themselves. This can include the indigenous Maya in Guatemala, others of poor socioeconomic status in Latin America, or even undocumented immigrants in a country with a well-developed healthcare system, such as the United States. [3] Comprehensive, universally accessible healthcare is necessary for the protection of these patients, and may help prevent CKD from transitioning to ESRD. The delivery of this care will be one of the challenges of the future as non-communicable diseases continue to increase in the developing world.
BMJ Case Reports invites authors to submit global health case reports that describe the delivery of renal care for vulnerable patients. These cases could focus on:
-Unique models of delivery in the developing world
-Successful interventions for providing access to vulnerable patients worldwide
-Challenges and complications of renal care in low-resource settings
Manuscripts may be submitted by students, physicians, nurses and allied health professionals to BMJ Case Reports at casereports.bmj.com. For more information, review our guidance on how to write a global health case report and look through our online collection.
To read more about renal care globally at BMJ Case Reports, please review:
–Acute peritoneal dialysis in a Jehovah's Witness post laparotomy
–Renal failure: unusual clinical presentation of an isolated intracranial hydatid cyst
To read more about kidney disease globally from other cited sources, please review:
[1] Awuah KT, Finkelstein SH, Finkelstein FO. Quality of life of chronic kidney disease patients in developing countries. Kidney international supplements. 2013 May 1;3(2):227-9.
[2] Russ AJ, Shim JK, Kaufman SR. "Is there life on dialysis?": time and aging in a clinically sustained existence. Medical anthropology. 2005 Oct 1;24(4):297-324.
[3] Campbell GA, Sanoff S, Rosner MH. Care of the undocumented immigrant in the United States with ESRD. American Journal of Kidney Diseases. 2010 Jan 1;55(1):181-91.
The post Making a difference providing equitable renal care globally appeared first on BMJ Case Reports blog.
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Perforation of appendiceal adenocarcinoma ex goblet cell carcinoid: a rare case
Abstract
Goblet cell carcinoid tumor is a rare form of carcinoid tumor of the appendix. It behaves more aggressively than classical carcinoid tumor of the appendix. Thus, special attention must be given to its disease course and treatment. Our case presentation is of a 68-year-old female who presented with abdominal pain. Computed tomography of her abdomen and pelvis showed a perforated appendicitis. She underwent an ileocectomy with pathological report showing a goblet cell carcinoid tumor of the appendix with negative lymph nodes. A subsequent colonoscopy done 5 months later showed no synchronous lesions and a healthy anastomosis. Given the limited amount of data available about goblet cell carcinoid tumors of the appendix, it is important to report all findings in an effort to improve our understanding and treatment approaches of this rare disease.https://ift.tt/2xn4vw6
Clostridium difficile Peritonitis: An Emerging Infection in Peritoneal Dialysis Patients
Recently, the incidence of Clostridium difficile- (C. difficile-) associated infection has increased significantly in hospital and ambulatory care settings in parallel to the increasing use of inappropriate antibiotics. According to the CDC, approximately 83,000 patients who developed C. difficile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis. Patients on dialysis (particularly peritoneal dialysis) are predisposed to this infection due to an inherent immunocompromised state and transmural translocation of the bacteria due to the close association of gastrointestinal tract and peritoneal cavity. C. difficile infection in peritoneal dialysis patients is problematic from two aspects: (1) because dialysis patients are immunocompromised, the infection can be devastating and (2) infection directly interferes with their renal replacement therapy. In this article, we present a case of peritoneal dialysis (PD)-related peritonitis caused by C. difficile-associated diarrhea and colitis. In this patient, the peritonitis was caused by transmural translocation of the enteric bacteria. While the peritoneal fluid culture did not grow the organism (possibly because of prior empiric broad-spectrum antibiotics use), the positive PCR on stool analysis suggested C. difficile-related peritonitis, along with the rapid clinical improvement induced by C. difficile-directed therapy (metronidazole) and discontinuation of broad-spectrum antibiotics. The patient was successfully treated with metronidazole without PD catheter removal. C. difficile infection is common and frequently internists are the first contact with such patients. This article highlights C. difficile infection in a PD patient and raises awareness of this infection in dialysis patients.
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Predatory Open-Access Publishing in Anesthesiology
Predatory publishing is an exploitative fraudulent open-access publishing model that applies charges under the pretense of legitimate publishing operations without actually providing the editorial services associated with legitimate journals. The aim of this study was to analyze this phenomenon in the field of anesthesiology and related specialties (intensive care, critical and respiratory medicine, pain medicine, and emergency care). Two authors independently surveyed a freely accessible, constantly updated version of the original Beall lists of potential, possible, or probable predatory publishers and standalone journals. We identified 212 journals from 83 publishers, and the total number of published articles was 12,871. The reported location of most publishers was in the United States. In 43% of cases (37/84), the reported location was judged as "unreliable" after being checked using the 3-dimensional view in Google Maps. Six journals were indexed in PubMed. Although 6 journals were declared to be indexed in the Directory of Open Access Journals, none were actually registered. The median article processing charge was 634.5 US dollars (interquartile range, 275–1005 US dollars). Several journals reported false indexing/registration in the Committee on Publication Ethics and International Committee of Medical Journal Editors registries and Google Scholar. Only 32% (67/212) reported the name of the editor-in-chief. Rules for ethics/scientific misconduct were reported in only 24% of cases (50/212). In conclusion, potential or probable predatory open-access publishers and journals are widely present in the broad field of anesthesiology and related specialties. Researchers should carefully check journals' reported information, including location, editorial board, indexing, and rules for ethics when submitting their manuscripts to open-access journals. Accepted for publication August 10, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Clinical trial number and registry URL: Not applicable. Reprints will not be available from the authors. Address correspondence to Andrea Cortegiani, MD, Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy. Address e-mail to cortegiania@gmail.com. © 2018 International Anesthesia Research Society
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https://ift.tt/2DaaDNs
Ultrasound-Assisted Technology Versus the Conventional Landmark Location Method in Spinal Anesthesia for Cesarean Delivery in Obese Parturients: A Randomized Controlled Trial
BACKGROUND: Spinal anesthesia, which is commonly used in cesarean deliveries, is often difficult to perform in obese parturients because of poorly palpable surface landmarks and positioning challenges. This study aimed to evaluate the benefits of ultrasound-assisted technology for performing spinal anesthesia in obese parturients. METHODS: Parturients with a body mass index (BMI) ≥30 kg/m2 scheduled for elective cesarean delivery were randomized to undergo spinal anesthesia using the conventional landmark location technique (landmark group, n = 40) or prepuncture ultrasound examination (ultrasound group, n = 40). All participants underwent spinal anesthesia in the lateral position. The primary outcome was the first-attempt success rate. Secondary outcomes were the number of skin punctures and needle passes, procedure times, patient satisfaction, changes in the intended interspace, and incidence of complications. RESULTS: The ultrasound group had a significantly higher first-attempt success rate (87.5% vs 52.5%; P = .001), fewer cases requiring >10 needle passes (1 vs 17; P 10 needle passes (P = .231), spinal injection time (P = .081), or total procedure time (P = .729); however, more time was required to identify the needle insertion site in the ultrasound group (P 10 needle passes (P ≤ .01), and shorter procedure times, including the time required to identify the needle insertion site (P
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https://ift.tt/2D9avhi
A Predictive Model for Determining Patients Not Requiring Prolonged Hospital Length of Stay After Elective Primary Total Hip Arthroplasty
BACKGROUND: Hospital length of stay (LOS) is an important quality metric for total hip arthroplasty. Accurately predicting LOS is important to expectantly manage bed utilization and other hospital resources. We aimed to develop a predictive model for determining patients who do not require prolonged LOS. METHODS: This was a retrospective single-institution study analyzing patients undergoing elective unilateral primary total hip arthroplasty from 2014 to 2016. The primary outcome of interest was LOS less than or equal to the expected duration, defined as ≤3 days. Multivariable logistic regression was performed to generate a model for this outcome, and a point-based calculator was designed. The model was built on a training set, and performance was assessed on a validation set. The area under the receiver operating characteristic curve and the Hosmer–Lemeshow test were calculated to determine discriminatory ability and goodness-of-fit, respectively. Predictive models using other machine learning techniques (ridge regression, Lasso, and random forest) were created, and model performances were compared. RESULTS: The point-based score calculator included 9 variables: age, opioid use, metabolic equivalents score, sex, anemia, chronic obstructive pulmonary disease, hypertension, obesity, and primary anesthesia type. The area under the receiver operating characteristic curve of the calculator on the validation set was 0.735 (95% confidence interval, 0.675–0.787) and demonstrated adequate goodness-of-fit (Hosmer–Lemeshow test, P = .37). When using a score of 12 as a threshold for predicting outcome, the positive predictive value was 86.1%. CONCLUSIONS: A predictive model that can help identify patients at higher odds for not requiring a prolonged hospital LOS was developed and may aid hospital administrators in strategically planning bed availability to reduce both overcrowding and underutilization when coordinating with surgical volume. Accepted for publication August 15, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Rodney A. Gabriel, MD, MAS, Department of Anesthesiology, University of California, San Diego, 200 W Arbor Dr, MC 8770, San Diego, CA 92103. Address e-mail to ragabriel@ucsd.edu. © 2018 International Anesthesia Research Society
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https://ift.tt/2D8GkGU
Development and Multidisciplinary Preliminary Validation of a 3-Dimensional–Printed Pediatric Airway Model for Emergency Airway Front-of-Neck Access Procedures
BACKGROUND: Pediatric-specific difficult airway guidelines include algorithms for 3 scenarios: unanticipated difficult tracheal intubation, difficult mask ventilation, and cannot intubate/cannot ventilate. While rare, these instances may require front-of-neck access (FONA) to secure an airway until a definitive airway can be established. The aim of this study was to develop a pediatric FONA simulator evaluated by both anesthesiology and otolaryngology providers, promoting multidisciplinary airway management. METHODS: A 3-dimensional–printed tracheal model was developed using rescaled, anatomically accurate dimensions from a computerized tomography scan using computer-aided design software. The medical grade silicone model was incorporated into a mannequin to create a low-cost, high-fidelity simulator. A multidisciplinary team of anesthesiology, otolaryngology, and simulation experts refined the model. Experts in airway management were recruited to rate the realism of the model's characteristics and features and their own ability to complete specific FONA-related tasks. RESULTS: Six expert raters (3 anesthesiology and 3 otolaryngology) were identified for multidisciplinary evaluation of model test content validity. Analysis of response data shows null variance within 1 or both specialties for a majority of the content validity tool elements. High and consistent absolute ratings for each domain indicate that the tested experts perceived this trainer as a realistic and highly valuable tool in its current state. CONCLUSIONS: The ability to practice front-of-neck emergency airway procedures safely and subsequently demonstrate proficiency on a child model has great implications regarding both quality of physician training and patient outcomes. This model may be incorporated into curricula to teach needle cricothyroidotomy and other FONA procedures to providers across disciplines. Accepted for publication July 26, 2018. Funding: K.J.K, A.R.P., and C.L.R. are supported by National Institutes of Health grant T32 DC005356 (T32 Training Grant). This work is supported by a research grant funded by the University of Michigan Clinical Simulation Center. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to David A. Zopf, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to davidzop@med.umich.edu. © 2018 International Anesthesia Research Society
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https://ift.tt/2NqxmcT
Retrospective Cohort Study on the Optimal Timing of Orogastric Tube/Nasogastric Tube Insertion in Infants With Pyloric Stenosis
BACKGROUND: Hypertrophic pyloric stenosis in infants can cause a buildup of gastric contents. Orogastric tubes (OGTs) or nasogastric tubes (NGTs) are often placed in patients with pyloric stenosis before surgical management to prevent aspiration. However, exacerbation of gastric losses may lead to electrolyte abnormalities that can delay surgery, and placement has been associated with increased risk of postoperative emesis. Currently, there are no evidence-based guidelines regarding OGT/NGT placement in these patients. This study examines whether OGT/NGT placement before arrival in the operating room was associated with a longer time to readiness for surgery as defined by normalization of electrolytes. Secondary outcomes included time from surgery to discharge and ability to tolerate feeds by 6 hours postoperatively in patients with and without early OGT/NGT placement. METHODS: In this multicenter retrospective cohort study, data were extracted from the medical records of 481 patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis from March 2013 to June 2016. Multivariable linear regression and Cox proportional hazard models were constructed to evaluate the association between placement of an OGT/NGT at the time of admission with increased time to readiness for surgery (defined as the time from admission to the first set of normalized laboratory values) and increased time from surgery to discharge. Multivariable logistic regression was used to evaluate the association between early OGT/NGT placement and the ability to tolerate oral intake at 6 hours postsurgery. Analyses were adjusted for site differences. RESULTS: Among patients admitted with electrolyte abnormalities, those with an OGT/NGT placed on presentation required more time until their serum electrolytes were at acceptable levels for surgery by regression analysis (19.2 hours difference; 95% confidence interval, 10.05–28.41; P
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https://ift.tt/2D9SyPz
Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters
Ventilator alarms have long been presumed to contribute substantially to the overall alarm burden in the intensive care unit. In a prospective observational study, we determined that each ventilator triggered an alarm cascade of up to 8 separate notifications once every 6 minutes. In 1 intensive care unit with different ventilator manufacturers, the distribution of high-priority alarms was manufacturer dependent with 8.6% of alarms from 1 type and 89.8% of alarms from another type of ventilator. Alarm limits were not a function of patient-specific ventilator settings. Accepted for publication August 17, 2018. Funding: Supported, in part, by a grant from the Association for the Advancement of Medical Instrumentation (AAMI). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Maria M. Cvach, DNP, RN, FAAN, Department of Integrated Healthcare Delivery, Johns Hopkins Health System, Room 631, 1830 Bldg, 1830 E Monument St, Baltimore, MD 21287. Address e-mail to mcvach@jhmi.edu. © 2018 International Anesthesia Research Society
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https://ift.tt/2Notvxa
Comparison of 7 Different Sensors for Detecting Low Respiratory Rates Using a Single Breath Detection Algorithm in Nonintubated, Sedated Volunteers
BACKGROUND: Numerous technologies are used to monitor respiratory rates in nonintubated patients. No technology has emerged as the standard. The primary aim of this study was to assess the limits of agreement between a reference sensor signal (respiratory inductance plethysmography bands) and 7 alternative sensor signals (nasal capnometer, nasal pressure transducer, oronasal thermistor, abdominal accelerometer, transpulmonary electrical impedance, peritracheal microphone, and photoplethysmography) for measuring low respiratory rates in sedated, nonintubated, supine volunteers. A unified approach based on a single breath detection algorithm was applied to each sensor to facilitate comparison. We hypothesized that all of the sensor signals would allow detection of low (80% of data points within ±2 breaths per minute. Impedance and photoplethysmograph signals had 58% and 64%, respectively. CONCLUSIONS: A unified approach can be applied to a variety of sensor signals to estimate respiratory rates in spontaneously breathing, nonintubated, sedated volunteers. However, detecting clinically relevant low respiratory rates (
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https://ift.tt/2NmyFtB
Effects of Intraoperative Infusion of Esmolol on Systemic and Pulmonary Inflammation in a Porcine Experimental Model of Lung Resection Surgery
BACKGROUND: Lung resection surgery (LRS) is associated with systemic and pulmonary inflammation, which can affect postoperative outcomes. Activation of β-adrenergic receptors increases the expression of proinflammatory and anti-inflammatory mediators, and their blockade may attenuate the systemic inflammatory response. The aim of this study was to analyze the effect of a continuous perioperative intravenous perfusion of esmolol on postoperative pulmonary edema in an experimental model of LRS requiring periods of one-lung ventilation (OLV). METHODS: Twenty-four large white pigs were randomly assigned to 3 groups: control (CON), esmolol (ESM), and sham. The ESM group received an intravenous esmolol bolus (0.5 mg/kg) and then an esmolol infusion (0.05 mg·kg−1·minute−1) throughout the procedure. The CON group received the same volume of 0.9% saline solution as the ESM group plus a continual infusion of saline. The sham group underwent a left thoracotomy without LRS or OLV. At the end of the LRS, the animals were awakened, and after 24 hours, they underwent general anesthesia again. Lung biopsies and plasma samples were obtained to analyze the levels and expression of inflammatory mediators, and the animals also received a bronchoalveolar lavage. RESULTS: At 24 hours after the operation, the ESM group had less lung edema and lower expression of the proinflammatory biomarkers tumor necrosis factor (TNF) and interleukin (IL)-1 compared to the CON group for both lung lobes. For the mediastinal lobe biopsies, the mean difference and 95% confidence interval (CI) between the groups for edema, TNF, and IL-1 were 14.3 (95% CI, 5.6–23.1), P = .002; 0.19 (95% CI, 0.07–0.32), P = .002; and 0.13 (95% CI, 0.04–0.22), P = .006, respectively. In the left upper lobe, the mean differences for edema, TNF, and IL-1 were 12.4 (95% CI, 4.2–20.6), P = .003; 0.25 (95% CI, 0.12–0.37), P
https://ift.tt/2D9S6AR
https://ift.tt/2D9S6AR
Addition of Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee and Adductor Canal Block to Periarticular Injection Enhances Postoperative Pain Control in Total Knee Arthroplasty: A Randomized Controlled Trial
BACKGROUND: Periarticular injections (PAIs) are becoming a staple component of multimodal joint pathways. Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the posterior knee (IPACK) and the adductor canal block (ACB), may augment PAI in multimodal analgesic pathways for knee arthroplasty, but supporting literature remains rare. We hypothesized that the addition of ACB and IPACK to PAI would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone. METHODS: This triple-blinded randomized controlled trial included 86 patients undergoing unilateral total knee arthroplasty. Patients either received (1) a PAI (control group, n = 43) or (2) an IPACK with an ACB and modified PAI (intervention group, n = 43). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption. RESULTS: The intervention group reported significantly lower NRS pain scores on ambulation than the control group on POD 1 (difference in means [95% confidence interval], −3.3 [−4.0 to −2.7]; P
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https://ift.tt/2Nmyyyb
The degree of adherence to CONSORT reporting guidelines for the abstracts of randomised clinical trials published in anaesthesia journals: A cross-sectional study of reporting adherence in 2010 and 2016
BACKGROUND Abstracts are intended to be concise summaries of the entire randomised clinical trial (RCT). Despite their importance, few studies have examined the reporting quality of abstracts in the anaesthesiology literature. OBJECTIVES To examine the quality of RCT abstract reporting according to the CONSORT for Abstracts guidelines and determine whether recommended items omitted from the abstract were present in the body of the article. DESIGN A cross-sectional study of RCTs. SETTING This study was performed at the University of Western Ontario and University Hospital, London Health Sciences Centre. PARTICIPANTS All RCTs meeting inclusion criteria that were published in 2010 or 2016 in six general anaesthesiology journals (Anaesthesia, Anesthesia & Analgesia, Anesthesiology, British Journal of Anaesthesia, Canadian Journal of Anesthesia and European Journal of Anaesthesiology). MAIN OUTCOME MEASURES The 16 checklist items from the CONSORT for Abstracts statement were used to create a convenience score as a proxy for RCT abstract reporting quality, with each criterion measured as being reported in abstract, not reported in abstract but reported in full-text article, or not reported in abstract or full-text article. RESULTS Of the 395 RCTs identified, 219 were published in 2010 and 176 were published in 2016. Out of the maximum possible score of 16, the median abstract score increased from 4 points [interquartile range (IQR): 3 to 5] in 2010 to 6 points [IQR: 5 to 8] in 2016. Although most checklist items showed improvement from 2010 to 2016, around 75% of RCTs in 2016 met fewer than half of the 16 items with no RCTs reporting all 16 items in the abstract. A majority of the RCTs had the information present in the full-text. In 2016, only 71 out of 176 (40%) of RCTs reported outcomes conforming to the CONSORT guidelines (with an effect size and a confidence interval around the effect size) in the Abstract. CONCLUSION Abstracts for many anaesthesiology RCTs are incomplete selective summaries of the entire article. Correspondence to Dr Philip M. Jones, MD, MSc, Rm C3–110 - University Hospital, London Health Sciences Centre, 339 Windermere Rd, London, ON N6A 5A5, Canada, Tel: +1 519 685 8500 x36306; e-mail: pjones8@uwo.ca Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology
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https://ift.tt/2plXyqw
How current transfusion practices in geriatric patients with hip fracture still differ from current guidelines and the effects on outcome: A retrospective observational study
BACKGROUND Transfusion guidelines have become increasingly restrictive. We investigated actual transfusion practices in geriatric hip fracture patients, why they differ from current guidelines and how this affects outcome. OBJECTIVES The primary aim was to examine transfusion timing, evaluate how many red blood cell (RBC) transfusions are in keeping with and how this affects morbidity (infection, cardiac events and delirium), mortality and length of stay (LOS). Our secondary aim was to test the hypothesis that guidelines were more likely to be guidelines are more likely to deviate with consecutive transfusions or before discharge. DESIGN A retrospective observational study. SETTING The Luzerner Kantonsspital, a major trauma centre, over a 12-month period from 1 February 2015 to 31 January 2016. PATIENTS All patients over 70 years of age admitted to the Luzerner Kantonsspital with hip fractures over a 12-month period in 2015 to 2016 were included. RESULTS 156 patients were included, and 141 units of RBCs were transfused. All pre and intra-operative transfusions were according to guidelines; 110 transfusions were postoperative and 37 of these were not according to guidelines. Patients who were transfused had longer LOS in hospital (P = 0.002) and an odds ratio (OR) of 2.7 of contracting an infection (P = 0.04) in comparison with patients who were not transfused. No significant differences in mortality, LOS or morbidity were found between patients transfused according to guidelines and more liberal thresholds. Guidelines were more likely to be deviated from within the last 2 days before discharge than prior to this (58 vs. 24%, P = 0.03). Furthermore, 24 stable patients received two consecutive RBC units resulting in posttransfusion haemoglobin values of between 83 and 124 g l−1. CONCLUSION Most RBC transfusions occur postoperatively, many still according to liberal transfusion thresholds, in particular shortly before discharge and as part of consecutive transfusions. Transfused patients had longer LOS and more infections than patients not transfused, but there was no difference in mortality, LOS or morbidity between patients transfused according to current guidelines and those where guidelines were deviated from. Correspondence to Dr Evelyn Leuzinger, Department of Anaesthesia, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern, Switzerland Tel: + 41 55 205 1111; e-mail: evelynctsa@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology
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https://ift.tt/2MLleOD
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